O2059: Racial Disparities in Delivery Hospital Neonatal Intensive Care Unit Quality for Very Low Birthweight Neonates

Background: It is well-established that delivering very low birth weight (VLBW, < 1500g) infants at hospitals with high-level, high-volume (HLHV) neonatal intensive care units (NICUs) improves survival and increases complications of prematurity, likely due to survival of younger and sicker infants at higher risk of developing morbidity. Our past work found that neonates of minoritized racial and ethnic background benefited more from delivering at HLHV hospitals than non-Hispanic white (NHW) neonates. We hypothesize that this is partially explained by a greater difference in NICU quality between the low-level and/or low-volume (LLLV) and the HLHV centers at which these minoritized infants deliver.

This study aims to describe differences in overall, LLLV, and HLHV delivery hospital NICU quality for non-Hispanic Black (NHB), Hispanic, and Asian American and Native Hawaiian/Pacific Islander (AANHPI) versus NHW neonates using risk-adjusted composite pre-discharge mortality and morbidity rates as hospital quality metrics.

Methods: This study involved secondary analysis of linked vital statistics and patient discharge data. Cohort included VLBW infants born in Michigan, Oregon, and South Carolina between 2010−2020 (n=24,823). Risk-adjusted pre-discharge mortality and morbidity rates—including bronchopulmonary dysplasia, severe retinopathy of prematurity, necrotizing enterocolitis, severe intraventricular hemorrhage, and serious bacterial infection—were calculated for each hospital-year. Risk-adjustment was performed using logistic regression, adjusting for birth weight, gestational age, small gestational age (SGA), multiple gestation, cesarean delivery, obstetric comorbidities, birth state, and birth year. HLHV was defined as a level 3 or 4 NICU caring for >50 VLBW infants annually. Lorenz estimation was used to describe differences in distribution of delivery hospital NICU quality by birthing parent self-identified race and ethnicity, stratified by NICU level/volume.

Results: Study population was 50% NHW, 40% NHB, 7% Hispanic, and 3% AANHPI, after excluding other and multiple race and ethnicity neonates. NHB VLBW neonates were least likely (20%) and Hispanic neonates were most likely (32%) to be born at LLLV centers (p < 0.001, Figure 1). Overall, NHB neonates were overrepresented at lower quality hospitals and NHW, Hispanic, and AANHPI neonates were overrepresented at higher quality hospitals (Figure 2). This pattern persisted in subgroup analysis by NICU level/volume, though significance is limited in the LLLV group due to small number of VLBW births at those centers.

Conclusion: Consistent with related studies using different cohorts and quality metrics, NHB VLBW infants were overrepresented at lower quality hospitals compared to infants of other racial and ethnic backgrounds in our cohort. Similar patterns were identified when stratifying for NICU level/volume, though evaluation was limited by sample size. Next steps (results available by fall 2024) will involve expanded analysis including additional states, as well as mediation analysis exploring relative contributions of delivery hospital NICU level, VLBW volume, and quality to racial and ethnic disparities in outcomes for VLBW/very preterm infants.