Neonatal Intensive Care for Low Birthweight Infants: Costs ...
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Transcript of Mortality Among Very Low Birthweight Infants in Hospitals Serving Minority Populations Support...
Mortality Among Very Low Birthweight Infants
in Hospitals Serving Minority Populations
Support Provided by: UCLA-Drew EXCEED Program (AHRQ), RWJ Minority Medical Faculty Development Program, and UCLA-RCMAR Center (NIA)
Leo Morales, M.D., Ph.D.Assistant Professor, UCLA
AcademyHealthJune 7, 2004
Morales-2 03/18/04
Key Collaborators
• Jeanette Rogowski, Ph.D., University of Medicine and Dentistry of New Jersey and RAND
• Douglas Staiger, Ph.D., Dartmouth University
• Jeffery Horbar, M.D., The Vermont Oxford Network (VON)
• Joe Carpenter, M.S., VON
• Mike Kenny, M.A., VON
• Jeff Geppert, M.A., National Bureau of Economic Research
Morales-3 03/18/04
I. BACKGROUND
Morales-4 03/18/04
Hospital Characteristics and Patient Outcomes
• Worse outcomes are associated with:
– Rural hospitals (Kahn, 1994)
– Non-teaching hospitals (Kuhn, 1994; Polanczyk, 2002; Taylor, 1999; Kahn, 1994)
– For-profit hospitals (Hartz, 1989; Haas, 2003)
– Lower expenses per admission (Burstin, 1993)
– Minority-serving hospitals (Brennan, 1991)
– Low volume and lower level of care (Phibbs, 1996)
• Little is known about the relationship of minority-serving hospital status to infant mortality
Morales-5 03/18/04
Trends in Infant Mortality
• Overall, infant mortality is decreasing for black and white infants
• However, the disparity between black and white infant mortality remains constant and maybe increasing (MacDorman, 2002)
– Black infant mortality 14.1 per 1,000 live births
– White infant mortality 5.7 per 1,000 live births
• Eliminating the racial disparity in infant mortality is one of six target areas in the Health People 2010 initiative
Morales-6 03/18/04
Very Low Birthweight Infants
• Definitions
– Low birthweight (LBW): <2500 grams
– Very low birthweight (VLBW): <1500 grams
• Small but high risk infant population
– LBW infants account for 7.6% of live births but 66% of all infant deaths (MacDorman, 2002)
– VLBW infants account for 1.4% of live births but 52% of all infant deaths (MacDorman, 2002)
Morales-7 03/18/04
Research Questions
• Do VLBW infants treated by minority-serving hospitals have similar neonatal mortality as those treated by other hospitals?
• Do hospital characteristics and process of care variables explain differences in neonatal mortality between minority-serving hospitals and other hospitals?
• Are black and white infants treated by minority-serving hospitals at similar risk for neonatal mortality?
Morales-8 03/18/04
II. METHODS
Morales-9 03/18/04
Primary Data Source
• 1995-2000 Vermont Oxford Network (VON)– 332 hospitals– 40% of US hospitals with NICUs– 50% of VLBW infants in US
• Abstracted medical records– Mortality outcomes– Case-mix variables– Process of care
• Institutional survey of participating hospitals– NICU level of care
Morales-10 03/18/04
Additional Data Sources
• American Hospital Association Annual Survey of Hospitals
– Hospital characteristics
• 1990 United States Census
– Maternal income and education
Morales-11 03/18/04
Study Subjects
• VLBW infants between 500g and 1500g
– White infants (n= 49,132)
– Black (n=24,918)
• Inborn infants only
Morales-12 03/18/04
Outcome Variable
• Neonatal mortality
– Mortality in the first 28 days after birth
– Mortality ascertained through transfers until discharge home
Morales-13 03/18/04
Main Explanatory Variable:Hospital Minority-Serving Status
• Hospitals assigned to 1 of 3 categories based on the proportion of infants treated between 1995 and 2000 who were Black
• % VLBW black infants = VLBW black infants / VLBW black and white infants
Category Number of Hospitals
Proportion of Hospitals
<15% Black Infants 113 34%
15%-35% Black Infants 121 36%
>35% Black Infants 98 30%
Morales-14 03/18/04
Explanatory Variables:Case-Mix Variables
• Gestational age (+ gestational age squared)*
• Birthweight*
• Small for gestational age
• Congenital malformation
• Multiple birth
• Any prenatal care
• 1-minute APGAR
• Sex
• Race
• Vaginal delivery
• Maternal income and education based on census
Morales-15 03/18/04
Explanatory Variables:Hospital Variables
• Geography– Region– Urban setting of >1,000,000
• NICU characteristics– Level of care– Volume
• Hospital characteristics– Ownership– Teaching status– Percent Medicaid admissions– Expenditures per admission– Average maternal income and education based on census
Morales-16 03/18/04
Explanatory Variables:Process of Care Variables
• Indicator variables:
– Treatment with surfactants
– Treatment with antenatal steroids
Morales-17 03/18/04
Statistical Models
• Descriptive analysis– Infants by case-mix, hospital, and process of
care variables
• Stratified regression by race– %black + case-mix
• Pooled regression– Model 1: %black + case-mix– Model 2: %black + case-mix + hospital– Model 3: %black + case-mix + hospital +
process of care
Morales-18 03/18/04
Estimation Methods
• Maximum-likelihood logistic regression models
• Robust standard errors
• Clustering of infants within hospitals
• STATA 8.0
Morales-19 03/18/04
III. RESULTS
Morales-20 03/18/04
Infants by Case-Mix Variables
All Infants(n=74,050)
Neonatal Infant Morality 11%
Birth Weight (grams) 1048.5
Gestational Age (weeks) 28.5
1-Minute APGAR Score 5.4
Male Sex 51%
Small for Gestational Age 21%
Multiple Birth 29%
Congenital Malformation 4%
Vaginal Delivery 38%
Maternal Black Race 34%
Had Prenatal Care 96%
Maternal Education (years) 12.41
Maternal Income ($1000s) 36.01
Antenatal Steroids 74%
Surfactants 60%
Morales-21 03/18/04
Infants by Hospital Variables
All Infants (n=74,050)
Minority Serving Status <15% 31% 15% to 35% 36% >35% 33%
Urban Hospital 53% Region
Northeast 19% Midwest 27% South 37% West 16%
Volume <40 Infants per Year 8% Level C NICU 28% Hospital Ownership
Government 11% Not For-Profit 83% For-Profit 7%
Member, Council of Teaching Hospitals 48% Percent Medicaid Admissions 16% Expense per Hospital Admission ($1000s) 11.7
Morales-22 03/18/04
Stratified Logistic Regressions:Neonatal Mortality on Case-Mix Variables
Note. Models include year dummies. *p<0.05 **p<0.01
White Infants Black Infants
Odds Ratio 95% CI Odds Ratio 95% CI
Minority-Serving Status
<15% Black Infants 1.00 1.00
15%-35% Black Infants 1.10 (0.97 – 1.27) 1.16 (0.91 – 1.47)
>35% Black Infants 1.30 (1.09 – 1.56)** 1.29 (1.01 – 1.64)*
Gestational Age 0.04 (0.04 – 0.53)** 0.04 (0.03 – 0.50)**
Gestational Age Squared 1.05 (1.05 – 1.05)** 1.05 (1.05 – 1.06)**
1-Minute APGAR Score 0.73 (0.71 – 0.74)** 0.75 (0.72 – 0.77)**
Small for Gestational Age 2.44 (2.14 – 2.77)** 2.28 (1.93 – 2.69)**
Multiple Birth 1.32 (1.20 – 1.45)** 1.22 (1.07 – 1.39)**
Congenital Malformation 16.50 (14.46 – 18.82)** 14.74 (11.48 – 18.9)**
Vaginal Delivery 1.36 (1.25 – 1.49)** 1.36 (1.21 – 1.52)**
Prenatal Care 0.94 (0.77 – 1.15) 0.85 (0.72 – 1.01)
Maternal Income 1.00 (1.00 – 1.01) 1.00 (0.99 – 1.01)
Maternal Education 1.01 (0.95 – 1.06) 0.99 (0.93 – 1.07)
Male 1.25 (1.17 – 1.34)** 1.28 (1.15 – 1.43)**
Morales-23 03/18/04
Pooled Regressions:Neonatal Mortality on Hospital and Case-Mix Variables
Model 1 Model 2 Model 3 Odds Ratio 95% CI Odds Ratio 95% CI Odds Ratio 95% CI Minority-serving Status
0-15% Black Infants 1.00 1.00 1.00 15-35 Black Infants 1.12 (0.98 - 1.27) 1.11 (0.98 - 1.27) 1.11 (0.98 - 1.27) >35% Black Infants 1.28 (1.10 - 1.50)** 1.25 (1.04 - 1.51)* 1.26 (1.04 - 1.52)*
Urban Setting 1.10 (0.98 - 1.23) 1.10 (0.97 - 1.24) Regional Location
Northeast 1.00 1.00 Midwest 1.09 (0.90 - 1.31) 1.09 (0.89 - 1.32) South 1.05 (0.90 - 1.23) 1.05 (0.90 - 1.24) West 1.21 (1.00 - 1.45)* 1.19 (0.98 - 1.44)
NICU Volume ?40 Infants 1.00 1.00 <40 Infants 1.29 (1.12 - 1.49)** 1.27 (1.10 - 1.46)**
Level of Care Levels A and B 1.00 1.00 Level C 0.86 (0.76 - 0.98)* 0.86 (0.76 - 0.98)*
Hospital Ownership Private Not-For-Profit 1.00 1.00 Private For-Profit 0.83 (0.67 - 1.02) 0.79 (0.65 - 0.95)* Government 1.07 (0.91 - 1.26) 1.07 (0.90 - 1.26)
Teaching Hospital 1.02 (0.91 - 1.15) 1.03 (0.91 - 1.17) % Medicaid Admissions 1.04 (0.55 - 1.97) 0.96 (0.51 - 1.84) Expenses per Admission ($1000s) 1.01 (0.99 - 1.02) 1.01 (0.99 - 1.03) Average Education (Hospital Level)
0.91 (0.80 – 1.03) 0.95 (0.83 - 1.09)
Average Income (Hospital Level) 1.00 (0.99 – 1.02) 1.00 (0.98 - 1.01) Treatment with Antenatal Steroids (Infant Level) 0.54 (0.50 - 0.58)** Treatment with Surfactants (Infant Level) 0.56 (0.50 - 0.62)**
Note. Models include case-mix model and year dummies. *p<0.05 **p<0.01
Morales-24 03/18/04
Thought Experiment-1
• What if black infants were treated by the three categories of hospitals we studied (e.g., <15% black, 15% to 35% black, >35% black) in the same proportions as white infants?
– Black infant mortality would drop by 8.5%
0%
20%
40%
60%
80%
100%
White Infants Black Ifants
<15%
15%-35%
>35%
Morales-25 03/18/04
Thought Expereiment-2
• What if neonatal mortality at hospitals where 15% or more of the treated infants were black were the same as hospitals where <15% of the infants treated were black?
– 10% lower for white infants
– 22% lower for black infants
Morales-26 03/18/04
IV. CONCLUSIONS
Morales-27 03/18/04
Conclusions
• Minority-serving hospitals had higher neonatal mortality than other hospitals
• The difference in neonatal mortality between minority-serving and other hospitals was not explained by the hospital variables or process of care variables
• Neonatal morality was similarly elevated for black and white VLBW infants treated by minority-serving hospitals
Morales-28 03/18/04
Implications
• Minority-serving hospitals may provide worse quality of care than other hospitals
• Hospital-level factors may be more important in understanding disparities in care than individual characteristics such as infant race per se, at least among VLBW infants
• Disparities in infant mortality nationally might be reduced by improving care for VLBW infants at minority-serving hospitals
Morales-30 03/18/04
Potential Explanations for Results
• Staffing patterns
– Nurse-to-patient ratio
– Board-certified specialists
• Maternal characteristics: smoking, drug and alcohol use
– Mediated by infant severity of illness
– Infant characteristics in minority-serving similar to other hospitals
– Maternal income and education had no effect
• Unmeasured severity of illness
– VON risk adjustment ROC=0.88
– SNAP ROC=0.73 to 0.91
Morales-31 03/18/04
Study Generalizability
• Compared with all US hospitals, VON hospitals are:
– More likely to be private non-profit
– Teaching hospitals
– Children’s hospitals
– More NICU beds
• Compared with all VLBW infants in US, VLBW infants treated by VON hospitals are:
– Differed in terms of birthweight but not gestational age
Morales-32 03/18/04
Hospital Characteristics
All (n=74,050)
White (n=49,132)
Black (n=24,918)
Minority-Serving Status <15% Black Infants 31% 39% 8% 15% to 35% Black Infants 36% 43% 35% >35% Black Infants 33% 18% 57%
Urban Hospital 53% 48% 64% Region
Northeast 19% 19% 20% Midwest 27% 29% 23% South 37% 32% 48% West 16% 20% 10%
Volume<40 Admits per Year 8% 8% 8% Level C (Highest Level of Care) 28% 30% 24% Hospital Ownership
Government 11% 9% 14% Not For-Profit 83% 84% 80% For-Profit 7% 7% 6%
Member, Council of Teaching Hospitals 48% 46% 52% Medicaid Admissions 16% 15% 19% Expense per Admission ($1000s) 11.7 11.8 11.4
Morales-33 03/18/04
Secondary Analyses
• Do the effects of risk-adjustment vary by race?
– Insignificant case-mix*race interactions
• Do the effects of minority-serving status vary by race?
– Insignificant percent black*race interactions
• Do the effects of hospital variables vary by percentage black infants treated?
– Insignificant percent black*hospital characteristic interactions