title: The Association of Level of Care With NICU Quality.
abstract: BACKGROUND
  Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.
  
  
  METHODS
  We conducted a cross-sectional analysis of 21,051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.
  
  
  RESULTS
  Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.
  
  
  CONCLUSIONS
  The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California; profit@stanford.edu.
authors.forename: Jochen
authors.initials: J
authors.lastname: Profit
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California;
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Gould
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California;
authors.forename: Mihoko
authors.initials: M
authors.lastname: Bennett
authors.affiliation: Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina;
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Goldstein
authors.affiliation: Department of Applied Mathematics and Statistics, Baskin School of Engineering, University of California, Santa Cruz, California; eBay Research Laboratories, San Jose, California; and.
authors.forename: David
authors.initials: D
authors.lastname: Draper
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; Veteran's Affairs Palo Alto Health Care System, Palo Alto, California.
authors.forename: Ciaran S
authors.initials: CS
authors.lastname: Phibbs
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California;
authors.forename: Henry C
authors.initials: HC
authors.lastname: Lee
mesh_terms: D002140:California; D003430:Cross-Sectional Studies; D006801:Humans; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal / Q000592:standards*; D017063:Outcome Assessment, Health Care; D019984:Quality Indicators, Health Care