1. Early findings: Regional variation in newborn special care in the U.S. David C. Goodman, MD MS Wade Harrison, MPH September 2015 Wennberg International Collaborative

2. tdi.dartmouth.edu Over the past 40 years, neonatal intensive care has dramatically reduced newborn mortality and morbidity. (Richardson DK. JAMA. 2001;286:1498- 505.) In the U.S. success has led to growth in capacity -- the number of Neonatal Intensive Care Units (NICU), NICU beds, and neonatologists -- while the number of live births has changed little. (Goodman, et al. Pediatrics, 2001) There is a remarkable degree of regional variation in NICU capacity. And capacity is poorly related to newborn risk or health status or mortality. (Goodman, et al. Pediatrics, 2001) (Goodman, et al. N Engl J Med, 2002) At the hospital level, both quality and mortality varies for newborns <1,500 g, even with very careful risk adjustment (Horbar J D et al. Pediatric Background

3. tdi.dartmouth.edu There have been no large population- based studies of newborn cohorts and the use of special (intensive & critical) care. Which newborns are admitted to NICUs today, what are their problems, and how much do the admission rates vary across regions and health systems? And what are the causes of the variation? Once newborns are admitted to NICUs, what are the care patterns, such as length of stay? And the causes? What are the costs of NICU care for different types of patients, and is better care sometimes less intensive and expensive? Research questions:

4. tdi.dartmouth.edu The Epidemiology of Newborn Care Three inter-related projects Funders: – Charles H. Hood Foundation – The State of Texas Medicaid Program – Anthem Foundation Research Team: – Dartmouth Institute (Goodman (PI), Wilkinson, Harrison, Little)) – University of Texas, School of Public Health (Franzini & Ganduglia) – University of Florida, Institute for Child Health Policy (Shenkam & Delcher) – State of Texas, Health and Human Services Commission (Ferrara & Blanton) – State of Texas, Univ. TX Health Science Center, Houston (Tyson) – Stanford University, School of Medicine (Gould)

5. tdi.dartmouth.edu Study populations FunderStudy populationData typesLive Births State of Texas Texas MedicaidNewborn & maternal claims linked with natality and mortality files 207,000 per yr x 2 years Anthem Foundation National commercially insured of one large plan Newborn & maternal claims ~220,000 per yr x 3 years Medicaid for selected states Newborn claims ~1 million per yr x 2 years Hood Foundation Nearly entire population of 4 states; BCBS claims of Texas Newborn claims~130,000 per yr x 2 years U.S. birth cohortLinked natality and mortality files ~3.8 million x multiple years

6. tdi.dartmouth.edu Today’s study aims A population-based study of the epidemiology of U.S. NICU admissions using natality files. 1.Describe the risk of NIU admission (level III/IV units) across the entire birth weight spectrum. 1.Describe the characteristics of the cohort of infants admitted to NICUs. 1.Measure trends. 2.Begin descriptions of variation in NICU admissions.

7. tdi.dartmouth.edu Study population 17,896,048 newborns (2007 – 12) with births recorded using “new” form:73% of U.S. birth cohort during this time – 2007: 22 states and 55% of the total cohort – 2012: 38 states plus D.C. and 88% of the total cohort Study Population Characteristics – Newborns: Consistent across years – Maternal: Increasingly older, more highly educated, and Hispanic

8. tdi.dartmouth.edu Methods Data Sources – 2007-2013 Birth Public Use Natality Files Study Population – Live births (>500 g) to U.S. residents (citizen and non-citizen) recorded using the 2003 birth certificate Measures – 1 o : NICU admission rates (to units with capability of prolonged ventilation) – 2 o : Composition of NICU cohort Statistical Analysis – Crude rates and proportions – Modified Poisson regression (trends in admission rates) Adjusted for: birth weight, gestational age, weight-for-gestational age, 5-minute Apgar, plurality, delivery mode, sex, parity, race/ethnicity, maternal age and education – Simple linear regression (trends in the NICU cohort )

9. tdi.dartmouth.edu JAMA Pediatrics published online 27 July, 2015

10. tdi.dartmouth.edu Level III/IV NICU Admissions by Birth Weight (2012 U.S. Birth Cohort) Newborns >2,500 g comprise 51.6% of NICU admissions

11. tdi.dartmouth.edu Trends in Level III/IV NICU Admission Composition

12. tdi.dartmouth.edu Variation in Rates of Admission to Level III/IV NICUs 2013 live births > 500 gm N=3,512,805

13. Rate of Level III/IV NICU Admissions (%) (2013) N=3.512 million live births (>500 g.) 217 Neonatal Intensive Care Regions overall rate: 7.8% Unpublished data

14. Very Low Birth Wt (500-1499 gm) Level III/V NICU Admissions (2013) N=44,029 Unpublished data

15. Standardized Rate of Level II/IV NICU Admissions by Birth Weight (2013) (Log scale) Unpublished data

16. tdi.dartmouth.edu A rarely traveled and poorly understood ecosystem

17. tdi.dartmouth.edu A rarely studied and poorly understood medical ecosystem