New study from Stanford Medicine Children’s Health points to importance of high-level NICU resources in California

Despite a recent trend toward California hospitals expanding the number of low-level and midlevel acuity neonatal intensive care units, it’s the high-level, high-volume facilities that have the lowest mortality rates when it comes to treating premature infants with necrotizing enterocolitis, a dangerous intestinal disease. But these high-care centers are shrinking in numbers, according to a new study by the Stanford University School of Medicine.

The findings, published online Nov. 10 in JAMA Pediatrics, provide an immediate opportunity for improvements, including the potential for centralizing important NICU resources and services in the state.

“The study helps us look at the current trend and at how we can make sure we have the appropriate patients for the assigned level of care at all NICU facilities, including early detection of the disease and even targeted triage to tertiary hospitals like ours,” said Karl G. Sylvester, MD, pediatric surgeon and co-director of the Center for Fetal and Maternal Health at Lucile Packard Children’s Hospital Stanford, home to a level IV NICU that provides the highest level of care available to premature infants. Sylvester is also an associate professor of surgery at the Stanford University School of Medicine and a co-author of the study.

“Furthermore, the study points out the need for comprehensive management of complex, high-risk premature infants so that diseases like necrotizing enterocolitis can be prevented, or recognized earlier,” Sylvester said.

The study shows that there was a tendency toward de-regionalization of NICUs from 2005 to 2011 and that mortality rates varied according to the level of care. Very-low-birth-weight infants under 1500 grams who also suffer from necrotizing enterocolitis, born into hospitals with midlevel or low-level NICUs, could have a 39 percent to 52 percent greater chance of dying than similar infants born at hospitals with the highest level NICUs, according to the study.

“Unfortunately, lower-acuity NICUs are unable to offer a full array of specialized care,” Sylvester said. “And our study found that mid-level hospitals tend to transfer these very sick babies to a high-level care facility later, after the disease has already progressed.”

Often infants with necrotizing enterocolitis born into lower-level centers weren’t transferred until the baby’s third week of life, according to the study. The disease is often difficult to identify, especially when doctors don’t manage a high volume of these high-risk infants, according to the authors.

Researchers found that with the expansion of lower-level NICUs, fewer very-low-birth-weight babies — only 26.5 percent in 2011, down from 42.5 percent in 2005 — are being born into high-level, high-volume facilities. In fact, the number of California’s high-level care NICUs dropped from 17 to 15 between 2005 and 2011, even though the total number of NICU centers increased from 98 to 127.
Researchers believe the decrease in high-level units is directly due to competition from the increase in midlevel centers.

“It’s not necessarily the case that these smaller NICUs should close down,” said study co-author and neonatologist Henry Lee, MD, director of research for the California Perinatal Quality Care Collaborative, a group of public and private healthcare leaders that collected the data used in the study. “But this is a good time to discuss transferring patients sooner to high-level and high-volume facilities, which have more experience treating necrotizing enterocolitis, more subspecialists and better availability of surgeons.”

Lee, who is also an assistant professor of pediatrics at the School of Medicine, said the study opens the door for more research into necrotizing enterocolitis and how doctors can better triage these cases. And researchers are hoping that the study will demonstrate the importance of training practitioners in early identification and increased management of the disease.

Other Stanford researchers involved in the study include lead author Zachary Kastenberg, MD, a surgical resident and fellow in Health Care Research and Health Policy; Jochen Profit, MD, assistant professor of pediatrics; and Jeffrey Gould, MD, professor of pediatrics.