The uneven landscape of newborn intensive care services: variation in the neonatology workforce.

CONTEXT: In the past 30 years, the number of neonatologists has increased while total births have remained nearly constant. It is not known how equitably this expanded workforce is distributed. OBJECTIVE: To determine the geographic distribution of neonatologists in the United States. DATA SOURCES: 1996 American Medical Association physician masterfiles; 1999 survey of all U.S. neonatal intensive care units; 1995 American Hospital Association hospital survey; and 1995 U.S. vital records. MEASURES: The number of neonatologists and neonatal mid-level providers per live birth within 246 market-based regions. RESULTS: The neonatology workforce varied substantially across neonatal intensive care regions. The number of neonatologists per 10,000 live births ranged from 1.2 to 25.6 with an interquintile range of 3.5 to 8.5. The weakly positive correlation between neonatologists and neonatal mid-level providers per live birth is not consistent with substitution of neonatal mid-level providers for neonatologists (Spearman rank-correlation coefficient, 0.17; P < 0.01). There was no difference in the percentage of neonatal fellows in the lowest and highest workforce quintile (14% vs. 16%) or in the percentage of neonatologists engaged predominantly in research, teaching, or administration (14% in lowest and highest quintiles). CONCLUSIONS: The regional supply of neonatologists varies dramatically and cannot be explained by the substitution of neonatal mid-level providers or by the presence of academic medical centers. Further research is warranted to understand whether neonatal intensive care resources are located in accordance with risk and whether more resources improve newborn outcomes.

Are neonatal intensive care resources located according to need? Regional variation in neonatologists, beds, and low birth weight newborns.

OBJECTIVE: Despite marked growth in neonatal intensive care during the past 30 years, it is not known if neonatologists and beds are preferentially located in regions with greater newborn risk. This study reports the relationship between regional measures of intensive care capacity and low birth weight infants using newly developed market-based regions of neonatal intensive care. DESIGN: Cross-sectional small-area analysis of 246 neonatal intensive care regions (NICRs). DATA SOURCES: 1996 American Medical Association and American Osteopathic Association masterfiles data of clinically active neonatologists; 1999 American Academy of Pediatrics Section on Perinatal Pediatrics survey of directors of neonatal intensive care units in the United States with 100% response rate; 1995 linked birth/death data. RESULTS: The number of total births per neonatologist across NICRs ranged from 390 to 8197 (median: 1722) and the number of total births per intensive care bed ranged from 72 to 1319 (median: 317). The associations between capacity measures and low birth weight rates across NICRs were statistically significant but negligible (R(2): 0.04 for neonatologists; 0.05 for beds). NICRs in the quintile with the greatest neonatologist capacity (average of only 863 births per neonatologist) had very low birth weight (VLBW) rates of 1.5% while those in the quintile of lowest neonatologist capacity (average of 3718 births per neonatologist) had VLBW rates of 1.3%; a similar lack of meaningful difference in VLBW rates was noted across quintiles of intensive care bed capacity. Including midlevel providers and intermediate care beds to the analyses did not alter the findings. CONCLUSIONS: Neonatal intensive care capacity is not preferentially located in regions with greater newborn need as measured by low birth weight rates. Whether greater capacity affords benefits to the newborns remains unknown.

State health agencies and quality improvement in perinatal care.

The origin of the federal-state partnership in Maternal and Child Health (MCH) can be traced from the Children's Bureau grants of 1912, through the Sheppard-Towner Act, to the creation of Title V and other programs of today that mandate planning, accountability, and systems development. In the past decade with the transformation of the health care system and the emergence of managed care, there has been a resurgence of interest in public, professional, and governmental interest in quality measurement and accountability. Regional perinatal systems have been implemented in all states with varying levels of involvement by state health agencies and the public sector. This historical framework discusses two primary themes: the decades of evolution in the federal-state partnership, and the emergence in the last three decades of perinatal regional system policy, and suggests that the structure of the federal-state partnership has encouraged state variation. A survey of state MCH programs was undertaken to clarify their operational and perceived role in promoting quality improvement in perinatal care. Data and information from the survey, along with five illustrative state case studies, demonstrate great variation in how individual state agencies function. State efforts in quality improvement, a process to make things better, have four arenas of activity: policy development and implementation, definition and measurement of quality, data collection and analysis, and communication to affect change. Few state health agencies (through their MCH programs and perinatal staff) are taking action in all four arenas. This analysis concludes that there are improvements MCH programs could implement without significant expansion in their authority or resources and points out that there is an opportunity for states to be more proactive as they have the legal authority and responsibility for assuring MCH outcomes.

The New Hampshire Perinatal Program: twenty years of perinatal outreach education.

OBJECTIVE: To describe 20 years of regional outreach education by the New Hampshire Perinatal Program, its interaction with all 26 community hospitals in the state with maternity services and an additional four in adjoining Vermont. STUDY DESIGN: This paper describes educational initiatives responsive to the needs of perinatal physicians and nurses. The core of the program is the transport conference held annually at each referring hospital in which maternal-fetal and infant referrals are discussed. There are additional community hospital-based programs, programs at convenient locations in the region and medical center conferences and skills programs. RESULTS: The program annually awards 10,000 continuing medical education credits (CME) and nursing contact hours. Evaluation and feedback from all participants is encouraged. New Hampshire has one of the lowest perinatal mortality rates in the county, which reflects in part the accomplishments of the program. CONCLUSION: Perinatal outreach education is a shared responsibility of providers in both the academic center and community hospitals and is necessary to ensure optimal care for mothers and infants.

Parental dreams, dilemmas, and decision-making in cinéma vérité.

Our film Dreams and Dilemmas: Parents and the Practice of Neonatal Care is on its way to meeting its goal of furthering the "Principles for Family Centered Neonatal Care" (Harrison H. Pediatrics 1993;92:643-50) through cinéma vérité depiction of parental involvement in decision-making. Reality-based filmmaking can provide valuable and successful educational material that advances care and understanding. However, there are real practical and ethical concerns such as privacy, consent, and uncertain or unknown future impact on participants. Successful reality-based filmmaking in a complex medical environment such as a neonatal intensive care unit requires careful attention to ways of ensuring full communication between all those involved and efforts to allay participants' anxiety about being portrayed unfavorably. The most important ingredient, however, is the skill and ability of the filmmaker to engender trust.

Neonatal and infant care and outcomes.

A major advance in neonatal care, surfactant replacement therapy, has received wide endorsement and approval after being subject to over 30 clinical trials. Details of clinical application and full impact on outcomes are in the process of being determined. Neonatal outcome data indicate that the focus of improvement in survival now rests primarily on the extremely low birth weight (less than 750 g) infant. There is additional need for clarity of actual survival by gestational age in the less-than-28-week cohort. The differences and limitations of neonatal and obstetric methods of gestational age assessment are important. Significant contributions to our knowledge of problems such as retinopathy of prematurity, syphilis, and infants of diabetic mothers have recently appeared.

A multicenter randomized, placebo-controlled trial of surfactant therapy for respiratory distress syndrome.

We carried out a multicenter randomized, placebo-controlled trial to evaluate the efficacy and safety of surfactant in the treatment of respiratory distress syndrome. The study population was made up of newborn infants weighing 750 to 1750 g who were receiving assisted ventilation with 40 percent or more oxygen. The eligible infants received a single dose of either surfactant (100 mg of phospholipid per kilogram of body weight [4 ml per kilogram]) or an air placebo (4 ml per kilogram), administered into the trachea within eight hours of birth by an investigator not involved in the clinical care of the infant. When compared with the infants who received the placebo (n = 81), the infants who were treated with surfactant (n = 78) had a 0.12 greater average increase in the ratio of arterial to alveolar oxygen tension (P less than 0.0001), a 0.20 greater average decrease in the fractional inspiratory oxygen concentration (P less than 0.0001), and a 0.26-kPa greater average decrease in the mean airway pressure (P less than 0.0001) during the 72 hours after treatment. Pneumothorax was less frequent among the infants treated with surfactant than in the control group (13 percent vs. 37 percent; P = 0.0005). There were no statistically significant differences between the groups in the proportion of infants in each of five ordered clinical-status categories on day 7 (P = 0.08) or day 28 (P = 0.75) after treatment. There were also no significant differences between the groups in the frequency of bronchopulmonary dysplasia, patent ductus arteriosus, necrotizing enterocolitis, or periventricular-intraventricular hemorrhage. In each group, 17 percent of the infants died by day 28. We conclude that treatment with the single-dose surfactant regimen used in this study reduces the severity of respiratory distress during the 72 hours after treatment and decreases the frequency of pneumothorax, but that it does not significantly improve clinical status later in the neonatal period and does not reduce neonatal mortality. Further study of different surfactant regimens and patient-selection criteria will be required to determine whether this initial improvement can be translated into reductions in mortality or serious morbidity.

Personnel in neonatal pediatrics: assessment of numbers and distribution.

There has not been an accurate assessment made of the number of practicing neonatologists, attrition rate of neonatologists, or geographic distribution of neonatologists; therefore, a telephone survey was conducted to assess these issues. The basic conclusion of this study is that numbers and distribution of neonatologists, as well as ratio to patient population, are not deficient or disproportionate when analyzed on a nationwide basis.