RESUMO
BACKGROUND AND OBJECTIVES: High-risk infant follow-up programs (HRIFs) are a recommended standard of care for all extremely low birth weight (ELBW) infants to help mitigate known risks to long-term health and development. However, participation is variable, with known racial and ethnic inequities, though hospital-level drivers of inequity remain unknown. We conducted a study using a large, multicenter cohort of ELBW infants to explore within- and between-hospital inequities in HRIF participation. METHODS: Vermont Oxford Network collected data on 19 503 ELBW infants born between 2006 and 2017 at 58 US hospitals participating in the ELBW Follow-up Project. Primary outcome was evaluation in HRIF at 18 to 24 months' corrected age. The primary predictor was infant race and ethnicity, defined as maternal race (non-Hispanic white, non-Hispanic Black, Hispanic, Asian American, Native American, other). We used generalized linear mixed models to test within- and between-hospital variation and inequities in HRIF participation. RESULTS: Among the 19 503 infants, 44.7% (interquartile range 31.1-63.3) were seen in HRIF. Twenty six percent of the total variation in HRIF participation rates was due to between-hospital variation. In adjusted models, Black infants had significantly lower odds of HRIF participation compared with white infants (adjusted odds ratio, 0.73; 95% confidence interval, 0.64-0.83). The within-hospital effect of race varied significantly between hospitals. CONCLUSIONS: There are significant racial inequities in HRIF participation, with notable variation within and between hospitals. Further study is needed to identify potential hospital-level targets for interventions to reduce this inequity.
Assuntos
Etnicidade , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Recém-Nascido , Lactente , Humanos , Seguimentos , Hispânico ou Latino , População Negra , Peso ao NascerRESUMO
Differences in race/ethnicity, gender, income and other social factors have long been associated with disparities in health, illness and premature death. Although the terms 'health differences' and 'health disparities' are often used interchangeably, health disparities has recently been reserved to describe worse health in socially disadvantaged populations, particularly members of disadvantaged racial/ethnic groups and the poor within a racial/ethnic group. Infants receiving disparate care based on race/ethnicity, immigration status, language proficiency, or social class may be discomforting to healthcare workers who dedicate their lives to care for these patients. Recent literature, however, has documented differences in neonatal intensive care unit (NICU) care quality that have contributed to racial and ethnic differences in mortality and significant morbidity. We examine the within-NICU and between-NICU mechanisms of disparate care and recommend approaches to address these disparities.
Assuntos
Equidade em Saúde , Unidades de Terapia Intensiva Neonatal , Recém-Nascido , Lactente , Humanos , Estados Unidos , Disparidades em Assistência à Saúde , Etnicidade , Grupos RaciaisRESUMO
BACKGROUND: Summary measures are used to quantify a hospital's quality of care by combining multiple metrics into a single score. We used Baby-MONITOR, a summary quality measure for NICUs, to evaluate quality by race and ethnicity across and within NICUs in the United States. METHODS: Vermont Oxford Network members contributed data from 2015 to 2019 on infants from 25 to 29 weeks' gestation or of 401 to 1500 g birth weight who were inborn or transferred to the reporting hospital within 28 days of birth. Nine Baby-MONITOR measures were individually risk adjusted, standardized, equally weighted, and averaged to derive scores for African American, Hispanic, Asian American, and American Indian infants, compared with white infants. RESULTS: This prospective cohort included 169 400 infants at 737 hospitals. Across NICUs, Hispanic and Asian American infants had higher Baby-MONITOR summary scores, compared with those of white infants. African American and American Indian infants scored lower on process measures, and all 4 minority groups scored higher on outcome measures. Within NICUs, the mean summary scores for African American, Hispanic, and Asian American NICU subsets were higher, compared with those of white infants in the same NICU. American Indian summary NICU scores were not different, on average. CONCLUSIONS: With Baby-MONITOR, we identified differences in NICU quality by race and ethnicity. However, the summary score masked within-measure quality gaps that raise unanswered questions about the relationships between race and ethnicity and processes and outcomes of care.
Assuntos
Unidades de Terapia Intensiva Neonatal/normas , Qualidade da Assistência à Saúde , Grupos Raciais , Etnicidade , Feminino , Humanos , Recém-Nascido , Masculino , Estudos Prospectivos , Estados UnidosRESUMO
The inequalities in income, wealth, and opportunity so deeply ingrained in our society's history of enslavement, genocide, racism, and discrimination are root causes of health disparities. Follow through is a comprehensive approach that begins before birth and continues into childhood, where health professionals, families, and communities partner to meet the social as well as medical needs of infants and families to achieve health equity. This article discusses potentially better practices for follow through, offering neonatal care providers tangible ways to address social determinants of health, the conditions in which people are born, grow, work, live, and age and the systems that creates these conditions.
Assuntos
Equidade em Saúde , Racismo , Criança , Humanos , Lactente , Recém-Nascido , Recém-Nascido PrematuroRESUMO
BACKGROUND: Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown. METHODS: The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program. RESULTS: Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine. CONCLUSIONS: The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.
Assuntos
Neonatologia/educação , Ressuscitação/educação , Pressão Positiva Contínua nas Vias Aéreas , Epinefrina/uso terapêutico , Bolsas de Estudo , Humanos , Recém-Nascido , Recém-Nascido de muito Baixo Peso , Intubação , Ressuscitação/métodos , VermontRESUMO
Importance: The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals. Objective: To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States. Design, Setting, and Participants: This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks' 0 days' to 25 weeks' 6 days' gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45â¯179 in VON for 2006 to 2012, and 25â¯969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019. Exposures: Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids. Main Outcomes and Measures: The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months' corrected age and measures of hospital resource use (days of hospitalization and ventilator use). Results: Among 4176 actively treated infants in the NRN cohort (48% female; mean [SD] gestational age, 24.2 [0.8] weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean [SD] gestational age, 24.2 [0.8] weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45â¯179 actively treated infants (47% female; mean [SD] gestational age, 24.1 [0.8] weeks) and 70% among 25â¯969 infants from 2013 to 2016 (48% female; mean [SD] gestational age, 24.1 [0.8] weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age-only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%). Conclusions and Relevance: An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.
Assuntos
Mortalidade Infantil/tendências , Lactente Extremamente Prematuro , Doenças do Recém-Nascido/mortalidade , Nascimento Prematuro/mortalidade , Feminino , Humanos , Lactente , Recém-Nascido , Doenças do Recém-Nascido/terapia , Masculino , Prognóstico , Estados Unidos/epidemiologia , Vermont/epidemiologiaRESUMO
Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.
Assuntos
Saúde da Família/etnologia , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Criança Pós-Termo/crescimento & desenvolvimento , Nascimento Prematuro/etnologia , Nascimento Prematuro/prevenção & controle , Racismo/etnologia , Determinantes Sociais da Saúde , Segregação Social , Criança , Desenvolvimento Infantil , Pré-Escolar , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Lactente , Recém-Nascido , Gravidez , Fatores Raciais , Medição de Risco , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers. METHODS: Infants 22 to 29 weeks' gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals for African American and Hispanic versus white infants by birth year. We tested temporal differences in mortality and morbidity rates between white and African American or Hispanic infants using a likelihood ratio test on nested binomial regression models. RESULTS: Disparities for certain care practices such as antenatal corticosteroids and for some in-hospital outcomes have narrowed over time for minority infants. Compared with white infants, African American infants had a faster decline for mortality, hypothermia, necrotizing enterocolitis, and late-onset sepsis, whereas Hispanic infants had a faster decline for mortality, respiratory distress syndrome, and pneumothorax. Other morbidities showed a constant rate difference between African American and Hispanic versus white infants over time. Despite the improvements, outcomes including hypothermia, mortality, necrotizing enterocolitis, late-onset sepsis, and severe intraventricular hemorrhage remained elevated by the end of the study period, especially among African American infants. CONCLUSIONS: Racial and ethnic disparities in vital care practices and certain outcomes have decreased. That the quality deficit among minority infants occurred for several care practice measures and potentially modifiable outcomes suggests a critical role for quality improvement initiatives tailored for minority-serving hospitals.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Hispânico ou Latino/estatística & dados numéricos , Mortalidade Infantil/etnologia , Lactente Extremamente Prematuro , Morbidade , Etnicidade , Feminino , Disparidades em Assistência à Saúde/tendências , Humanos , Lactente , Mortalidade Infantil/tendências , Unidades de Terapia Intensiva Neonatal/tendências , Gravidez , Complicações na Gravidez/epidemiologia , Porto Rico/epidemiologia , Fatores Raciais , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia , População Branca/etnologiaRESUMO
Importance: Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear. Objective: To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States. Design, Setting, and Participants: This cohort study of 743 NICUs in the Vermont Oxford Network included 117â¯982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks' gestation from January 2014 to December 2016. Analysis began January 2018. Main Outcomes and Measures: The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index. Results: Infants (36â¯359 black [31%], 21â¯808 Hispanic [18%], 5920 Asian [5%], and 53â¯895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46-0.53], Hispanic: 0.58 [95% CI, 0.54-0.61], and Asian: 0.45 [95% CI, 0.40-0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02-0.13], Hispanic: -0.10 [95% CI, -0.17 to -0.04], and Asian: -0.26 [95% CI, -0.32 to -0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: -0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants. Conclusions and Relevance: Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.