Multilevel social factors and NICU quality of care in California

Socioeconomic disparities in the postnatal growth of preterm infants: a systematic review

OBJECTIVE

To determine the effect of parental socioeconomic status (SES) on the postnatal growth of preterm infants.

METHODS

A systematic review (PROSPERO registration CRD42020225714) of original articles from Medline, Embase, CINAHL Plus and Web of Science published 1946-2023 was undertaken. Studies were included if they reported anthropometric growth outcomes for preterm infants according to parental SES. Data extraction and assessments of bias and health equity impact were conducted using custom-designed forms.

RESULTS

A narrative synthesis of twelve included studies was performed. Most infants were moderate to late preterm. The settings, growth outcomes, timings of growth measurement, and SES measures were heterogenous. Six studies demonstrated an adverse effect of low parental SES on the extrauterine growth of preterm infants, five studies showed no effect, and one study showed a potentially beneficial effect. All studies had a high risk of bias, especially confounding and selection bias. The health equity impact of included studies was largely negative.

CONCLUSION

Limited and low-quality evidence suggests that socioeconomic minoritisation may adversely impact the growth of preterm infants, thereby widening existing socioeconomic health inequities. Observational studies informed by theorisation of the mechanistic pathways linking socioeconomic minoritisation to adverse postnatal growth are required to identify targets for intervention.

IMPACT

Limited evidence suggests low parental socioeconomic status (SES) adversely affects the postnatal growth of preterm infants across different settings. Early growth of preterm infants predicts neurodevelopmental outcomes and the risk of cardiovascular and metabolic disease in adulthood. Systematic screening of over 15,000 articles identified only twelve studies which reported postnatal growth outcomes for preterm infants according to parental SES. The health equity impact of the included studies was systematically assessed, and found to be negative overall. This study highlights limitations in existing evidence on the association between parental SES and postnatal growth, and delineates avenues for future research.

A novel approach to patient portal activation data to power equity improvements

BACKGROUND

There are significant disparities in access and utilization of patient portals by age, language, race, and ethnicity.

MATERIALS AND METHODS

We developed ambulatory and inpatient portal activation equity dashboards to understand disparities in initial portal activation, identify targets for improvement, and enable monitoring of interventions over time. We selected key metrics focused on episodes of care and filters to enable high-level overviews and granular data selection to meet the needs of health system leaders and individual clinical units.

RESULTS

In addition to highlighting disparities by age, preferred language, race and ethnicity, and insurance payor, the dashboards enabled development and monitoring of interventions to improve portal activation and equity.

DISCUSSION AND CONCLUSIONS

Data visualization tools that provide easily accessible, timely, and customizable data can enable a variety of stakeholders to understand and address healthcare disparities, such as patient portal activation. Further institutional efforts are needed to address the persistent inequities highlighted by these dashboards.

Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study

OBJECTIVE

Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explored expert opinion on their etiology, potential solutions, and the ability of health equity dashboards to meaningfully capture NICU disparities.

STUDY DESIGN

We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis.

RESULT

We identified three sources of disparity: interpersonal bias, care process and institutional barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited, because clinical metrics do not account for many of the aforementioned sources of disparities.

CONCLUSION

Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

Quality, outcome, and cost of care provided to very low birth weight infants in California

OBJECTIVE

To examine association of costs with quality of care and patient outcome across hospitals in California.

METHODS

Retrospective study of very low birth weight (VLBW) births from 2014-2018 linking birth certificate, hospital discharge records and clinical data. Quality was measured using the Baby-MONITOR score. Clinical outcome was measured using survival without major morbidity (SWMM). Hierarchical generalized linear models, adjusting for clinical factors, were used to estimate risk-adjusted measures of costs, quality, and outcome for each hospital. Association between these measures was evaluated using Pearson correlation coefficient.

RESULTS

In total, 15,415 infants from 104 NICUs were included. Risk-adjusted Baby-MONITOR score, SWMM rate, and costs varied substantially. There was no correlation between risk-adjusted cost and Baby-MONITOR score (r = 0, p = 0.998). Correlation between risk-adjusted cost and SWMM rate was inverse and not significant (r = -0.07, p = 0.48).

CONCLUSIONS

With the metrics used, we found no correlation between cost, quality, and outcomes in the care of VLBW infants.

Understanding the Domains of Experiences of Black Mothers with Preterm Infants in the United States: A Systematic Literature Review

OBJECTIVE

To report the domains of Black mothers' experiences with preterm infants in the neonatal intensive care unit (NICU) and to determine the frameworks used.

METHODS

A systematic review of the literature using the PRISMA guideline was performed. An electronic database search of published literature between 2000 and 2022 was conducted based on predetermined search terms and parameters.

RESULTS

Twenty-seven articles met the inclusion and exclusion criteria. Eleven articles focused on feeding practices, ten reported on nursing/maternal care experiences, five reported mental health/social support, and only one focused on mother-infant relationships. Only five papers reported using any frameworks, comprising grounded theory framework (n = 2), theory of planned behavior (n = 1), research justice framework (n = 1), and the patient and public engagement protocol (n = 1).

DISCUSSION

A holistic approach to understanding the multifactorial experiences of Black mothers with preterm infants needs to be socio-culturally competent to ensure their diverse intersections and identities are accurately represented and understood. Rigorous research at the intersection of Black maternal health and the NICU hold promises for advancing maternal health equity in the United States.

Understanding Facilitators and Barriers to Providing Equity-Oriented Care in the NICU

The current study examined the use of immersive technology as a way to improve access to high-quality interpersonal breastfeeding interactions in an undergraduate clinical lactation course. In particular, we investigated the impact of immersive consultation videos and related activities on student self-efficacy, motivational beliefs, and perceived skill level. Results indicate that usability was high, with participants rating videos, interactives, and activities positively. Although no significant improvements in their level of interest or perceived skill were found, students did report a significant increase in self-efficacy and their perceived ability to meet the course learning objectives. Our results demonstrate that high-quality immersive videos can be an important learning tool for teaching clinical skills when access to direct patient care is limited or absent.

Disparities and Equity Dashboards in the Neonatal Intensive Care Unit: A Qualitative Study of Expert Perspectives

Objective

Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explore expert opinion on their root causes, potential solutions, and the ability of health equity dashboards to meaningfully address NICU disparities.

Study Design

We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis.

Result

Participants identified three sources of disparity: interpersonal bias, care process barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited because clinical metrics do not account for many of the aforementioned sources of disparities.

Conclusion

Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

Measuring Equity for Quality Improvement

Applying an equity lens to quality improvement (QI) by collecting, reviewing, and using data that measure health disparities helps identify whether QI interventions improve outcomes evenly and equally across the population or have a greater impact in an advantaged or disadvantaged group. Methodological issues inherent in measuring disparities include appropriately selecting data sources; ensuring reliability and validity of equity data; choosing a suitable comparison group; and understanding between-group variation. The integration and utilization of QI techniques to promote equity is dependent on meaningful measurement to develop targeted interventions and provide a means of ongoing real-time assessment.

Environmental influences on child health outcomes: cohorts of individuals born very preterm

The National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) Program was designed to address solution-oriented research questions about the links between children's early life environment and their risks of pre-, peri-, and post-natal complications, asthma, obesity, neurodevelopmental disorders, and positive health. Children born very preterm are at increased risk for many of the outcomes on which ECHO focuses, but the contributions of environmental factors to this risk are not well characterized. Three ECHO cohorts consist almost exclusively of individuals born very preterm. Data provided to ECHO from cohorts can be used to address hypotheses about (1) differential risks of chronic health and developmental conditions between individuals born very preterm and those born at term; (2) health disparities across social determinants of health; and (3) mechanisms linking early-life exposures and later-life outcomes among individuals born very preterm. IMPACT: The National Institutes of Health's Environmental Influences on Child Health Outcomes Program is conducting solution-oriented research on the links between children's environment and health. Three ECHO cohorts comprise study participants born very preterm; these cohorts have enrolled, to date, 1751 individuals born in 14 states in the U.S. in between April 2002 and March 2020. Extensive data are available on early-life environmental exposures and child outcomes related to neurodevelopment, asthma, obesity, and positive health. Data from ECHO preterm cohorts can be used to address questions about the combined effects of preterm birth and environmental exposures on child health outcomes.

What Black Mothers with Preterm Infants Want for Their Mental Health Care: A Qualitative Study

Title

"I think that some culturally sensitive mental health information could have been provided": What Black mothers with preterm infants want for their mental health care: A qualitative study.

Background

In the United States, preterm birth (PTB) rates in Black women are 50% higher than in non-Hispanic White and Hispanic mothers. Existing discriminatory sociohistorical and contemporary health care practices have been linked to the alarmingly higher rates of PTB among Black families. While it is well-known that PTB is associated with increased mental health (MH) problems, Black women experience elevated MH burdens due to inequities along the care continuum in the neonatal intensive care unit (NICU). Consequently, culturally responsive MH care holds promises to achieve maternal MH equity. This study aimed to explore the available MH services and resources in the NICU for Black mothers with preterm infants. We also sought to discover potential recommendations and strategies for MH programs through a cultural lens.

Materials and Methods

Semistructured interviews were conducted with Black mothers with preterm infants using a Grounded Theory approach embedded in the Black feminist theory.

Results

Eleven mothers who gave birth to a preterm infant between 2008 and 2021 participated in this study. Eight women reported not receiving MH services or resources in the NICU. Interestingly, of the three mothers who received MH referrals/services, two did so one-year postbirth and did not utilize the services. Three main themes emerged: stress and the NICU experience, coping mechanisms, and culturally appropriate MH care with diverse providers are needed. Overall, our finds suggest that MH care is not prioritized in the NICU.

Conclusion

Black mothers with preterm infants encounter numerous negative and stressful experiences that exacerbate their MH during and beyond the NICU. However, MH services in the NICU and follow-up services are scarce. Mothers in this study endorsed creating culturally appropriate MH programs that addresses their unique intersections.

Parental experiences in neonatal intensive care unit in Ethiopia: a phenomenological study

INTRODUCTION

Neonatal intensive care unit is important to save the lives of a sick neonate; however, parents are challenged by several stressful conditions during their stay. Therefore, this study aimed to explore the lived experiences of parents in neonatal intensive care units in Ethiopia.

METHODS

We used a phenomenological study design. The data were collected using an in-depth interview method from purposively selected parents. In addition, we followed a thematic analysis approach and used Open Code Software Version 4.02 to process the data.

RESULTS

In this study, 18 parents were interviewed. The researchers have identified six themes. Parents complained of psychological problems like anxiety, stress, worries, hopelessness, and a state of confusion. In addition, anger, crying, sadness, frustration, dissatisfaction, regret, disappointment, feeling bad, self-blaming, nervousness, disturbance, and lack of self-control were major emotional problems raised by the parents. Parents expressed that health care providers showed indiscipline, lack of commitment, and uncooperative behaviour. Likewise, shortage of medicines, money, and limited time to visit their neonates were the other concerns of many parents. At the same time, parents were provided minimal information and limited cooperation from health care providers.

CONCLUSION

Parents whose infants admitted to the NICU were suffered from various psychological and emotional problems. Researchers recommend that health care providers should be supported parents with psycho-emotional problems, strengthen parents-healthcare workers' interaction, and scale up neonatal intensive care unit services to the primary health care centres.KEY MESSAGESParents whose infants admitted to the NICU were suffered from psychological and emotional problems.Poor NICU environment, shortage of equipment, long hospital stay, the presence of pandemic COVID-19, and lack of parental involvement in the care were identified barriers that affected parents' stay.

Unequal care: Racial/ethnic disparities in neonatal intensive care delivery

Advances in neonatal intensive care have improved outcomes for preterm newborns, but significant racial/ethnic disparities persist. Neonatal disparities have their origin in a complex set of factors that include systemic racism and structural disadvantages endured by minority families, but differential quality of care in the neonatal intensive care unit (NICU) remains an important and modifiable source of disparity. NICU care has been shown to be segregated and unequal: Black and Hispanic infants are more likely to be cared for in lower quality NICUs and may receive worse care within a NICU. To eliminate disparities in care and outcomes, it is important to identify and address the mechanisms that lead to lower quality care for minority preterm infants. In this review, we identify improvements in both technical (clinical) and relational (engaging and supporting families) processes of care as critical to better outcomes for minority infants and families.