Quality of Care in US NICUs by Race and Ethnicity

Abstract

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.

FIGURE 1

Point estimates and 99% compatibility intervals indicated with error bars for Baby-MONITOR scores by racial and ethnic group, compared with those of white infants. Positive scores indicate that multiracial racial and ethnic groups scored better across NICUs than white infants. A, Process, outcome, and summary Baby-MONITOR scores by race and ethnicity compared with those of white infants across all NICUs. B, Baby-MONITOR measure scores for racial/ethnic groups compared to white infants across all NICUs. CLD, chronic lung disease; HAI, hospital-acquired infection.

FIGURE 2

Distributions of process, outcome, and summary Baby-MONITOR scores by race and ethnicity within US Census Division, compared with those of white infants in the same US Census Division. Point estimates and 99% compatibility intervals are indicated with error bars for Baby-MONITOR scores for racial and ethnic group, compared with white infants. Positive scores indicate that multiracial racial and ethnic groups scored better than white infants. CLD, chronic lung disease; ENC, East North Central (IL, IN, MI, OH, and WI); ESC, East South Central (AL, MS, KY, and TN); HAI, hospital-acquired infection; M, Mountain (AZ, CO, ID, MT, NM, NV, UT, and WY); MA, Middle Atlantic (NJ, NY, and PA); NE, New England (CT, MA, ME, NH, and VT); P, Pacific (AK, CA, HI, OR, and WA); SA, South Atlantic (DC, FL, GA, MD, NC, SC, WV, and VA); WNC, West North Central (IA, KS, MN, MO, ND, NE, and SD); WSC, West South Central (AR, LA, OK, and TX).

FIGURE 3

Box and whisker chart revealing the distributions of NICU Baby-MONITOR scores by racial and ethnic group, compared with those of white infants in the same NICU. Boxes are used to represent the interquartile range; the notched midline represents median score; whiskers represent 1.5 times the interquartile range; and points represent outliers. A score of 0 indicates no difference from white infants in the same NICU, positive scores indicate that multiracial racial and ethnic group infants scored better than white infants in the NICU, and negative scores indicate that white infants scored better than the multiracial racial and ethnic group infants in the NICU. A, Distributions of process, outcome, and summary Baby-MONITOR scores by race and ethnicity compared with those of white infants in the same NICU. B, Distributions of Baby-MONITOR measure scores by race and ethnicity compared with those of white infants in the same NICUs. CLD, chronic lung disease; HAI, hospital-acquired infection.