The ultimate measure of the quality of any health care system is its ability to rescue the most vulnerable patients in an equitable and fair manner. Perhaps no group is more vulnerable than extremely preterm infants. Despite unprecedented advances in modern neonatal intensive care, extreme prematurity remains a major contributor to infant morbidity and mortality and is a source of substantial fiscal burden on the health care system.1,2 Relatedly, ongoing advances in perinatal medicine have not benefitted every racial and ethnic group to the same degree. Indeed, racial and ethnic disparity in pediatric health outcomes has remained an intransigent problem in the United States such that regardless of the metric used, children of racial and ethnic minority have poorer outcomes than their white peers. In neonatal medicine, Black infants are 50% more likely to be born preterm and twice as likely to be born very preterm than white infants.2,3 Beyond disparities in the rates of preterm births, premature infants of racial and ethnic minority have poorer outcomes compared with their premature white peers. For example, in a recent study, Howell et al4 found that among New York City hospitals, mortality of very preterm infants was highest for Black (32%) and Hispanic (28.1%) infants compared with white infants (22.5%).
Although disparities in the quality of care provided at NICUs to very low birth weight (VLBW) infants are well documented, and Black infants are often cared for in lower-quality NICUs,5,6 a standardized method of comparing NICU quality was previously not available. With the development of Baby–Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR),7 a tool for benchmarking NICUs across the United States, it became possible to compare NICUs by using both a composite quality indicator and the individual process and outcome component measures that compose the Baby-MONITOR quality metric. An earlier study comparing the quality of NICUs across California used individual component scores of Baby-MONITOR. The study revealed that at the population level, African American and Hispanic infants tended to have lower scores on process measures and higher scores on outcome measures of the Baby-MONITOR metric compared with white infants.5 At the NICU level, minimal disparities in care were noted within NICUs of overall lower quality (low composite Baby-MONITOR score). But white infants fared substantially better than African American infants within those NICUs of higher overall quality.
In this issue of Pediatrics, Edwards et al8 extended the findings of the preceding study by examining disparity in the quality of NICU care across participating centers in the United States and specifically focused their analysis on very preterm and VLBW infants. Exploiting data from 2014 to 2019 in the Vermont Oxford Network on a cohort of 169 400 infants born at 22 to 29 weeks’ gestation or with a birth weight of 401 to 1500 g, the authors evaluated quality by race and ethnicity across and within NICUs in the United States. They concluded that compared with white infants, Asian American, Hispanic, African American and American Indian infants all had positive outcome measure scores (survival to hospital discharge, no chronic lung disease, no pneumothorax, greater than median growth velocity). However, African American and American Indian infants had lower process measure scores (any human milk at discharge, no admission hypothermia, antenatal steroid exposure, no health care–associated infection, timely retinal examination) compared with white infants. Relatedly, the investigators also found that even within the same hospitals, African American infants received lower average scores on important markers of quality of care, such as receipt of antenatal steroids and no hypothermia on admission, suggesting that disparity exists in the care provided to infants at the local NICU level.
This report by Edwards et al8 adds to the undeniable body of evidence about disparity in the care and subsequent outcomes of our tiniest tots.9,10 The results should not be surprising given that NICUs are a microcosm of a larger society. Beyond showing disparity in the quality of care delivered to infants of ethnic minority, the authors also highlighted the disparity that exists even within the same NICUs. To this end, the findings by Edwards et al8 raise a number of complex issues. First, simply identifying low-performing NICUs is but a small piece of the puzzle that is racial disparity in health outcomes. If this were the main problem, then we could argue for improving care at all NICUs and ensuring that care is standardized. This approach may provide equality in care. However, we would argue that the documentation of disparity in care within NICUs raises a second issue: what is needed is equity in the care provided to our most vulnerable patients. Equity in care should ensure that personalized care is provided to all children not just on the basis of their clinical variables but with full consideration given to sociocultural and economic background.
The report by Edwards et al8 also forces us to consider a broader (albeit philosophical) issue: although development and use of benchmarking reports to identify racial and ethnic disparity in the quality of care at hospitals is commendable, these instruments are only as good as the people using them. Put simply, we cannot legislate or protocolize our way out of the deep-rooted social problem of systemic racism. Understanding that implicit biases may impact the quality of care we deliver, especially to the smallest and most vulnerable among us, is a vital first step toward dismantling the complex problem of racial and ethnic disparity in the care and outcomes of our children.
Despite the inherent strength of the study by Edwards et al,8 which uses a comprehensive quality score database containing data on nearly 90% of the preterm VLBW infants delivered annually in the United States, certain limitations of the report (beyond those outlined by the authors) must be considered in the interpretation of their results. In the race-specific comparative analyses, the authors did not account for within-NICU clustering of the Baby-MONITOR scores. A positive correlation of the Baby-MONITOR score would exist between neonates from the same NICU, thus creating a cluster. Clustering would violate the assumption of independence of Baby-MONITOR scores between observations. Furthermore, scores obtained from the same NICU across different years would also be correlated. These correlations would bias the estimated SEs and compatibility intervals of the scores. The magnitude of the bias depends on how similar 2 neonates from the same cluster (NICU) are, with greater similarities indicating greater bias. In the present report, Edwards et al8 did not account for these issues with correlation. In future studies using the Baby-MONITOR database, researchers should apply statistical techniques that quantify the degree of intracluster correlation to ensure robustness of the conclusions. Finally, although the Baby-MONITOR provides patient-level quantitative measures of quality, it does not account for the clustering of health care practitioners. Patients receiving care from a particular practitioner may have similar scores, resulting in a positive correlation that biases the SEs and compatibility intervals.
Despite these potential limitations in the analysis, Edwards et al8 add to an important and sobering body of literature describing the racial and ethnic inequities in health care delivery to the most vulnerable among us. Given the prevailing disparity in outcomes across the life span of patients of racial and ethnic minority, there is no better place to begin the journey of equity of care than with the birth of preterm and VLBW infants.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-037622.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.