The need to address racial healthcare disparities has been a priority over the past year due to a number of high-profile papers emphasizing racial disparities and recent current events.1 In this month’s Pediatrics, Edwards et al (10.1542/peds.2020-037622) utilize the Vermont Oxford Baby-MONITOR (Measure Of Neonatal InTensive care Outcomes Research) dataset to analyze variation in quality of care by racial groups across national neonatal intensive care units (NICUs). This Baby-MONITOR metric was developed in order to use a select number of evidence-based quality measures such as having received any human milk at discharge, being hypothermic at admission, and healthcare associated infections as process measures to reflect the overall quality of care a baby receives. It also assesses quality-related outcomes measures such as survival to discharge, incidence of bronchopulmonary dysplasia, and median growth velocity. Aligning with many other publications that have cited healthcare-related racial disparities, the authors found that African American and Native American infants had lower average process measure scores compared to white infants, while Asian American and Hispanic groups had lower scores in specific components such as breastmilk exposure, but no significant difference in process measures on average. The authors also found that process measure scores varied by geographic location, and the geographic variation somewhat surprisingly did not align with geopolitical or geo-economic regions. Additionally, all of the racial cohorts they examined had higher process scores than white babies in the same NICU, suggesting that morbidity and mortality happened less in the non-white racial categories despite a lower quality of care. The reasons for this apparent discrepancy were not totally evident based on this dataset, which was not designed to analyze that question.
The accompanying commentary by Drs. Willer and Nafiu (10.1542/peds.2021-051298) gives important extended context to the paper’s findings of disparate care for racial minorities within the same NICU. The commentary underscores the fact that even after adjusting for clinical severity and birth characteristics, in many NICUs, non-white infants do not receive the same quality of care that white infants do. This discrepancy points to institutionalized racism and individual human factors related to racism as causes for sub-standard care rather than regional or NICU-specific variances in care delivery.
These articles emphasize the need for further national studies on racial disparities in neonatal care quality. Further, they suggest that interventions to improve quality of care may need to target individual biases, both unconscious and overt, rather than systems of care delivery. This is quite the opposite of most care quality related interventions, where the emphasis is on systems of care rather than personal actions, and it may take some innovative approaches to achieve these types of changes.
Reference:
1. Hoyert DL, Uddin SFG, Miniño AM. Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths. Natl Vital Stat Rep. 2020 Jan;69(1):1-25
