Neonatal Care in U.S. Doesn't Reflect the Needs

Many regions of U.S. have surplus of neonatologists, study says

WEDNESDAY, May 15, 2002 (HealthDayNews) -- During the last 30 years, there's been an explosion in the number of neonatal intensive care units and neonatologists in the United States.

But the growth has been uneven, with some regions of the country accruing more than four times the number of neonatal beds and neonatologists -- pediatricians with extra training to care for ill newborns -- than other areas.

Which begs the question: Does the current distribution reflect actual need, and is there a real relationship between neonatology resources and mortality?

A new study says the answer is "no" to both questions.

To get to that answer, researchers at Dartmouth College in New Hampshire looked at the number of neonatologists and neonatal intensive care beds in 246 regions served by neonatal intensive care units. They also assessed need as measured by the number of low birth weight babies, multiple births, along with the marital status, age and race of the mothers in each region. And they reviewed premature infant mortality during the first 27 days using birth and death records from the 1995 U.S. Birth Cohort.

The researchers found that areas with what they consider a "very low" supply of neonatologists -- 2.7 per 10,000 births -- had a 7 percent higher mortality rate than areas that had 4.3 neonatologists, also considered a low supply. But once the number of specialists rose beyond that in a region -- the medium was 5.9 -- there appeared to be no further benefit from that supply.

"Neither neonatologists nor beds were distributed in relation to where they were needed, which was striking," notes the lead author of the study, Dr. David Goodman, an associate professor of pediatrics at Dartmouth Medical School. and lead author of the study, which appears in tomorrow's New England Journal of Medicine.

"We were surprised to learn that number of beds made no difference," Goodman adds.

"That suggested, at least on mortality, that there are few areas that are underserved but many areas where there is an ample number and perhaps a surplus," Goodman says.

Dr. Eduardo Bancalari is a professor of pediatrics and director of neonatology at the University of Miami School of Medicine. He says, "I don't think that the results [of the Dartmouth study] are surprising."

"Essentially what they show is when there is a serious shortage of physicians, mortality is higher, but increasing above that level didn't make much of a difference. It's something intuitively you can expect," Bancalari says.

The study authors speculate that the surplus of neonatologists could lead to worse care, rather than better care. For instance, in an area with a large supply of beds, infants with less serious illnesses might be admitted to a neonatal intensive care unit and subjected to unnecessary and invasive tests and treatments.

The situation is also terribly inefficient, experts say.

"At this point, many neonatologists are providing care to the [higher birth weight] kids because the pediatricians are too busy," Bancalari says. "It's an essential service but it's a waste of resources because the neonatologists are overqualified and are doing jobs that could be done by a pediatrician or even a nurse practitioner."

The explosion and uneven distribution of neonatal resources is largely the result of market forces, as more hospitals have added prestigious -- and often lucrative -- neonatal units, the Dartmouth researchers say.

"It's been driven by institutional and market forces without any prospective planning," Goodman says. "The broader interest is how to have healthier newborns, and the best way is to prevent the occurrence in the first place of a premature birth or of a low birth weight baby."

This is something that neonatologists, who enter the picture after the birth, have no influence on.

"We can do all that we want in neonatal intensive care, but we have a fundamental problem we haven't really addressed," Goodman says. "Should [neonatologists] be ever-growing when we have these well-recognized unmet needs that are sometimes more fundamental?"

What to Do: For more information, visit Neonatology on the Web. For recommendations on preventive pediatric health care, see the American Academy of Pediatrics.

SOURCES: David Goodman, M.D., associate professor of pediatrics, Dartmouth Medical School, Hanover, N.H.; Eduardo Bancalari, M.D., professor of pediatrics and director of neonatology, University of Miami School of Medicine, Miami; May 16, 2002, New England Journal of Medicine
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