Racial/Ethnic Disparity in NICU Quality of Care Delivery

Abstract

Background: Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.

Methods: Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs.

Results: We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents.

Conclusions: Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.

FIGURE 1

Study population flowchart.

FIGURE 2

Baby-MONITOR scores with and without adjustment for race and/or ethnicity. Baby-Monitor scores are expressed in SD units, unadjusted (o) and adjusted (x) for race and/or ethnicity. NICUs with more than 20 infants during the study periods are shown (120 NICUs). Adjustment for race and/or ethnicity has a minimal effect on NICU rankings (Pearson correlation = 0.995 [P < .0001]).

FIGURE 3

Baby-MONITOR subcomponent score by race and/or ethnicity. Each subcomponent is listed on the x-axis; standardized observed minus expected z scores are shown on the y-axis. Scores >0 indicate better than expected performance. Comparison of African American and white infants. HM, human milk. ** P < .05, * P < .1.

FIGURE 4

Baby-MONITOR subcomponent score by race and/or ethnicity. Each subcomponent is listed on the x-axis; standardized observed minus expected z scores are shown on the y-axis. Comparison of Hispanic and white infants. CLD, chronic lung disease; DC, discharge; HAI, health care–associated infection; HM, human milk. ** P < .05, * P < .1.

FIGURE 5

Baby-MONITOR scores for each NICU by race and/or ethnicity. NICUs with at least 10 infants in each race are shown in the graphs. Race- and/or ethnicity-specific Baby-MONITOR scores standardized against all infants are used (y-axis). The overall composite score (not race- and/or ethnicity-adjusted) is used on x-axis. The correlations with the overall Baby-MONITOR score are as follows: white = 0.88; African American = 0.70; Hispanic = 0.89; Asian American = 0.69; all P < .0001. Overall and white versus African American (n =53).

FIGURE 6

Baby-MONITOR scores for each NICU by race and/or ethnicity. NICUs with at least 10 infants in each race are shown in the graphs. Race- and/or ethnicity-specific Baby-MONITOR scores standardized against all infants are used (y-axis). The overall composite score (not race- and/or ethnicity-adjusted) is used on x-axis. The correlations with the overall Baby-MONITOR score are as follows: white = 0.88; African American = 0.70; Hispanic = 0.89; Asian American = 0.69; all P < .0001. Overall and white versus Hispanic (n = 88).

FIGURE 7

Baby-MONITOR scores for each NICU by race and/or ethnicity. NICUs with at least 10 infants in each race are shown in the graphs. Race- and/or ethnicity-specific Baby-MONITOR scores standardized against all infants are used (y-axis). The overall composite score (not race- and/or ethnicity-adjusted) is used on x-axis. The correlations with the overall Baby-MONITOR score are as follows: white = 0.88; African American = 0.70; Hispanic = 0.89; Asian American = 0.69; all P < .0001. Overall and white versus Asian American (n = 53).

FIGURE 8

Baby-MONITOR scores for each NICU by race and/or ethnicity. NICUs with at least 10 infants in each race are shown in the graphs. Race- and/or ethnicity-specific Baby-MONITOR scores standardized against all infants are used (y-axis). The overall composite score (not race- and/or ethnicity-adjusted) is used on x-axis. The correlations with the overall Baby-MONITOR score are as follows: white = 0.88; African American = 0.70; Hispanic = 0.89; Asian American = 0.69; all P < .0001. Overall and all races and/or ethnicities (n = 40).