The Resource Use Inflection Point for Safe NICU Discharge Adam B. Goldin, MD, MPH,a,b Mehul V. Raval, MD, MS,d Cary W. Thurm, PhD,e Matt Hall, PhD,e Zeenia Billimoria, MD,c Sandra Juul, MD, PhD,c Loren Berman, MDf

OBJECTIVES: (1) To identify a resource use inflection point (RU-IP) beyond which patients in the abstract NICU no longer received NICU-level care, (2) to quantify variability between hospitals in patient-days beyond the RU-IP, and (3) to describe risk factors associated with reaching an RU-IP. METHODS: We evaluated infants admitted to any of the 43 NICUs over 6 years. We determined the day that each patient’s total daily standardized cost was ,10% of the mean first-day NICU room cost and remained within this range through discharge (RU-IP). We compared days beyond an RU-IP, the total standardized cost of hospital days beyond the RU-IP, and the percentage of patients by hospital beyond the RU-IP. RESULTS: Among 80 821 neonates, 80.6% reached an RU-IP. In total, there were 234 478 days after the RU-IP, representing 24.3% of the total NICU days and $483 281 268 in costs. Variability in the proportion of patients reaching an RU-IP was 33.1% to 98.7%. Extremely preterm and very preterm neonates, patients discharged with home health care services, or patients receiving mechanical ventilation, extracorporeal membrane oxygenation, or feeding support exhibited fewer days beyond the RU-IP. Conversely, receiving methadone was associated with increased days beyond the RU-IP. CONCLUSIONS: Identification of an RU-IP may allow health care systems to identify readiness for discharge from the NICU earlier and thereby save significant NICU days and health care dollars. These data reveal the need to identify best practices in NICUs that consistently discharge infants more efficiently. 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.

’ aDivision of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington; bDepartment WHAT S KNOWN ON THIS SUBJECT: Variation in health of General Surgery and cDivision of Neonatology, Department of Pediatrics, School of Medicine, University of care is known to increase cost and decrease quality and Washington, Seattle, Washington; dDivision of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie safety. Inadequate anticipation of parental needs and Children’s Hospital of Chicago, Chicago, Illinois; eChildern’s Hospital Association, Overland Park, Kansas; and education at discharge from the NICU, balanced against f Department of Pediatric Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware physician readiness to discharge infants, can lead to Dr Goldin conceptualized and designed the study, participated in the analysis and interpretation of variation and longer length of stay. the data, drafted the initial manuscript, and reviewed and revised the manuscript for important WHAT THIS STUDY ADDS: With our findings, we identify intellectual content; Drs Raval and Berman conceptualized and designed the study, participated in significant variation between freestanding children’s the analysis and interpretation of the data, and reviewed and revised the manuscript for important hospitals. Addressing this variation could provide intellectual content; Drs Thurm and Hall conceptualized and designed the study, accessed the data, a potential cost savings of .$483 million for the conducted the initial analyses, participated in the analysis and interpretation of the data, and reviewed and revised the manuscript for important intellectual content; Drs Billimoria and Juul healthiest patients in the NICU among only 43 hospitals participated in the analysis and interpretation of the data and reviewed and revised the manuscript and far greater cost savings if generalized across NICUs for important intellectual content; and all authors approved the final manuscript as submitted and nationally. agree to be accountable for all aspects of the work. To cite: Goldin AB, Raval MV, Thurm CW, et al. The DOI: https://doi.org/10.1542/peds.2019-3708 Resource Use Inflection Point for Safe NICU Discharge. Pediatrics. 2020;146(2):e20193708

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 2, July 2020:e20193708 ARTICLE Neonatal intensive care is among the received minimal NICU-level billable freestanding children’shospital most expensive aspects of health care care. If infants were stratified into 2 NICUs (N = 167 337) abstracting in the United States. A significant statistically adjusted groups on the data into the PHIS data set. All NICUs component of total NICU cost is basis of whether the RU-IP was are classified as level III or IV given length of stay (LOS), which is reached before discharge, the that each care for patients who are at determined in part by patient-level assumption could be made that those ,32 weeks’ gestation. Data from 5 medical characteristics: prematurity, who never reached the RU-IP before hospitals were excluded before ventilator dependence, need for discharge were being discharged performing the analysis because of constant monitoring, temperature more efficiently. To support this known data quality issues with control, and feeding dependence, hypothesis, we also sought to detailed resource use in these – among other factors.1 3 Some quantify the variability between specifichospitals(n =16102). portion of NICU LOS, however, is hospitals in terms of the number of Because our aim was to study likely related to nonmedical factors days patients remain in the NICU characteristics at the time of often guided by individual and beyond the RU-IP. Identification of an transition from the NICU to either institutional historical practice RU-IP may allow health care systems home or a lower level of care, we patterns rather than evidence. to identify readiness for discharge excluded neonates who died during Patients and families or care from the NICU earlier and thereby the admission (n = 6377), had providers must often balance the save hospital days and health care unknown discharge status (n = competing desire to make the dollars. 1248), or were discharged to hospice transition out of the NICU versus the care (n = 73). To minimize patient- desire to remain in the NICU for fear related variability and confounding METHODS that their infant is not yet medically in the evaluation of LOS, we decided stable enough to transition out Data Source a priori to simplify the study safely.4 Health care providers must population and exclude patients with For this retrospective study we used balance the parental perspective complex chronic conditions (CCCs) administrative data between 2010 against their own clinical judgment (n = 62 716), defined by Feudtner and 2015 from hospitals 5–8 to determine when it is safe to et al as any medical condition that contributing to the Pediatric Health discharge. This balance between can be expected to last ∼12 months Information System (PHIS) perceptions and comfort of the (unless death intervenes) and to database. Children’sHospital patient families and that of the involve either several different organ Association (Lenexa, KS) maintains health care providers is likely to lead systems or 1 organ system enough the PHIS database, which includes to variability in determining to require specialty pediatric care daily clinical and resource use data readiness for discharge when NICUs and some potential period of (pharmacy, imaging, laboratory, do not have standardized discharge hospitalization in a tertiary care room and board, and supplies) from criteria. center. inpatient, emergency, ambulatory Under the assumption that most surgery, and observation encounters Daily Resource Use ’ people tend to err on the side of safer at 48 tertiary care children s We defined the RU-IP as the hospital conservative decision-making when hospitals in the United States. The day that a patient’s total daily determining readiness for discharge data are subject to numerous standardized cost fell within from the NICU, we hypothesize that validity and reliability checks before a percentage of the mean first-day many children remain hospitalized incorporation into the database, and NICU room cost and remained within fi longer than clinically necessary. If this data are deidenti ed at the time of this range until the last 2 days of the is true, we expect the daily cost of submission to the PHIS. Data hospitalization. Patients determined patients in the NICU to taper along warehouse function is provided by to have met this cost criterion were with the majority of high-cost critical Truven Health Analytics (Ann Arbor, determined to have reached the RU- interventions occurring early in the MI). The study was reviewed and IP. To identify the most appropriate hospitalization. As patients stabilize approved by the Institutional cost to be used to determine the RU- ’ and are safe for transition to a lower- Review Board of Seattle Children s IP, we first graphed the percentage of level inpatient unit or to the Hospital. patients who would reach the RU-IP outpatient environment, there would against all percentages between 0% be fewer billable events over time. Study Population and Setting and 30% of the mean cost (Fig 1). Our aim for this study was to identify We included neonates ,7 days of age This graph supported our prediction a resource use inflection point admitted between January 2010 and that as the percentage greater than (RU-IP) beyond which NICU patients December 2015 to any of the 48 the mean NICU cost increased, the

Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 GOLDIN et al beyond the RU-IP. Covariates included level of prematurity, yearly case volume, race and/or ethnicity, payer type, and disposition. Medical covariates included mechanical ventilation, feeding support, extracorporeal membrane oxygenation (ECMO), and methadone use. Prematurity was considered carefully in our model because many patients remain in the NICU until they reach term status.10 NICU LOS was defined as LOS in the NICU (as opposed to total LOS). Readmission and emergency department (ED) visits were defined as returns to the index hospital. FIGURE 1 Percentage of the entire cohort reaching the RU-IP within a percentage margin of the admission Statistical Analysis room cost. Categorical variables were summarized by using frequencies and percentage of patients reaching the many patients were receiving percentages. Continuous variables RU-IP would increase. We identified expensive treatments, such as were summarized by using medians a change in the slope between 10% immunizations and feeding-tube and interquartile ranges (IQRs). and 15%. All authors subsequently placements, on the last 2 days of Intergroup differences were tested fi x2 independently reviewed summaries hospitalization to prepare for NICU for signi cance by using the or and specific types of billable events discharge. These days were included, Wilcoxon rank test. We used generalized linear mixed-effects occurring on days after an RU-IP at however, in the overall LOS. regression analyses with a negative 25%, 10%, and 5% greater than the binomial distribution to examine all mean NICU room cost (Supplemental Standardized-Cost Methodology relationships between the covariates Tables 5–7). As predicted, as the To eliminate unit-cost level variation, and outcome measures using hospital percentage decreased, the types of we standardized the cost of each of as a random intercept to control for events that occurred were less likely the $22 000 items in the PHIS data hospital clustering. Adjusted odds to require NICU-level care to as the overall median hospital costs ratios (ORs) were calculated as well perform. We chose to move forward for that item.9 For example, the cost as 95% confidence intervals (CIs). with the 10% cutoff because it was of a total bilirubin laboratory test Because of the large sample size, in all closest to the natural inflection point ranged from $2 to $425 across the analyses, we used 2-tailed tests with identified in Fig 1, but because it was 43 hospitals, with a median cost of an a priori significance level of to the left of the inflection, we would $22. We then recalculated every P , .001. capture a smaller population and hospital bill using the standardized therefore improve the sensitivity of cost of each item (in this example, our findings while maintaining $22) and attributed any differences RESULTS events considered by the authors not in cost across hospitals to differences We identified 80 821 neonates to require NICU-level care to in volume of use rather than hospitalized in NICUs across 43 perform (Supplemental Table 8). We differences in costing methodology. children’s hospitals between 2010 therefore chose to continue our All currency is expressed in US and 2015. Of these patients, 80.6% evaluation using only this 10% dollars. (n = 65 139) reached an RU-IP cohort, defining this as the inflection- during their hospitalization pointcohort(IPC)andthosewhodid Outcome Measures and Covariates (Table 1). In comparison with the not reach an inflection point as the Ultimately, patients were stratified non-IPC, the IPC was term (50.2% non-IPC. We chose to ignore costs into 2 groups: those who reached the vs 54.4%), was non-Hispanic white incurred during the last 2 days of RU-IP and those who did not. We (45.4% vs 50.7%), and had private- hospitalization after finding that examined the total number of days payer insurance (39.6% vs 42.1%)

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 2, July 2020 3 TABLE 1 Overall Patient Characteristics Characteristic Overall 10% Non-IPC 10% IPC P N = 80 821 n = 15 682 (19.4%) n = 65 139 (80.6%) Gestational age, n (%) ,.001 Extremely preterm, ,28 wk 2835 (3.5) 666 (4.2) 2169 (3.3) Very preterm, 28–,32 wk 9065 (11.2) 2232 (14.2) 6833 (10.5) Moderate to late preterm, 32–,37 wk 25 581 (31.7) 4909 (31.3) 20 672 (31.7) Term or greater than term, $37 wk 43 340 (53.6) 7875 (50.2) 35 465 (54.4) NICU LOS, median (IQR) 5 (2–12) 5 (3–9) 6 (2–13) .927 LOS of entire hospitalization, median (IQR) 7 (3–15) 7 (4–17) 6 (3–14) ,.001 Standardized costs, $, median (IQR) ,.001 Per patient 17 631 (7647–39 350) 21 597 (12 308–46 918) 16 555 (6798–37 689) Per d 2496 (2343–2771) 2634 (2473–2946) 2462 (2325–2721) Race and/or ethnicity, n (%) ,.001 Non-Hispanic white 40 129 (49.7) 7121 (45.4) 33 008 (50.7) Non-Hispanic black 10 478 (13) 2589 (16.5) 7889 (12.1) Hispanic 14 382 (17.8) 2229 (14.2) 12 153 (18.7) Asian 3096 (3.8) 622 (4) 2474 (3.8) Other 12 736 (15.8) 3121 (19.9) 9615 (14.8) Payer, n (%) ,.001 Private 33 646 (41.6) 6204 (39.6) 27 442 (42.1) Government 43 978 (54.4) 8965 (57.2) 35 013 (53.8) Other payer 3197 (4) 513 (3.3) 2684 (4.1) Sex, n (%) .981 Female 35 853 (44.4) 6958 (44.4) 28 895 (44.4) Male 44 968 (55.6) 8724 (55.6) 36 244 (55.6) Disposition, n (%) ,.001 Home 71 206 (88.1) 13 999 (89.3) 57 207 (87.8) Home health care 4310 (5.3) 832 (5.3) 3478 (5.3) Hospital 4867 (6) 759 (4.8) 4108 (6.3) Other 438 (0.5) 92 (0.6) 346 (0.5) Discharge year, n (%) ,.001 2010 9233 (11.4) 1921 (12.2) 7312 (11.2) 2011 9389 (11.6) 1743 (11.1) 7646 (11.7) 2012 11 401 (14.1) 2324 (14.8) 9077 (13.9) 2013 15 234 (18.8) 2495 (15.9) 12 739 (19.6) 2014 17 430 (21.6) 3640 (23.2) 13 790 (21.2) 2015 18 134 (22.4) 3559 (22.7) 14 575 (22.4)

more frequently. LOS within the home (89.3% vs 87.8%) and, .80% of patients reached the RU-IP NICU did not differ significantly conversely, a higher proportion (Fig 2). The variability between between the non-IPC and the IPC discharged to another care facility hospitals extended to the populations (5 days [IQR 3–9] vs (4.8% vs 6.3%). When comparing proportion of total days of 6days[IQR2–13]; P = .927). inpatient, ED, or combined all- hospitalization spent beyond the Standardized costs were found to cause readmission rates at 7, 30, RU-IP (1.7%–56.7%) (Fig 3). be higher in the non-IPC, whether and90days,nosignificant Across all of the institutions examining this as a cost per patient differences were noted between the examined, we observed a net of ($21 597 [IQR $12 308–$46 918] vs 2 groups (Table 2). When 234 478 total days beyond the RU- $16 555 [IQR $6798–$37 689]; P , comparing the median days to IP, representing 24.3% of the total .001) or as a cost per day ($2634 inpatient readmission within 90 hospital days across the cohort. [IQR $2473–$2946] vs $2462 [IQR days, patients from the IPC This was calculated to represent fi $2325–$2721]; P , .001). Although returned signi cantly sooner (18 vs $483 281 268 in standardized costs P , statistically significant due to the 10 days; .001). accumulated beyond the RU-IP in large sample size, patient The proportion of patients all 43 hospitals, or 18.9% of the disposition status was similar hospitalized beyond an RU-IP varied total standardized cost of care across both populations, with between institutions (range: $128 228–$51 780 080; a lower proportion of IPC neonates (33.1%–98.7%), and in the majority 0.5%–50.9% of individual hospital discharged from the hospital to of hospitals (32 of 43;74.4%), cost, respectively).

Downloaded from www.aappublications.org/news by guest on October 2, 2021 4 GOLDIN et al TABLE 2 Readmission Characteristics at 7, 30, and 90 Days Characteristic Overall 10% Non-IPC 10% IPC P N = 80 821 n = 15 682 (19.4%) n = 65 139 (80.6%) 7-d readmissions Inpatient readmission rate, n (%) 429 (0.5) 60 (0.4) 369 (0.6) .004 Median days to inpatient readmission (IQR) 3 (1–4) 3 (1–4.5) 3 (1–4) .951 ED readmission rate, n (%) 1254 (1.6) 226 (1.4) 1028 (1.6) .213 Median days to ED readmission (IQR) 4 (2–5) 4 (2–6) 4 (2–5) .907 All-cause readmission rate, n (%) 1655 (2) 290 (1.8) 1365 (2.1) .051 Median days to all-cause readmission (IQR) 3 (2–5) 4 (2–5) 3 (2–5) .303 30-d readmissions Inpatient readmission rate, n (%) 768 (1) 137 (0.9) 631 (1) .271 Median days to inpatient readmission (IQR) 6 (2–14) 10 (3–18) 6 (2–14) .005 ED readmission rate, n (%) 4279 (5.3) 822 (5.2) 3457 (5.3) .743 Median days to ED readmission (IQR) 13 (6–22) 14 (7–22) 13 (6–22) .152 All-cause readmission rate, n (%) 5189 (6.4) 1005 (6.4) 4184 (6.4) .947 Median days to all-cause readmission (IQR) 13 (6–21) 14 (6–22) 13 (5–21) .009 90-d readmissions Inpatient readmission rate, n (%) 1033 (1.3) 205 (1.3) 828 (1.3) .718 Median days to inpatient readmission (IQR) 12 (3–31) 18 (6–41) 10 (3–29) ,.001 ED readmission rate, n (%) 8679 (10.7) 1646 (10.5) 7033 (10.8) .275 Median days to ED readmission (IQR) 31 (14–54) 31 (14–55) 31 (14–54) .89 All-cause readmission rate, n (%) 10 443 (12.9) 2008 (12.8) 8435 (12.9) .628 Median days to all-cause readmission (IQR) 31 (13–54) 30 (14–54) 31 (13–55) .587

To examine factors contributing to with slightly more post–RU-IP days. in potential excess costs. A review of neonates reaching the RU-IP, we Patients discharged with home the top 25 resources used in this modeled the outcome of reaching the health care services exhibited fewer population during the post–RU-IP RU-IP against several hospital- and days beyond the RU-IP (RR: 0.89; period of hospitalization patient-level characteristics (Table 3). 95% CI: 0.86–0.92; P , .001) (Supplemental Table 8) confirms that Compared with neonates discharged compared with those patients these resources are important but not from the hospital to home, neonates discharged from the hospital without necessarily indications for NICU-level discharged to other care facilities services. Receiving mechanical care, such as laboratory draws (eg, were more likely to reach the RU-IP ventilation (RR: 0.79; 95% CI: bilirubin levels, but not lights for (OR: 1.29; 95% CI: 1.17–1.42; P , 0.75–0.78; P , .001), feeding treatment), hepatitis vaccines, .001) during their NICU support (RR: 0.65; 95% CI: vitamins, and oximetry (but not hospitalization. Conversely, neonates 0.64–0.66; P , .001), or ECMO (RR: oxygen). receiving mechanical ventilation (OR: 0.59; 95% CI: 0.48–0.71; P , .001) at There are of course many potential 0.78; 95% CI: 0.74–0.83; P , .001) or any point during the hospitalization causes for prolonged LOS, and it is feeding support (OR: 0.65; 95% CI: was associated with fewer post–RU- likely that we are identifying these 0.6–0.68; P , .001) during their NICU IP days. Conversely, receiving associations within a complex and hospitalization were less likely to methadone during the changing health care environment. reach the RU-IP. hospitalization was associated with Before the advent of standardization, an increased number of days beyond We also examined factors associated timing for discharge from a NICU the RU-IP (RR: 1.14; 95% CI: with the number of days beyond the was a balance between several 1.06–1.24; P , .001). RU-IP (Table 4). Extremely preterm factors; the confidence of the health (risk ratio [RR]: 0.46; 95% CI: care team in an infant’sclinical 0.44–0.48; P , .001) and very stability, the confidence of the health preterm (RR: 0.71; 95% CI: DISCUSSION care team in the family or guardian’s 0.69–0.73; P , .001) neonates were In this cohort of NICU patients ability to care for the infant outside found to have fewer days beyond the without CCCs in 43 children’s of the NICU, and the parent or RU-IP compared with term neonates, hospitals over 5 years, we measured guardian’sconfidence to care for that whereas moderate to late preterm a potential excess NICU LOS of infant at home.11 Each of these neonates (RR: 1.08; 95% CI: 234 478 days, representing 24.3% of components can in turn be affected 1.06–1.09; P , .001) were associated the total NICU days and $483 281 268 by several variables.

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 2, July 2020 5 theIPCwasmorefrequentlynon- Hispanic white, term, privately insured, and discharged to facilities rather than home. Additionally, they returned to the hospital at ahigherratewithinthefirst week and in fewer days from discharge. Adjusted, the IPC remained more likely to be term and discharged to a facility rather than home and was less likely to be mechanically vented or to require feeding support. Longer LOS may simply allow more time to preparefordischargeandmeet historical discharge criteria. Historically neonates remain in the NICU for the intensive nursing care that supports the growth and maturation of the newborn, including monitoring and correcting temperature, respiratory, and metabolic instability. Early consensus statements recommended discharge criteria that included both objective criteria, such as aweightof2kg,andsubjective criteria, such as feeding stability.11,14 Evidence-based FIGURE 2 standardization fundamentally By hospital, the percentage of patients reaching RU-IP. controls bias at the individual patient level. The variability between hospitals in the First, providers may not trust that significant difference between the percentage of patients reaching the a patient is medically stable for cohorts in 7- or 30-day all-cause RU-IP (33%–99%) may be discharge, and therefore physicians returns to the system. Our data may explainedinpartbywhich and hospital systems in general therefore suggest that discharging hospitals in our study have may increase LOS to prevent home infants from the NICU more instituted standardized pathways. adverse events that lead to efficiently likely does not result in Standardized care pathways have in 12,13 increased readmissions or ED readmissions or ED visits. fact been shown to decrease LOS visits, and more importantly, there Foreseeing the argument that and minimize provider- and is no obvious protective effect of amoreaggressiveapproachto patient-level bias.15,16 These alongerLOS. discharge may result in increased standardized quality improvement revisits, we compared readmission Counterintuitively, in our study, we pathwaysaremorelikelytobe and ED visit rates between the IPC identified that patients who were developed for sicker patient and non-IPC and found that the IPC sicker were more likely to be populations, and this could in fact had a significantly higher among the non-IPC. Infants who contribute to their higher inpatient readmission rate at were on ECMO, were mechanically frequency in the non-IPC. Although 7 days and that although there was ventilated, or required feeding one might argue that the longer not a difference at 30 or 90 days, support were all more likely to be LOS of the IPC is required to meet thosewhodidreturnwithinthese discharged before reaching the RU- the discharge criteria referenced time periods came in significantly IP or to accrue fewer days after here, the significant variability sooner. It is important to emphasize reaching it compared with their among hospitals strongly suggests that we did not identify any healthier counterparts. Unadjusted, that other factors are influencing

Downloaded from www.aappublications.org/news by guest on October 2, 2021 6 GOLDIN et al health literacy, the health-related education that they have received before discharge, the support they have at home, their economic resources, and their life experiences, among many other factors. Authors have shown that parents of infants with greater medical complexity are more likely to feel prepared for discharge.20 On the flip side, others have shown that families that do not feel prepared are more likely to experience problems after discharge and have described a process of iterative process improvement through measurement of the family’s and the nurse’s assessments of the emotional and technical readiness for discharge.21

The significant variability we described among hospitals may suggestthatthereisanopportunity to identify practices in centers that result in more efficient discharge processes. For example, one opportunity may be to transfer patients who need continued observation, but do not require all of the resources of a level III or IV FIGURE 3 NICU, to a lower level of care within By hospital, the percentage of NICU hospitalization days reaching the RU-IP. thesamehospitalorinanother facility. Additional opportunities may be to standardize practices decision-making in terms of emotionally ready for discharge, such as early parent engagement in readiness for discharge. leading to prolonged LOS. Provider- care, and discharge based on and hospital-level practice patterns fi physiologic stability instead of One speci c NICU population that has and perception of parent competence asimpleweightcriterion.14,20,22 historically experienced long LOS is in caring for complex neonates at Several clinical and administrative the group diagnosed with neonatal home have been shown to influence collaboratives exist that could abstinence syndrome. We noted that discharge planning.4 The confidence identify such best practices, which patients in our study who received of the health care team in the infant’s could then be leveraged to identify methadone were more likely to be in stability and in the family’s ability to fi best practices across hospitals. We the IPC. These ndings are not care for the infant outside of the NICU maythenbeabletouseapositive- surprising given recent reports that may be affected by the age and deviance approach to standardize have revealed the variation in care experience of the nurse or fi objective discharge criteria that speci cally among children with neonatologist, how long they have wouldlikelyresultincostsavingsin neonatal abstinence syndrome and been on service (and therefore how addition to safer and higher-quality that have similarly offered solutions familiar they are with the patient and neonatal care.23 Although the to this problem through standardized family), and their particular clinical treatment pathways that decrease variability and increased LOS we biases. fi LOS and diminish disparities in identi ed may be responsible for – care.17 19 Third, parents may not feel ready for increased measurable costs of discharge. A family’s confidence in hospitalizations, as described by Second, physicians and nurses may their ability to care for the infant may these data, they may also be not trust that a family is technically or be related to their education level, responsible for additional

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 2, July 2020 7 TABLE 3 Factors Contributing to Neonates Reaching the RU-IP revenue.24 Our data support that Effect OR 95% CI P shifting to fewer post–RU-IP days Prematurity (reference: greater than or equal to term) mayleadtoanincreaseinhospital Moderate to late preterm (33–,37 wk) 1.023 0.976–1.071 .349 revenue. The greater average daily Very preterm (29–#32 wk) 1.024 0.954–1.099 .508 and total hospitalization cost of the Extremely preterm (#28 wk) 0.959 0.862–1.066 .437 non-IPC ($2634) compared with the . Median No. cases of entire cohort (references: 280 cases per y) IPC ($2462) suggests that hospitals #280 cases per y 0.959 0.502–1.832 .899 Race and/or ethnicity (reference: non-Hispanic white) would replace discharged patients Non-Hispanic black 1.013 0.952–1.078 .682 with a higher-acuity NICU Hispanic 0.987 0.921–1.056 .697 population that, in turn, has higher Asian 0.942 0.848–1.046 .265 daily billing. Other 1.021 0.962–1.083 .493 Payer (reference: private) There are several limitations to this – Government 0.959 0.917 1.002 .063 study. First, reviews of large Other payer 1.034 0.926–1.156 .55 Disposition (reference: home) databases are subject to the risk of Home health care 1.002 0.913–1.101 .959 misclassification. In this study, Hospital 1.288 1.173–1.415 ,.001 however, we focused on billing Other 0.964 0.745–1.248 .782 events, which in general tend to be Clinical factors (reference: did not receive) accurate. Second, the PHIS database Received mechanical ventilation 0.781 0.739–0.825 ,.001 Received feeding support 0.645 0.613–0.679 ,.001 represents tertiary referral pediatric Received ECMO 0.786 0.501–1.234 .295 hospitals often with level IV NICUs, Received methadone use 1.41 1.046–1.901 .024 leading to our potential inability to generalize the findings. These referral centers by definition, however, tend immeasurable costs related to predictable, if not shorter, LOS, to care for more complex patients. If fi staffing and resource allocation. thereby stabilizing a NICU’scensus the ndings that healthier children Minimizing variability has been to a predictable model. The overall may in fact contribute a higher shown to improve the overall effect of creating shorter LOS and proportion of hospital days beyond quality and safety of care in many minimizing variability is to improve the RU-IP, then the potential cost areas of health care and has the resource allocation and staffing and savings in level I, II, and III centers additional benefitofcreatingmore decrease cost, thereby increasing may be even greater. Third, there may be important events occurring during the hospitalization beyond the RU-IP TABLE 4 Factors Associated With the Number of Days Beyond the RU-IP that are critical and can only be performed within the inpatient Effect Rate Ratio 95% CI P context but cannot be identified Prematurity (reference: greater than or equal to term) through billable events. In our Moderate to late preterm (33–,37 wk) 1.075 1.056–1.093 ,.001 Very preterm (29–#32 wk) 0.709 0.691–0.728 ,.001 current system, however, it is hard to Extremely preterm (#28 wk) 0.463 0.443–0.483 ,.001 identify any such events that would No. cases (reference: .280 cases per y) require hospitalization but would not #280 cases per y 0.898 0.616–1.309 .575 require a billable record. Fourth, the Race/ethnicity (reference: non-Hispanic white) PHIS database only captures returns Non-Hispanic black 1.03 1.005–1.055 .019 Hispanic 0.987 0.965–1.011 .293 to the same hospital, and we may Asian 1.021 0.98–1.064 .312 have therefore underestimated Other 1.007 0.983–1.031 .582 readmissions to other hospitals. Fifth, Payer (reference: private) we were not able to identify hospitals – Government 0.982 0.966 0.999 .034 that may have step-down units using Other payer 1.014 0.973–1.057 .503 Disposition (reference: home) billing data. Home health care 0.893 0.863–0.924 ,.001 Hospital 1.013 0.974–1.053 .532 Other 0.91 0.807–1.026 .125 CONCLUSIONS Clinical factors (reference: did not receive) Received mechanical ventilation 0.764 0.74814–0.78036 ,.001 To our knowledge, no study has yet Received feeding support 0.649 0.63648–0.66161 ,.001 assessed the overall burden of excess Received ECMO 0.585 0.4807–0.71093 ,.001 NICU hospital days on the health care – , Received methadone use 1.144 1.05916 1.23625 .001 system. Our findings suggest that

Downloaded from www.aappublications.org/news by guest on October 2, 2021 8 GOLDIN et al there is vast opportunity to decrease opportunity to improve both ABBREVIATIONS costs of care by improving efficiency efficiency and long-term health and and standardizing the NICU discharge patient safety by engaging and CCC: complex chronic condition process. Having been focused first on educating parents early in the CI: confidence interval the NICU population without CCCs, hospitalization regarding ongoing ECMO: extracorporeal membrane these findings suggest beginning to needs of their child after oxygenation investigate opportunities for cost discharge.27–29 Solutions for this ED: emergency department savings with healthier patients, potential excess cost and LOS will IPC: inflection-point cohort perhaps by identifying interventions therefore need to address both the IQR: interquartile range that are focused on parent and health clinical and nonclinical drivers of this LOS: length of stay care provider perceptions. Qualitative observation. Reducing variability in OR: odds ratio research has revealed that some the discharge process from the NICU, PHIS: Pediatric Health Information parents perceive delays in discharge however, may provide an opportunity System processes or feel rushed at the time of to identify readiness for discharge RR: risk ratio discharge because of inadequate from the hospital either to home or to RU-IP: resource use inflection anticipation of parental educational step-down units earlier, increasing point needs.25,26 There may therefore be an the value of the care we provide.

Accepted for publication Apr 20, 2020 Address correspondence to Adam B. Goldin, MD, MPH, Department of Surgery, School of Medicine, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 10 GOLDIN et al The Resource Use Inflection Point for Safe NICU Discharge Adam B. Goldin, Mehul V. Raval, Cary W. Thurm, Matt Hall, Zeenia Billimoria, Sandra Juul and Loren Berman Pediatrics 2020;146; DOI: 10.1542/peds.2019-3708 originally published online July 22, 2020;

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 The Resource Use Inflection Point for Safe NICU Discharge Adam B. Goldin, Mehul V. Raval, Cary W. Thurm, Matt Hall, Zeenia Billimoria, Sandra Juul and Loren Berman Pediatrics 2020;146; DOI: 10.1542/peds.2019-3708 originally published online July 22, 2020;

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