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Variation in NICU utilization: a narrative review and path forward

Journal of Perinatology volume 45, pages 1034–1039 (2025)Cite this article

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Abstract

Utilization of the Neonatal Intensive Care Unit (NICU) varies widely in the United States. Over recent decades, there has been a growth in NICUs, that varies by region, and has not been correlated to changes in demand or illness severity. Unnecessary NICU admissions are costly, stressful to families, may increase the risk of hospital acquired morbidities, and decrease breast feeding. Most of the variation in NICU utilization is based on the care of late preterm, early term, and term babies and is related to hospital level factors, including financial incentives, driving utilization. Improvement strategies to reduce variation include regionalization of care, certificate of need legislation, improving discharge processes, and caring for babies with some conditions such as Neonatal Opioid Withdrawal Syndrome or those with risk factors for sepsis outside of the NICU.

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References

  1. Waitzman NJ, Jalali A, Grosse SD. Preterm birth lifetime costs in the United States in 2016: an update. Semin Perinatol. 2021;45:151390.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Sharek PJ, Horbar JD, Mason W, Bisarya H, Thurm CW, Suresh G, et al. Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006;118:1332–40.

    Article  PubMed  Google Scholar 

  3. Braun D, Edwards EM, Schulman J, Profit J, Pursley DWM, Goodman DC. Choosing wisely for the other 80%: what we need to know about the more mature newborn and NICU care. Semin Perinatol. 2021;45:151395.

    Article  PubMed  Google Scholar 

  4. Davis R, Stuchlik PM, Goodman DC. The relationship between regional growth in neonatal intensive care capacity and perinatal risk. Med Care. 2023;61:729–36.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Freedman S. Capacity and utilization in health care: the effect of empty beds on neonatal intensive care admission. Am Econ J Econ Policy. 2016;8:154–85.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Haidari ES, Lee HC, Illuzzi JL, Phibbs CS, Lin H, Xu X. Hospital variation in admissions to neonatal intensive care units by diagnosis severity and category. J Perinatol. 2021;41:468–77.

    Article  CAS  PubMed  Google Scholar 

  7. Carroll AE. The concern for supply-sensitive neonatal intensive care unit care: if you build them, they will come. JAMA Pediatr. 2015;169:812–3.

    Article  PubMed  Google Scholar 

  8. Pineda R, Kati Knudsen, Breault CC, Rogers EE, Mack WJ, Fernandez-Fernandez A. NICUs in the US: levels of acuity, number of beds, and relationships to population factors. J Perinatol. 2023;43:796–805.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Goodman DC, Little GA, Harrison WN, Moen A, Mowitz ME, Ganduglia-Cazaban C. The Dartmouth Atlas of Neonatal Intensive Care A Report of the Dartmouth Atlas Project. Dartmouth Institute for Health Policy and Clinical Practice. 2019. https://www.ncbi.nlm.nih.gov/books/NBK584993/

  10. Goodman DC, Ganduglia-Cazaban C, Franzini L, Stukel TA, Wasserman JR, Murphy MA, et al. Neonatal intensive care variation in medicaid-insured newborns: a population-based study. J Pediatr. 2019;209:44–51.e2.

    Article  PubMed  Google Scholar 

  11. Goodman DC, Stuchlik P, Ganduglia-Cazaban C, Tyson JE, Leyenaar JA, Avritscher EBC, et al. Hospital-level NICU capacity utilization, and 30-day outcomes in Texas. JAMA Netw Open. 2024;7:E2355982.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kroelinger CD, Rice ME, Okoroh EM, DeSisto CL, Barfield WD. Seven years later: state neonatal risk-appropriate care policy consistency with the 2012 American Academy of Pediatrics Policy. J Perinatol. 2022;42:595–602.

    Article  PubMed  Google Scholar 

  13. Boghossian NS, Geraci M, Phibbs CS, Lorch SA, Edwards EM, Horbar JD. Trends in resources for neonatal intensive care at delivery hospitals for infants born younger than 30 Weeks’ Gestation, 2009-2020. JAMA Netw Open. 2023;6:E2312107.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kim Y, Ganduglia-Cazaban C, Chan W, Lee MJ, Goodman DC. Trends in neonatal intensive care unit admissions by race/ethnicity in the United States, 2008–2018. Sci Rep. 2021;11:23795.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Harrison W, Goodman D. Epidemiologic trends in neonatal intensive care, 2007-2012. JAMA Pediatr. 2015;169:855–62.

    Article  PubMed  Google Scholar 

  16. Braun D, Braun E, Chiu V, Burgos AE, Gupta M, Volodarskiy M, et al. Trends in neonatal intensive care unit utilization in a large integrated health care system. JAMA Netw Open. 2020;3:e205239.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Pang EM, Liu J, Lu T, Joshi NS, Gould J, Lee HC. Evaluating epidemiologic trends and variations in NICU Admissions in California, 2008 to 2018. Hosp Pediatr. 2023;13:976–83.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Schulman J, Braun D, Lee HC, Profit J, Duenas G, Bennett MV, et al. Association between neonatal intensive care unit admission rates and illness acuity. JAMA Pediatr. 2018;172:17–23.

    Article  PubMed  Google Scholar 

  19. Harrison WN, Wasserman JR, Goodman DC. Regional variation in neonatal intensive care admissions and the relationship to bed supply. J Pediatr. 2018;192:73–79.e4.

    Article  PubMed  Google Scholar 

  20. Edwards EM, Horbar JD. Variation in use by NICU Types in the United States. Pediatrics. 2018;142:e20180457.

    Article  PubMed  Google Scholar 

  21. Ziegler KA, Paul DA, Hoffman M, Locke R. Variation in NICU admission rates without identifiable cause. Hosp Pediatr. 2016;6:255–60.

    Article  PubMed  Google Scholar 

  22. Zupancic JAF, Hudak ML, Edwards EM, Horbar JD, Mao WY, Miedema D, et al. Using the neonatal intensive care unit wisely: a national survey of clinicians regarding practices for lower-acuity care. J Pediatr. 2023;253:165–172.e1.

    Article  PubMed  Google Scholar 

  23. Joshi NS, Flaherman VJ, Halpern-Felsher B, Chung EK, Congdon JL, Lee HC. Admission and care practices in United States well newborn nurseries. Hosp Pediatr. 2023;13:208–15.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Fleming PF, Arora P, Mitting R, Aladangady N. A national survey of admission practices for late preterm infants in England. BMC Pediatr. 2014;14:150.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Wickremasinghe AC, Kuzniewicz MW, Walsh EM, Li S, Newman TB. NICU versus mother/baby unit admission for low-acuity infants born at 35 Weeks’ Gestation. Pediatrics. 2023;151:e2022056861. Apr 1

    Article  PubMed  Google Scholar 

  26. Milliren CE, Gupta M, Graham DA, Melvin P, Jorina M, Ozonoff A. Hospital variation in neonatal abstinence syndrome incidence, treatment modalities, resource use, and costs across pediatric hospitals in the United States, 2013 to 2016. Hospital Pediatr. 2018;8:15–20.

    Article  Google Scholar 

  27. Lembeck AL, Tuttle D, Locke R, Lawler L, Jimenez P, Mackley A, et al. Outcome differences in neonates exposed in-utero to opioids managed in the NICU Versus pediatric floor. J Addict Med. 2019;13:75–78.

    Article  CAS  PubMed  Google Scholar 

  28. Profit J, McCormick MC, Escobar GJ, Richardson DK, Zheng Z, Coleman-Phox K, et al. Neonatal intensive care unit census influences discharge of moderately preterm infants. Pediatrics. 2007;119:314–9.

    Article  PubMed  Google Scholar 

  29. Smith VC, Love K, Goyer E. NICU discharge preparation and transition planning: guidelines and recommendations. J Perinatol. 2022;42:7–21.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Stark AR, Adamkin DH, Batton DG, Bell EF, Bhutani VK, Denson SE, et al. Hospital discharge of the high-risk neonate committee on fetus and newborn. Pediatrics. 2008;122:1119–26.

    Article  Google Scholar 

  31. Eichenwald EC, Blackwell M, Lloyd JS, Tran T, Wilker RE, Richardson DK. Inter-neonatal intensive care unit variation in discharge timing: influence of Apnea and feeding management. Pediatrics. 2001;108:928–33.

    Article  CAS  PubMed  Google Scholar 

  32. Chandrasekharan P, Rawat M, Reynolds AM, Phillips K, Lakshminrusimha S. Apnea, bradycardia and desaturation spells in premature infants: Impact of a protocol for the duration of ‘spell-free’ observation on interprovider variability and readmission rates. J Perinatol. 2018;38:86–91.

    Article  CAS  PubMed  Google Scholar 

  33. Coughlin K, Posencheg M, Orfe L, Zachritz W, Meadow J, Yang K, et al. Reducing variation in the management of apnea of prematurity in the intensive care nursery. Pediatrics. 2020;145:e20190861.

    Article  PubMed  Google Scholar 

  34. Zupancic JA, Richardson DK, O'Brien BJ, Eichenwald EC, Weinstein MC. Cost-effectiveness analysis of predischarge monitoring for apnea of prematurity. Pediatrics. 2003;111:146–52.

    Article  PubMed  Google Scholar 

  35. Bull MJ, Engle WA, Smith GA, Baum CR, Dowd MD, Durbin DR, et al. Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics. 2009;123:1424–9.

    Article  PubMed  Google Scholar 

  36. Braun D, Kaempf JW, Ho NJ, Nguyen MH, Passi R, Burgos AE, et al. Discontinuation of car seat tolerance screening and postdischarge adverse outcomes in infants born preterm. J Pediatr. 2023;261:113577.

    Article  PubMed  Google Scholar 

  37. Guillén Ú, Zupancic JAF, Litt JS, Kaempf J, Fanaroff A, Polin RA, et al. Community considerations for aggressive intensive care therapy for infants <24+0 weeks of gestation. J Pediatr. 2024;268:113948.

    Article  PubMed  Google Scholar 

  38. Gizzi C, Gagliardi L, Trevisanuto D, Ghirardello S, Di Fabio S, Beke A, et al. Variation in delivery room management of preterm infants across Europe: a survey of the Union of European Neonatal and Perinatal Societies. Eur J Pediatr. 2023;182:4173–83.

    Article  PubMed  Google Scholar 

  39. Higgins BV, Baer RJ, Steurer MA, Karvonen KL, Oltman SP, Jelliffe-Pawlowski LL, et al. Resuscitation, survival and morbidity of extremely preterm infants in California 2011–2019. J Perinatol. 2024;44:209–16.

    Article  PubMed  Google Scholar 

  40. Rysavy MA, Bennett MM, Ahmad KA, Patel RM, Shah ZS, Ellsbury DL, et al. Neonatal Intensive Care Unit resource use for infants at 22 Weeks’ Gestation in the US, 2008-2021. JAMA Netw Open. 2024;7:e240124.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Cheah IGS. Economic assessment of neonatal intensive care. Transl Pediatr. 2019;8:246–56.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Lambiase CV, Mansi G, Salomè S, Conelli ML, Vendemmia M, Zurlo MC, et al. The financial burden experienced by families during NICU hospitalization and after discharge: a single center, survey-based study. Eur J Pediatr. 2024;183:903–13.

    Article  PubMed  Google Scholar 

  43. Beam AL, Fried I, Palmer N, Agniel D, Brat G, Fox K, et al. Estimates of healthcare spending for preterm and low-birthweight infants in a commercially insured population: 2008–2016. J Perinatol. 2020;40:1091–9.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Rolnitsky A, Unger S, Urbach D, Bell CM. The price of neonatal intensive care outcomes – in-hospital costs of morbidities related to preterm birth. Front Pediatr. 2023;11:1068367.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Weimer KED, Bidegain M, Shaikh SK, Couchet P, Tanaka DT, Athavale K. Comparison of short-term outcomes of 35-weeks’ gestation infants cared for in a level II NICU vs mother-baby, a retrospective study. J Neonatal Perinat Med. 2022;15:643–51.

    Article  CAS  Google Scholar 

  46. Bua J, Dalena P, Mariani I, Girardelli M, Ermacora M, Manzon U, et al. Parental stress, depression, anxiety and participation in care in neonatal intensive care unit: a cross-sectional study in Italy comparing mothers versus fathers. BMJ Paediatr Open. 2024;8:e0022429.

    Article  Google Scholar 

  47. Ivashchuk A, Guillen U, Mackley A, Locke R, Sturtz W. Parental protective factors and stress in NICU mothers and fathers. J Perinatol. 2021;41:2000–8.

    Article  PubMed  Google Scholar 

  48. Allen EC, Manuel JC, Legault C, Naughton MJ, Pivor C, Michael O’shea T. Perception of child vulnerability among mothers of former premature infants. Pediatrics. 2004;113:267–73.

    Article  PubMed  Google Scholar 

  49. Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of pediatric inpatient services in the United States. Pediatrics. 2021;148:e2020041723.

    Article  PubMed  Google Scholar 

  50. Baker EL, Parker LA, Alissa R, Dowling D, Schierholz E, Parker L. Decreasing Admissions to the NICU: an official transition bed for neonates. Adv Neonatal Care. 2021;21:87–91.

    Article  PubMed  Google Scholar 

  51. Basuray RG, Cacioppo C, Inuzuka V, Cooper K, Hardy C, Perry MF. Increasing exclusive nursery care of late preterm and low birth weight infants. Hosp Pediatr. 2023;13:992–1000.

    Article  Google Scholar 

  52. Leonardi BM, Binder M, Griswold KJ, Yalcinkaya GF, Walsh MC. Utilization of a neonatal early-onset sepsis calculator to guide initial newborn management. Pediatr Qual Saf. 2019;4:e214.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Young LW, Ounpraseuth ST, Merhar SL, Hu Z, Simon AE, Bremer AA, et al. Eat, sleep, console approach or usual care for neonatal opioid withdrawal. N. Engl J Med. 2023;388:2326–37.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Edwards EM, Greenberg LT, Ehret DEY, Lorch SA, Horbar JD. Discharge age and weight for very preterm infants: 2005-2018. Pediatrics. 2021;147:e2020016006.

    Article  PubMed  Google Scholar 

  55. Lockyear C, Coe K, Greenberg RG, Clark RH, Aleem S. Trends in morbidities of late preterm infants in the neonatal intensive care unit. J Perinatol. 2023;43:1379–84.

    Article  PubMed  Google Scholar 

  56. McCord H, Fieldhouse E, El-Naggar W. Criteria for discharge of preterm infants from Canadian neonatal intensive care units. Eur J Pediatr. 2024;183:1759–63.

    Article  PubMed  Google Scholar 

  57. Kaemingk BD, Hobbs CA, Streeton AC, Morgan K, Schuning VS, Melhouse JK, et al. Improving the timeliness and efficiency of discharge from the NICU. Pediatrics. 2022;149:e2021052759.

    Article  PubMed  Google Scholar 

  58. Lagatta JM, Uhing M, Acharya K, Lavoie J, Rholl E, Malin K, et al. Actual and potential impact of a home nasogastric tube feeding program for infants whose neonatal Intensive Care Unit discharge is affected by delayed oral feedings. J Pediatr. 2021;234:38–45.e2.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Beltempo M, Sargi E, Patel S, Lacroix G, Lapointe A, Taylor-Ducharme S, et al. Neonatal intensive care unit occupancy rate and probability of discharge of very preterm infants. J Perinatol. 2023;43:490–5.

    Article  PubMed  Google Scholar 

  60. Howell EM, Richardson D, Ginsburg P, Foot B. Deregionalization of neonatal intensive care in urban areas. Am J Public Health. 2002;92:119–24.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Xie L, Boudreaux M, Franzini L. Maryland’s Global Budget Revenue Program Impact on Neonatal Intensive Care Unit Admissions and Infant Mortality. Med Care. 2021;59:663–70.

    Article  PubMed  Google Scholar 

  62. Salazar EG, Handley SC, Greenberg LT, Edwards EM, Lorch SA. Association between Neonatal Intensive Care Unit type and quality of care in moderate and late preterm infants. JAMA Pediatr. 2023;177:278–85.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Oren MS, Barkhuff WD, Stefanescu A, Stefanescu BM, DuPont TL. The impact of the baby friendly hospital initiative on neonatal hypoglycemia. J Perinatol. 2020;40:1828–33.

    Article  PubMed  Google Scholar 

  64. Fradkin EC, Lafferty MA, Greenspan JS, Aghai ZH. Neonatal intensive care unit admissions before and after the adoption of the baby friendly hospital initiative. J Matern-Fetal Neonatal Med. 2022;35:657–62.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA

    David A. Paul & Stephen A. Pearlman

  2. Department of Pediatrics, ChristianaCare, Newark, DE, USA

    Stephen A. Pearlman

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  1. David A. Paul
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  2. Stephen A. Pearlman
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DAP contributed to the concept of the manuscript, literature review, writing the manuscript, finalizing the manuscript content. SAP contributed to the concept of the manuscript, literature review, writing the manuscript, finalizing the manuscript content

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Correspondence to David A. Paul.

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Paul, D.A., Pearlman, S.A. Variation in NICU utilization: a narrative review and path forward. J Perinatol 45, 1034–1039 (2025). https://doi.org/10.1038/s41372-024-02129-5

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