Characteristics of High Versus Low-Performing Hospitals for Very Preterm Infant Morbidity and Mortality

Overview

Journal J Pediatr X

Specialty Pediatrics

Date 2024 Jan 8

PMID 38186750

Authors

Shoshanna Sofaer

Kimberly B Glazer

Amy Balbierz

Anna Kheyfets

Jennifer Zeitlin

Elizabeth A Howell

Affiliations

Soon will be listed here.

Abstract

Objective: To ascertain organizational attributes, policies, and practices that differentiate hospitals with high versus low risk-adjusted rates of very preterm neonatal morbidity and mortality (NMM).

Methods: Using a positive deviance research framework, we conducted qualitative interviews of hospital leadership and frontline clinicians from September-October 2018 in 4 high-performing and 4 low-performing hospitals in New York City, based on NMM measured in previous research. Key interview topics included NICU physician and nurse staffing, professional development, standardization of care, quality measurement and improvement, and efforts to measure and report on racial/ethnic disparities in care and outcomes for very preterm infants. Interviews were audiotaped, professionally transcribed, and coded using NVivo software. In qualitative content analysis, researchers blinded to hospital performance identified emergent themes, highlighted illustrative quotes, and drew qualitative comparisons between hospital clusters.

Results: The following features distinguished high-performing facilities: 1) stronger commitment from hospital leadership to diversity, quality, and equity; 2) better access to specialist physicians and experienced nursing staff; 3) inclusion of nurses in developing clinical policies and protocols, and 4) acknowledgement of the influence of racism and bias in healthcare on racial-ethnic disparities. In both clusters, areas for improvement included comprehensive family engagement strategies, care standardization, and reporting of quality data by patient sociodemographic characteristics.

Conclusions And Relevance: Our findings suggest specific organizational and cultural characteristics, from hospital leadership and clinician perspectives, that may yield better patient outcomes, and demonstrate the utility of a positive deviance framework to center equity in quality initiatives for high-risk infant care.

References

Howell E, Ahmed Z, Sofaer S, Zeitlin J . Positive Deviance to Address Health Equity in Quality and Safety in Obstetrics. Clin Obstet Gynecol. 2019; 62(3):560-571. PMC: 6988184. DOI: 10.1097/GRF.0000000000000472. View

Howell E, Sofaer S, Balbierz A, Kheyfets A, Glazer K, Zeitlin J . Distinguishing High-Performing From Low-Performing Hospitals for Severe Maternal Morbidity: A Focus on Quality and Equity. Obstet Gynecol. 2022; 139(6):1061-1069. PMC: 9710203. DOI: 10.1097/AOG.0000000000004806. View

Bailey Z, Krieger N, Agenor M, Graves J, Linos N, Bassett M . Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017; 389(10077):1453-1463. DOI: 10.1016/S0140-6736(17)30569-X. View

Profit J, Sharek P, Cui X, Nisbet C, Thomas E, Tawfik D . The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care. J Patient Saf. 2018; 16(4):e310-e316. PMC: 6504623. DOI: 10.1097/PTS.0000000000000546. View

Litt J, McCormick M . Preterm infants are less likely to have a family-centered medical home than term-born peers. J Perinatol. 2018; 38(10):1391-1397. DOI: 10.1038/s41372-018-0180-1. View

Rogowski J, Horbar J, Staiger D, Kenny M, Carpenter J, Geppert J . Indirect vs direct hospital quality indicators for very low-birth-weight infants. JAMA. 2004; 291(2):202-9. DOI: 10.1001/jama.291.2.202. View

Mehra R, Boyd L, Ickovics J . Racial residential segregation and adverse birth outcomes: A systematic review and meta-analysis. Soc Sci Med. 2017; 191:237-250. DOI: 10.1016/j.socscimed.2017.09.018. View

Howell E, Zeitlin J . Improving hospital quality to reduce disparities in severe maternal morbidity and mortality. Semin Perinatol. 2017; 41(5):266-272. PMC: 5592149. DOI: 10.1053/j.semperi.2017.04.002. View

Tawfik D, Thomas E, Vogus T, Liu J, Sharek P, Nisbet C . Safety climate, safety climate strength, and length of stay in the NICU. BMC Health Serv Res. 2019; 19(1):738. PMC: 6805564. DOI: 10.1186/s12913-019-4592-1. View

10.

Tawfik D, Profit J, Lake E, Liu J, Sanders L, Phibbs C . Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health Serv Res. 2019; 55(2):190-200. PMC: 7080382. DOI: 10.1111/1475-6773.13249. View

11.

Bradley E, Holmboe E, Mattera J, Roumanis S, Radford M, Krumholz H . A qualitative study of increasing beta-blocker use after myocardial infarction: Why do some hospitals succeed?. JAMA. 2001; 285(20):2604-11. DOI: 10.1001/jama.285.20.2604. View

12.

Green C, Johnson J, Vladutiu C, Manuck T . The association between maternal and paternal race and preterm birth. Am J Obstet Gynecol MFM. 2021; 3(4):100353. PMC: 8555705. DOI: 10.1016/j.ajogmf.2021.100353. View

13.

Janevic T, Zeitlin J, Egorova N, Hebert P, Balbierz A, Howell E . Neighborhood Racial And Economic Polarization, Hospital Of Delivery, And Severe Maternal Morbidity. Health Aff (Millwood). 2020; 39(5):768-776. PMC: 9808814. DOI: 10.1377/hlthaff.2019.00735. View

14.

Ravi D, Tawfik D, Sexton J, Profit J . Changing safety culture. J Perinatol. 2020; 41(10):2552-2560. DOI: 10.1038/s41372-020-00839-0. View

15.

Phibbs C, Baker L, Caughey A, Danielsen B, Schmitt S, Phibbs R . Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med. 2007; 356(21):2165-75. DOI: 10.1056/NEJMsa065029. View

16.

Hsieh H, Shannon S . Three approaches to qualitative content analysis. Qual Health Res. 2005; 15(9):1277-88. DOI: 10.1177/1049732305276687. View

17.

Lasswell S, Barfield W, Rochat R, Blackmon L . Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA. 2010; 304(9):992-1000. DOI: 10.1001/jama.2010.1226. View

18.

Mehra R, Keene D, Kershaw T, Ickovics J, Warren J . Racial and ethnic disparities in adverse birth outcomes: Differences by racial residential segregation. SSM Popul Health. 2019; 8:100417. PMC: 6545386. DOI: 10.1016/j.ssmph.2019.100417. View

19.

Profit J, Kowalkowski M, Zupancic J, Pietz K, Richardson P, Draper D . Baby-MONITOR: a composite indicator of NICU quality. Pediatrics. 2014; 134(1):74-82. PMC: 4067636. DOI: 10.1542/peds.2013-3552. View

20.

Lake E, Staiger D, Horbar J, Cheung R, Kenny M, Patrick T . Association between hospital recognition for nursing excellence and outcomes of very low-birth-weight infants. JAMA. 2012; 307(16):1709-16. PMC: 3640284. DOI: 10.1001/jama.2012.504. View