Billions could be saved if babies discharged when NICU-level care no longer needed

Hospitals could save hundreds of millions of dollars if they moved patients out of neonatal intensive care units (NICUs) when that care becomes clinically unnecessary, researchers found.

According to a study of infants admitted to NICUs over a period of 6 years, almost a quarter of total NICU days represented time beyond which patients in the NICU no longer received NICU-level care.

The study, by Adam B. Goldin, MD, MPH, School of Medicine, University of Washington and Seattle Children’s Hospital, and colleagues, was published in Pediatrics.

Neonatal intensive care is one of the most expensive components of healthcare in the United States, the cost of which is determined to a large extent by NICU length of stay. And, while length of stay depends on medical-level characteristics, such as prematurity, ventilator dependence, and the need for constant monitoring, nonmedical factors are at play as well.

“Patients and families or care providers must often balance the competing desire to make the transition out of the NICU versus the desire to remain in the NICU for fear that their infant is not yet medically stable enough to transition out safely,” Goldin and colleagues wrote. “Health care providers must balance the parental perspective against their own clinical judgment to determine when it is safe to discharge.”

This balancing act, according to the authors, is likely to lead to a wide variation in determining when patients are ready to be discharged from NICUs. Furthermore, they suggested it will likely result in many children remaining in the NICU longer than clinical necessary, considering the likelihood that doctors and parents will err on the side of caution when determining readiness for NICU discharge.

“Our aim for this study was to identify a resource use inflection point (RU-IP) beyond which NICU patients received minimal NICU-level billable care,” wrote Goldin and colleagues, adding that the ability to identify an RU-IP could save hospital days in the NICU and result in substantial savings.

This retrospective study included administrative data from hospitals contributing to the Pediatric Health Information System (PHIS) database, which includes daily clinical and resource use data from inpatient, emergency, ambulatory surgery, and observation encounters at 48 tertiary care children’s hospitals in the United States.

The authors defined the RU-IP as the day of a NICU stay on which daily charges dropped to <10% of the first-day NICU room cost, and remained there through discharge.

The authors identified 80,821 patients hospitalized in NICUs across 43 children’s hospitals between 2010 and 2015. They found that the vast majority of these patients remained in the NICU after RU-IP was reached (80.6%), and that 24.3% of NICU days occurred after this point.

These extra days in the NICU represented almost a half a billion dollars in costs for the 43 hospitals in this study, Goldin and colleagues calculated. Considering the significant variation among hospitals regarding the percentage of patients who reached an RU-IP (33.1 to 98.7%) in this study, “addressing this variation could provide a potential cost savings of > $483 million for the healthiest patients in the NICU among only 43 hospitals and far greater cost savings if generalized across NICUs nationally,” they added.

“These data reveal the need to identify best practices in NICUs that consistently discharge infants more efficiently,” concluded Goldin and colleagues. “Once these best practices are known, they can be disseminated to offer guidance in creating quality improvement projects to provide safer and more predictable care across hospitals for patients of all socioeconomic statuses.”

In a commentary accompanying the study, John A.F. Zupancic, MD, ScD, Beth Israel Deaconess Medical Center, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, and colleagues wrote that decisions on whether to transfer or discharge an infant from a NICU is a complex question.

While clinicians and policy makers understand NICU care is expensive, they wrote, there is less appreciation for the fact that NICU costs are quantitatively and qualitatively different from the costs in other areas of critical care. “Undertaking a new, quantitative phase of thinking about length and locus of stay will not be an easy undertaking,” added Zupancic and colleagues. “Such an undertaking, however, is critical for us to be both responsible stewards of the precious resources we have for pediatric care and clinicians responsible for the safety of these vulnerable infants and their families.”

  1. Many infants remain in neonatal intensive care units (NICUs) past the point at which that high-level care is clinically necessary.

  2. Hospitals could achieve substantial cost savings by safely and efficiently moving infants out of NICUs.

Michael Bassett, Contributing Writer, BreakingMED™

Goldin and Zuancic did not disclose any relevant relationships.

Cat ID: 138

Topic ID: 85,138,502,791,730,41,138,192,925