Dartmouth Atlas Study Questions NICU Use

Researchers suggest that the NICU growth over the past three decades may be driven more by hospital competition than by medical need.

Nearly half of all newborns admitted to the nation's neonatal intensive care units are of normal birth weight, according to a new study from The Dartmouth Atlas.

This is happening, the researchers found, while at the same time 15% of very low birth weight babies (less than 1500 grams/3.3 pounds) don't get care in Level III or IV NICUs.

"We should not spare a dollar in providing the best care for newborns. But spending more doesn't help infants if they could receive the care they need in a maternity unit or home with their mothers," said principal author David C. Goodman, MD, of The Dartmouth Institute for Health Policy & Clinical Practice.

“It is very troubling that such a valuable and expensive health care resource is not distributed where it is needed," he said.

Three decades ago, most NICU newborns were of low birth weight. In 2017, normal birthweight babies accounted for 48% of NICU admissions, the researchers found.

From 1995-2013, the number of NICU beds across the nation grew 65% from 1995-2013, and the numbers of neonatologists increased 75%, even as the numbers of newborns remained stable.

The researcher said the increasing numbers of NICU beds and neonatologists has led to increasing numbers of lower risk newborns being admitted to NICUs. 

The Dartmouth study suggests that the "high-margin" NICU boom may be driven more by hospital competition than by medical need.

The researchers cited a 2013 March of Dimes study which found that hospitalization costs average $54,000 for preterm infants. They also cited a 2010 article in Managed Care magazine which reported that NICUs account for 75% of all dollars spent for newborn care.

"This is a strong financial incentive for further building and expansion of NICUs and for keeping those beds full, potentially leading to overuse of services, especially in lower-risk newborns," the researchers said.

Even with the proliferation of NICUs, however, access to specialized neonatal care has been uneven. The researchers found that the growth of NICU beds has lagged in areas that most need those services.  

"Regions of the country with a high proportion of premature newborns, or other factors related to newborn illness, such as maternal education level or the rate of cesarean sections, are not the regions with higher supply of NICU beds or neonatologists," they said.

"Regardless of the infant population we studied, newborn and NICU care varied markedly across regions and hospitals," the researchers said. "Little of the variation was explained by differences in newborn health needs. The care that similar newborns receive is strikingly different in one hospital compared to another."  

In addition to being a poor use of resources, the Dartmouth researchers said that the unnecessary use of NICUs poses potential threats to low-risk newbornds.

"Those with less severe illnesses have less to gain from intensive care yet are still exposed to the possible adverse effects of a hospital setting designed primarily for critical care," the report states.