The Concern for Supply-Sensitive Neonatal Intensive Care Unit Care If You Build Them, They Will Come

When people acknowledge that life expectancy has increased dramatically in the past 5 decades, manymistakenly believe it is because of huge improvements in care for diseases that affect adults and the elderly at the end of their lives. What is missed is that many, ifnotmost,of thegains we have seen are the result of saving the lives of children and infants. Saving an infant addsmanymore years to overall life expectancyat birth thandoesprolonging anolderperson’s life for a few years. Almost no intervention has done as much to save young infants as the establishment of neonatal intensive care units (NICUs).1 Since the first one was opened in the United States in 1960, the neonatal mortality rate dropped from 18.73 per 1000 live births live births to 4.01 per 1000 live births in 2012.2 With the level of care that they provide, NICUs save lives and markedly improve outcomes for infants at the highest risk for health issues. Too often, though, when something works in the United Stateswestart tooveruse it.3Therearemanyreasons thismight occur. It is understandable that, as pediatricians,whenwe see aneffective intervention for onepatientwe think itmighthelp with another. It is common forus towant todoall thatwe can, especially for infants.Whynotprovide themwith themostcare possible? Financial incentives also induce us to provide care when it might not be necessary. We want to believe that we are not influenced by such things, but there is a wealth of evidence4 demonstrating thatphysicians areoften influencedbymoney. There is a reason that 10-cent coupons exist: they work. The amount ofmoney tobemadebyprovidingmore care ismuch, much larger than the amount gained by providing usual care. Sometimes the volume of care that patients receive is related tohowmuchof it canbedelivered in a region rather than to how sick people in the region are. For example, the number of patient visits to a cardiologist among Medicare enrollees, after controlling for patient-level factors, can vary from almost none to more than 2, depending on how many cardiologists are located in the area.5 Thenumber of practicing cardiologists accounts for approximately half of all the variation in the number of visits to one of these specialists. Physicians tend to “drum up” business for themselves. Research also shows that infrastructure can be related to the volumeof care delivered. In theMedicare population, the number of discharges fromahospital can range fromapproximately 100 tomore than 350 per 1000 beneficiaries, depending on howmany acute care beds are available in that region after controlling for other factors.5More thanhalf of thevariation in rates of hospitalization formedical conditions is associatedwith local bed capacity. If you build the beds, hospitals tend to find ways to use them. This associationbetween theamountof caredeliveredand our capacity to delivermore of it is known as supply-sensitive care6; this level of care is concerning for 2 reasons. The first is, obviously, cost. Many of these same studies show that spending goesupas supply-sensitive care increases.7 The second reason is harm.8 Care is not risk free: it can have physical and emotional consequences for both patients and families. In this issue of JAMAPediatrics, Harrison andGoodman,9 both of the Dartmouth Institute for Health Policy & Clinical Practice, explorehow,atapopulation level, theadmissionrates to NICUs in the United States have changed over time. They exploit a change in the live-birth certificates that allowed them tomeasure these rates and stratify themby birthweight, gestational age,weight at birth, andwhether infantswere receiving assisted ventilation. What this study foundmayhave implications forbothcurrent health care and future health policy. Admission rates to NICUs increased during a 6-year period from 64 to almost 78 per 1000livebirths.These increasesoccurred inallbirthweight categories rather than because there was an increase in the number of very premature or low-birth-weight infants born during that time. In fact, during the study period, infants admitted to NICUs were larger and less premature overall. Therearemany limitations toa studysuchas this thatwarrant careful consideration.Thedatadidnotallowthe researchers to account for theuse of level II nurseries, so itmaybe that some or all of these increased admissions were not necessarily infantswho had been transferred fromnewborn nurseries to NICUs. Socioeconomic or other unmeasured factors could be causing these changes. It is also possible that the increase in use of NICUs was warranted. Perhaps this increased level of care led to better outcomes; we cannot know for certain. However, this study9 should give us pause. Placing an infant in the NICU is not necessarily benign.Many studies have shown10,11 thatmore intensive care carries ahigher risk.Moreover, NICU care is likely to cause a great deal of stress for parents, aswell as interferewithmother-childbonding thatwould otherwise occur more naturally in a newborn nursery or at home.12,13 NICU care is also very costly. Deregionalizationhas led to increasingnumbers ofNICUs appearing throughout theUnitedStates.14The idea tobroaden thedistributionwas that very sick and at-risk infants could be cared for closer to home and that more deliveries could happen in hospitals where intensive care was available when needed.15However, achieving such caremeant buildingmany more NICUs. These units need to be busy to pay for themselves.Manyhospitals alsodependonthe revenue theseNICUs provide to remain financially sound overall. Related article page 855 Opinion Editorial