title: Quality Indicators but Not Admission Volumes of Neonatal Intensive Care Units Are Effective in Reducing Mortality Rates of Preterm Infants.
abstract: OBJECTIVE
  To investigate how two different strategies to form larger neonatal intensive care units (NICU) impact neonatal mortality rates.
  
  
  METHODS
  Cross-sectional study modeling admission volumes and mortality rates of 177,086 VLBW infants aggregated into 862 NICUs. Cumulative 3-year data was abstracted from Vermont Oxford Network. The model simulated a reduction in number of NICUs by stepwise exclusion using either admission volume (VOL) or quality (QUAL) cut-offs. After randomly redirecting infants of excluded to remaining NICUs resulting system mortality rates were calculated with and without adjusting for effects of experience levels (EL) using published data to reflect effects of different team-to-patient exposure.
  
  
  RESULTS
  The quality-based strategy is more effective in reducing mortality; while VOL alone was not able to reduce system mortality, QUAL already achieved a 5% improvement after reducing 8% of NICUs and redirecting 6% of infants. Including "EL", a 5% improvement of mortality was achieved by reducing 77% (VOL) vs. 7% (QUAL) of NICUs and redirecting 54% (VOL) vs. 5% (QUAL) of VLBW infants, respectively.
  
  
  CONCLUSIONS
  While a critical number of admissions is needed to maintain skills this study emphasizes the importance of including quality parameters to restructure neonatal care. The findings can be generalized to other medical fields.
authors: Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada.
authors: Niels
authors: N
authors: Rochow
authors: Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada.
authors: Erin
authors: http://orcid.org/0000-0003-3512-732X
authors: E
authors: Landau-Crangle
authors: Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada.
authors: Sauyoung
authors: S
authors: Lee
authors: Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada.
authors: Holger
authors: H
authors: Schünemann
authors: Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada.
authors: Christoph
authors: C
authors: Fusch
mesh_terms: D003430:Cross-Sectional Studies; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D007234:Infant, Premature; D019102:Infant, Very Low Birth Weight; D015931:Intensive Care, Neonatal / Q000706:statistics & numerical data*; D009026:Mortality; D010343:Patient Admission / Q000706:statistics & numerical data; D019984:Quality Indicators, Health Care; D014707:Vermont