My primary interest is the optimization of quality and equity of care delivery to sick newborns. This interest includes health care delivery design at the macro-system level, organizational context at the hospital and neonatal intensive care unit level, as well as improvement of care processes in the clinical setting. In addition, I have a keen interest in the use of information technology to support families, care professionals, and policy makers in their efforts to facilitate optimal care.

Clinical Focus

  • Neonatal-Perinatal Medicine

Academic Appointments

Administrative Appointments

  • Co-Director and Co-Principal Investigator, California Maternal and Perinatal Quality of Care Collaboratives (2023 - Present)
  • Member, Advisory Board, NEC Society (2019 - Present)
  • Chief Quality Officer, California Perinatal Quality Care Collaborative (2018 - 2023)
  • Chief Scientific Officer, California Perinatal Quality Care Collaborative (2017 - 2018)
  • Core Lead For Health Organization Performance, Center for Policy, Outcomes and Prevention, Department of Pediatrics, Stanford University (2014 - Present)
  • Director, Perinatal Health Systems Research, Department of Pediatrics, Stanford University School of Medicine (2013 - Present)

Honors & Awards

  • Marie McCormick Lectureship in Health Services Research and Epidemiology, Harvard Newborn Medicine (10/19/2017)
  • Social Disparities in NICU Care, NICHD (R01) (04/01/2016)
  • Dashboard of Racial/Ethnic Disparity in the Care Provided by NICUs, NICHD (R01) (12/01/2015)
  • WISER Study, NICHD (R01) (08/01/2015)

Boards, Advisory Committees, Professional Organizations

  • Member, American Pediatric Society (2023 - Present)
  • Scientific Advisory Committee, NEC Society (2019 - Present)
  • Board Member, California Association of Neonatolgists (2014 - Present)
  • Member, Academy Health (2010 - Present)
  • Member, Society for Pediatric Research (2009 - Present)
  • Fellow, American Academy of Pediatrics (2006 - Present)

Professional Education

  • Board Certification: American Board of Pediatrics, Pediatrics (2013)
  • Certificate, Rice University, Houston, TX, Medical and Healthcare Management (2010)
  • Certificate, Intermountain Healthcare, Advanced Training Program in Quality Improvement (2008)
  • Board Certification: American Board of Pediatrics, Neonatal-Perinatal Medicine (2005)
  • Fellowship: Harvard Medical School (2005) MA
  • Neonatologist, Harvard University, School of Medicine, Boston, MA (2005)
  • MPH, Harvard School of Public Health (2005)
  • Residency: Tufts Medical Center Graduate Medical Education (2002) MA
  • Pediatrician, Tufts University, School of Medicine, Boston, MA (2002)
  • Residency: St Josefskrankenhaus (1999) Germany
  • Medical Education: Albert-Ludwigs-University Freiburg (1997) Germany
  • MD, Albert-Ludwigs-University, Freiburg, Germany (1997)

Community and International Work

  • Vermont Oxford Network


    Strategies to promote health care provider well being and improve quality of care

    Populations Served

    Health care workers, patients and families in the neonatal intensive care unit setting



    Ongoing Project


    Opportunities for Student Involvement


  • California Perinatal Quality Care Collaborative


    Achieving care excellence for sick newborns and their families across the state

    Partnering Organization(s)

    California Maternal Quality Care Collaborative

    Populations Served

    Newborns and mothers across California



    Ongoing Project


    Opportunities for Student Involvement


  • Improving NICU Care in Mexico, Monterrey, Mexico


    Quality improvement

    Partnering Organization(s)

    Tech de Monterrey

    Populations Served

    Preterm infants



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Funded by NIH R01 grants:

1) Development and application of composite measure of NICU quality - Baby-MONITOR

2) High reliability, safety culture and caregiver resilience as modifiers of care quality

3) Modifiable racial/ethnic disparities in quality of care delivery

4) Effectiveness of regionalized care delivery systems for preterm newborns

Clinical Trials

  • Web-based Implementation for the Science of Enhancing Resilience Study Not Recruiting

    Resilience means a healthcare provider's ability to cope, recover, and learn from stressful events, as well as their access to resources that promote health and well-being. Neonatal intensive care unit (NICU) health professionals' need to have particularly good resilience, because their work is extremely stressful and their patients, fragile preterm infants, require their undivided attention. The investigators propose a feasible and engaging intervention to enhance resilience among NICU health professionals promoting their ability to provide safe care.

    Stanford is currently not accepting patients for this trial. For more information, please contact Sanary Lou, BA, 650-736-4062.

    View full details

2023-24 Courses

Stanford Advisees

All Publications

  • Magnesium sulfate and risk of hypoxic ischemic encephalopathy in a high-risk cohort. American journal of obstetrics and gynecology Minor, K. C., Liu, J., Druzin, M. L., El-Sayed, Y. Y., Hintz, S. R., Bonifacio, S. L., Leonard, S. A., Lee, H. C., Profit, J., Karakash, S. D. 2024


    Hypoxic ischemic encephalopathy contributes to morbidity and mortality among neonates ≥ 360 weeks' gestation. Evidence of preventative antenatal treatment is limited. Magnesium sulfate has neuroprotective properties among preterm fetuses. Hypertensive disorders of pregnancy are a risk factor for hypoxic ischemic encephalopathy and magnesium sulfate is recommended for maternal seizure prophylaxis among patients with pre-eclampsia with severe features.1) Determine trends in incidence of hypertensive disorders of pregnancy, antenatal magnesium sulfate and hypoxic ischemic encephalopathy, 2) evaluate the association between hypertensive disorders of pregnancy and hypoxic ischemic encephalopathy and 3) evaluate if, among patients with hypertensive disorders of pregnancy, the odds of hypoxic ischemic encephalopathy is mitigated by receipt of antenatal magnesium sulfate. STUDY DESIGN: We conducted an analysis of a prospective cohort of live births ≥360 weeks' gestation between 2012-2018 within the California Perinatal Quality Care Collaborative registry, linked with the California Department of Health Care Access and Information files. We used Cochran-Armitage tests to assess trends in hypertensive disorders, encephalopathy diagnoses, and magnesium sulfate utilization, and compared demographic factors between patients with or without hypertensive disorders of pregnancy or treatment with magnesium sulfate. Hierarchical logistic regression models were built to explore if hypertensive disorders of pregnancy were associated with any severity and moderate/severe hypoxic ischemic encephalopathy. Separate hierarchical logistic regression models were built among those with hypertensive disorders of pregnancy to evaluate the association of magnesium sulfate with hypoxic ischemic encephalopathy.Among 44,314 unique infants, the diagnosis of hypoxic ischemic encephalopathy, maternal hypertensive disorders of pregnancy and the use of magnesium sulfate increased over time. Compared to patients with hypertensive disorders of pregnancy alone, patients with hypertensive disorders treated with magnesium sulfate represented a higher risk population. They were more likely to be publicly insured, born 36-38 weeks' gestation, be small for gestational age, have lower Apgar scores, require a higher level of resuscitation at delivery, have prolonged rupture of membranes, preterm labor, fetal distress, and undergo operative delivery (all p-values <0.002). Hypertensive disorders of pregnancy were associated with hypoxic ischemic encephalopathy (aOR 1.26, 95% CI 1.13-1.40, p-value <.001) and specifically moderate/severe hypoxic ischemic encephalopathy (aOR 1.26, 95% CI 1.11-1.42, p-value <.001). Among patients with hypertensive disorders of pregnancy, treatment with magnesium sulfate was associated with 29% reduction in the odds of neonatal hypoxic ischemic encephalopathy (aOR 0.71, 95% CI 0.52-0.97, p-value= 0.03) and a 37% reduction in the odds of moderate/severe neonatal hypoxic ischemic encephalopathy (aOR 0.63, 95% CI 0.42-0.94, p-value=0.03).Hypertensive disorders of pregnancy are associated with hypoxic ischemic encephalopathy and specifically, moderate/severe disease. Among people with hypertensive disorders, receipt of antenatal magnesium sulfate is associated with significant reduction in the odds of hypoxic ischemic encephalopathy and moderate/severe disease in a neonatal cohort admitted to the NICU ≥360 weeks' gestation. The findings of this observational study cannot prove causality and are intended to be hypothesis generating for future clinical trials on MgSO4 in term infants.

    View details for DOI 10.1016/j.ajog.2024.04.001

    View details for PubMedID 38580044

  • Predicting Primary Care Physician Burnout From Electronic Health Record Use Measures. Mayo Clinic proceedings Tawfik, D., Bayati, M., Liu, J., Nguyen, L., Sinha, A., Kannampallil, T., Shanafelt, T., Profit, J. 2024


    To evaluate the ability of routinely collected electronic health record (EHR) use measures to predict clinical work units at increased risk of burnout and potentially most in need of targeted interventions.In this observational study of primary care physicians, we compiled clinical workload and EHR efficiency measures, then linked these measures to 2 years of well-being surveys (using the Stanford Professional Fulfillment Index) conducted from April 1, 2019, through October 16, 2020. Physicians were grouped into training and confirmation data sets to develop predictive models for burnout. We used gradient boosting classifier and other prediction modeling algorithms to quantify the predictive performance by the area under the receiver operating characteristics curve (AUC).Of 278 invited physicians from across 60 clinics, 233 (84%) completed 396 surveys. Physicians were 67% women with a median age category of 45 to 49 years. Aggregate burnout score was in the high range (≥3.325/10) on 111 of 396 (28%) surveys. Gradient boosting classifier of EHR use measures to predict burnout achieved an AUC of 0.59 (95% CI, 0.48 to 0.77) and an area under the precision-recall curve of 0.29 (95% CI, 0.20 to 0.66). Other models' confirmation set AUCs ranged from 0.56 (random forest) to 0.66 (penalized linear regression followed by dichotomization). Among the most predictive features were physician age, team member contributions to notes, and orders placed with user-defined preferences. Clinic-level aggregate measures identified the top quartile of clinics with 56% sensitivity and 85% specificity.In a sample of primary care physicians, routinely collected EHR use measures demonstrated limited ability to predict individual burnout and moderate ability to identify high-risk clinics.

    View details for DOI 10.1016/j.mayocp.2024.01.005

    View details for PubMedID 38573301

  • Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study. Journal of perinatology : official journal of the California Perinatal Association Razdan, S., Hedli, L. C., Sigurdson, K., Profit, J., Morton, C. H. 2023


    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.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.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.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.

    View details for DOI 10.1038/s41372-023-01856-5

    View details for PubMedID 38155228

    View details for PubMedCentralID 6503514

  • Quality, outcome, and cost of care provided to very low birth weight infants in California. Journal of perinatology : official journal of the California Perinatal Association Lapcharoensap, W., Bennett, M., Xu, X., Lee, H. C., Profit, J., Dukhovny, D. 2023


    To examine association of costs with quality of care and patient outcome across hospitals in California.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.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).With the metrics used, we found no correlation between cost, quality, and outcomes in the care of VLBW infants.

    View details for DOI 10.1038/s41372-023-01792-4

    View details for PubMedID 37805592

    View details for PubMedCentralID 1752207

  • In Situ Simulation and Clinical Outcomes in Infants Born Preterm. The Journal of pediatrics Chitkara, R., Bennett, M., Bohnert, J., Yamada, N., Fuerch, J., Halamek, L. P., Quinn, J., Padua, K., Gould, J., Profit, J., Xu, X., Lee, H. C. 2023: 113715


    To evaluate impact of a multi-hospital collaborative quality improvement project implementing in situ simulation training for neonatal resuscitation on clinical outcomes for infants born preterm.Twelve neonatal intensive care units (NICUs) were divided into 4 cohorts; each completed a 15-month long program in a stepped wedge manner. Data from California Perinatal Quality Care Collaborative were used to evaluate clinical outcomes. Very low birthweight (VLBW) infants born between 22 through 31 weeks gestation were included. Primary outcome was survival without chronic lung disease (CLD); secondary outcomes included intubation in the delivery room (DR), DR continuous positive airway pressure (CPAP), hypothermia (<36ºC) upon NICU admission, severe intraventricular hemorrhage, and mortality prior to hospital discharge. A mixed effects multivariable regression model was used to assess the intervention effect.Between March 2017 and December 2020, a total of 2,626 eligible VLBW births occurred at 12 collaborative participating sites. Rate of survival without CLD at participating sites was 74.1% in Mar-Aug2017 and 76.0% in Jul-Dec 2020 (RR 1.03 [0.94,1.12]; no significant improvement occurred during the study period for both participating and non-participating sites. The effect of in situ simulation on all secondary outcomes was stable.Implementation of a multi-hospital collaborative providing in situ training for neonatal resuscitation did not result in significant improvement in survival without CLD. Ongoing in situ simulations may have an impact on unit practice and unmeasured outcomes.

    View details for DOI 10.1016/j.jpeds.2023.113715

    View details for PubMedID 37659586

  • Cohort selection and the estimation of racial disparity in mortality of extremely preterm neonates. Pediatric research Gould, J. B., Bennett, M. V., Profit, J., Lee, H. C. 2023


    BACKGROUND: Racial disparities in preterm neonatal mortality are long-standing. We aimed to assess how cohort selection influences mortality rates and racial disparity estimates.METHODS: With 2014-2018 California data, we compared neonatal mortality rates among Black and non-Hispanic White very low birth weight (VLBW, <1500g) or very preterm infants (22-29 weeks gestational age). Relative risks were estimated by different cohort selection criteria. Blinder-Oaxaca decomposition quantified factors contributing to mortality differential.RESULTS: Depending upon standard selection criteria, mortality ranged from 6.2% (VLBW infants excluding first 12-h deaths) to 16.0% (22-29 weeks' gestation including all deaths). Black observed neonatal mortality was higher than White infants only for delivery room deaths in VLBW infants (5.6 vs 4.2%). With risk adjustment accounting for higher rate of low gestational age, low Apgar score and other factors, White infant mortality increased from 15.9 to 16.6%, while Black infant mortality decreased from 16.7 to 13.7% in the 22-29 weeks cohort. Across varying cohort selection, risk adjusted survival advantage among Black infants ranged from 0.70 (CL 0.61-0.80) to 0.84 (CL 0.76-0.93).CONCLUSIONS: Standard cohort selection can give markedly different mortality estimates. It is necessary to reduce prematurity rates and perinatal morbidity to improve outcomes for Black infants.IMPACT: In this population-based observational cohort study that encompassed very low birth weight infant hospitalizations in California, varying standard methods of cohort selection resulted in neonatal mortality ranges from 6.2 to 16.0%. Across all cohorts, the only significant observed Black-White disparity was for delivery room deaths in Very Low Birth Weight births (5.6 vs 4.2%). Across all cohorts, we found a 16-30% survival advantage for Black infants. Cohort selection can result in an almost three-fold difference in estimated mortality but did not have a meaningful impact on observed or adjusted differences in neonatal mortality outcomes by race and ethnicity.

    View details for DOI 10.1038/s41390-023-02766-0

    View details for PubMedID 37580552

  • Neonatal Healthcare Professionals' Experiences When Implementing a Simulation and Debriefing Program in Neonatal Intensive Care Settings: A Qualitative Analysis. Advances in neonatal care : official journal of the National Association of Neonatal Nurses Quinn, J., Quinn, M., Lieu, B., Bohnert, J., Halamek, L. P., Profit, J., Fuerch, J. H., Chitkara, R., Yamada, N. K., Gould, J., Lee, H. C. 2023


    BACKGROUND: Simulation-based training (SBT) and debriefing have increased in healthcare as a method to conduct interprofessional team training in a realistic environment.PURPOSE: This qualitative study aimed to describe the experiences of neonatal healthcare professionals when implementing a patient safety simulation and debriefing program in a neonatal intensive care unit (NICU).METHODS: Fourteen NICUs in California and Oregon participated in a 15-month quality improvement collaborative with the California Perinatal Quality Care Collaborative. Participating sites completed 3 months of preimplementation work, followed by 12 months of active implementation of the simulation and debriefing program. Focus group interviews were conducted with each site 2 times during the collaborative. Content analysis found emerging implementation themes.RESULTS: There were 234 participants in the 2 focus group interviews. Six implementation themes emerged: (1) receptive context; (2) leadership support; (3) culture change; (4) simulation scenarios; (5) debriefing methodology; and (6) sustainability. Primary barriers and facilitators with implementation of SBT centered around having a receptive context at the unit level (eg, availability of resources and time) and multidisciplinary leadership support.IMPLICATIONS FOR PRACTICE AND RESEARCH: NICUs have varying environmental (context) factors and consideration of unit-level context factors and support from leadership are integral aspects of enhancing the successful implementation of a simulation and debriefing program for neonatal resuscitation. Additional research regarding implementation methods for overcoming barriers for both leaders and participants, as well as determining the optimal frequency of SBT for clinicians, is needed. A knowledge gap remains regarding improvements in patient outcomes with SBT.

    View details for DOI 10.1097/ANC.0000000000001085

    View details for PubMedID 37399571

  • Disparities and Equity Dashboards in the Neonatal Intensive Care Unit: A Qualitative Study of Expert Perspectives. Research square Razdan, S., Hedli, L., Sigurdson, K., Profit, J., Morton, C. 2023


    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.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.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.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.

    View details for DOI 10.21203/

    View details for PubMedID 37461712

    View details for PubMedCentralID PMC10350244

  • Association of Primary Language with Very Low Birthweight Outcomes in Hispanic Infants in California. The Journal of pediatrics Feister, J., Kan, P., Bonifacio, S. L., Profit, J., Lee, H. C. 2023: 113527


    To determine the association of Spanish as a primary language for a family with the health outcomes of Hispanic infants with very low birthweight (VLBW, <1500g).Data from the California Perinatal Quality Care Collaborative linked to hospital discharge records were analyzed. Hispanic infants with VLBW born between 2009-2018 with a primary language of English or Spanish were included. Outcomes selected were hypothesized to be sensitive to language barriers. Multivariable logistic regression models and mixed models estimated associations between language and outcomes.Of 18,364 infants meeting inclusion criteria, 27% (n=4,976) were born to families with Spanish as a primary language. In unadjusted analyses, compared with infants of primarily English-speaking families, these infants had higher odds of hospital readmission within 1 year [OR 1.11 (95% CI 1.02-1.21)], higher odds to receive human milk at discharge [OR 1.32 (95% CI 1.23-1.42)], and lower odds of discharge home with oxygen [OR 0.83 (95% CI 0.73-0.94)]. In multivariable analyses, odds of readmission and home oxygen remained significant when adjusting for infant but not maternal and hospital characteristics. Higher odds for receipt of any human milk at discharge were significant in all models. Remaining outcomes did not differ between groups.Significant differences exist between Hispanic infants with VLBW of primarily Spanish- versus English-speaking families. Exploration of strategies to prevent readmissions of infants of families with Spanish as a primary language is warranted.

    View details for DOI 10.1016/j.jpeds.2023.113527

    View details for PubMedID 37263521

  • Prevalence of burnout and its relation to the neuroendocrine system among pediatric residents during the early Covid-19 pandemic: A pilot feasibility study. Comprehensive psychoneuroendocrinology Tawfik, D. S., Rovnaghi, C., Profit, J., Cornell, T. T., Anand, K. J. 2023; 14: 100174


    Background: Measuring burnout relies on infrequent and subjective surveys, which often do not reflect the underlying factors or biological mechanisms that promote or prevent it. Burnout correlates with cortisol levels and dysregulation of the hypothalamic-pituitary-adrenal axis, but the chronology and strength of this relationship are unknown.Objective: To determine the prevalence and feasibility of studying burnout in pediatric residents using hair cortisol and hair oxytocin concentrations.Design: /Methods: Longitudinal observational cohort study of pediatric residents. We assessed burnout using the Stanford Professional Fulfillment Index and hair cortisol (HCC), and hair oxytocin concentrations (HOC) at four 3-month intervals from January 2020-January 2021. We evaluated test-retest reliability, sensitivity to change using Pearson product-moment correlations, and relationships between burnout and hair biomarkers using hierarchical mixed-effects linear regression.Results: 17 Pediatrics residents provided 78 wellness surveys and 54 hair samples. Burnout symptoms were present in 39 (50%) of the surveys, with 14 (82%) residents reporting burnout in at least one time point. The lowest (41%) and highest (60%) burnout prevalence occurred in 04/2020 and 01/2021, respectively. No significant associations between burnout scores and HCC (beta -0.01, 95%CI: 0.14-0.13), HOC (beta 0.06, 95%CI: 0.06-0.19), or the HCC:HOC ratio (beta -0.04, 95%CI: 0.09-0.02) were noted in separate analyses. Intra-individual changes in hair cortisol concentration were not associated with changes in burnout score.Conclusions: Burnout was prevalent among Pediatrics residents, with highest prevalence noted in January 2021. This pilot longitudinal study demonstrates the feasibility of evaluating burnout with stress and resilience biomarkers in Pediatrics residents.

    View details for DOI 10.1016/j.cpnec.2023.100174

    View details for PubMedID 36742128

  • Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Adair, K. C., Levoy, E., Tawfik, D. S., Palassof, S., Profit, J., Frankel, A., Leonard, M., Proulx, J., Sexton, B. 2023; 49 (3): 166-173


    Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism.In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's α, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics.A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric properties (Cronbach's α = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and nonsurgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness.The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and variation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

    View details for DOI 10.1016/j.jcjq.2022.12.007

    View details for Web of Science ID 000965658900001

    View details for PubMedID 36717344

  • Leadership Behavior Associations with Domains of Safety Culture, Engagement, and Health Care Worker Well-Being JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Tawfik, D. S., Adair, K. C., Palassof, S., Sexton, B. J., Levoy, E., Frankel, A., Leonard, M., Proulx, J., Profit, J. 2023; 49 (3): 156-165


    Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey.The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care context, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed-effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related domains, adjusted for role and work-setting characteristics.Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 ± 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics.Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

    View details for DOI 10.1016/j.jcjq.2022.12.006

    View details for Web of Science ID 000991813200001

    View details for PubMedID 36658090

    View details for PubMedCentralID PMC9974844

  • Racial and ethnic disparities in postnatal growth among very low birth weight infants in California. Journal of perinatology : official journal of the California Perinatal Association Lee, S. M., Sie, L., Liu, J., Profit, J., Main, E., Lee, H. C. 2023


    OBJECTIVE: To identify racial/ethnic disparities in postnatal growth by year and gestational age among very low birth weight infants.STUDY DESIGN: Total 37,122 infants, with birth weight 500-1500g or gestational age 23-34 weeks in the California Perinatal Quality Care Collaborative in 2008-2016. Postnatal growth failure (PGF) was defined as change in weight Z-score from birth to discharge below -1.28. Multivariable regression analysis with birth hospital as random effect was used to estimate odds ratios (OR).RESULTS: Infants born to Hispanic mothers had highest risk of PGF at 30%, compared to white (24%, OR 1.33), Black (22%, OR 1.50), or Asian/Pacific Islander mothers (23%, OR 1.38). PGF incidence decreased from 2008 (27.4%) to 2016 (22.8%) with differences in trends by race. Each increasing gestational age week was associated with decreasing risk for PGF (OR 0.73, 95% confidence interval 0.72-0.74).CONCLUSION: Targeted interventions addressing PGF are needed to address disparities.

    View details for DOI 10.1038/s41372-023-01612-9

    View details for PubMedID 36737570

  • Getting to health equity in NICU care in the USA and beyond. Archives of disease in childhood. Fetal and neonatal edition Profit, J., Edwards, E. M., Pursley, D. 2022


    Differences in race/ethnicity, gender, income and other social factors have long been associated with disparities in health, illness and premature death. Although the terms 'health differences' and 'health disparities' are often used interchangeably, health disparities has recently been reserved to describe worse health in socially disadvantaged populations, particularly members of disadvantaged racial/ethnic groups and the poor within a racial/ethnic group. Infants receiving disparate care based on race/ethnicity, immigration status, language proficiency, or social class may be discomforting to healthcare workers who dedicate their lives to care for these patients. Recent literature, however, has documented differences in neonatal intensive care unit (NICU) care quality that have contributed to racial and ethnic differences in mortality and significant morbidity. We examine the within-NICU and between-NICU mechanisms of disparate care and recommend approaches to address these disparities.

    View details for DOI 10.1136/archdischild-2021-323533

    View details for PubMedID 36379698

  • Physician Health and Wellness. Pediatrics McClafferty, H. H., Hubbard, D. K., Foradori, D., Brown, M. L., Profit, J., Tawfik, D. S., SECTION ON INTEGRATIVE MEDICINE, SECTION ON INTEGRATIVE MEDICINE, Brown, M. L., Breuner, C. C., Esparham, A., Gold, M. A., Misra, S. M., Morris, C. R., Tsai, S., Weydert, J. A., Bhakta, H. C., Salus, T. 2022


    Physician health and wellness is a complex topic relevant to all pediatricians. Survey studies have established that pediatricians experience burnout at comparable rates to colleagues across medical specialties. Prevalence of burnout increased for all pediatric disciplines from 2011 to 2014. During that time, general pediatricians experienced a more than 10% increase in burnout, from 35.3% to 46.3%. Pediatric medical subspecialists and pediatric surgical specialists experienced slightly higher baseline rates of burnout in 2011 and similarly increased to just under 50%. Women currently constitute a majority of pediatricians, and surveys report a 20% to 60% higher prevalence of burnout in women physicians compared with their male counterparts. The purpose of this report is to update the reader and explore approaches to pediatrician well-being and reduction of occupational burnout risk throughout the stages of training and practice. Topics covered include burnout prevalence and diagnosis; overview of national progress in physician wellness; update on physician wellness initiatives at the American Academy of Pediatrics; an update on pediatric-specific burnout and well-being; recognized drivers of burnout (organizational and individual); a review of the intersection of race, ethnicity, gender, and burnout; protective factors; and components of wellness (organizational and individual). The development of this clinical report has inevitably been shaped by the social, cultural, public health, and economic factors currently affecting our communities. The coronavirus disease 2019 (COVID-19) pandemic has layered new and significant stressors onto medical practice with physical, mental, and logistical challenges and effects that cannot be ignored.

    View details for DOI 10.1542/peds.2022-059665

    View details for PubMedID 36278292

  • Risk factors and pregnancy outcomes vary among Asian American, Native Hawaiian, and Pacific Islander individuals giving birth in California. Annals of epidemiology Bane, S., Abrams, B., Mujahid, M., Ma, C., Shariff-Marco, S., Main, E., Profit, J., Xue, A., Palaniappan, L., Carmichael, S. L. 2022


    OBJECTIVE: To compare frequencies of risk factors and pregnancy outcomes in ethnic groups versus the combined total of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations.METHODS: Using linked birth and fetal death certificate and maternal hospital discharge data (California 2007-2018), we estimated frequencies of 15 clinical and sociodemographic exposures and 11 pregnancy outcomes. Variability across 15 AANHPI groups was compared using a heat map and compared to frequencies for the total group (n=904,232).RESULTS: AANHPI groups varied significantly from each other and the combined total regarding indicators of social disadvantage (e.g., range for high school-level educational or less: 6.4% Korean-55.8% Samoan) and sociodemographic factors (e.g., maternal age <20 years: 0.2% Chinese-8.8% Guamanian) that are related to adverse pregnancy outcomes. Perinatal outcomes varied significantly (e.g., severe maternal morbidity: 1.2% Korean-1.9% Filipino). No single group consistently had risk factors or outcome prevalence at the extremes, i.e., no group was consistently better or worse off across examined factors.CONCLUSIONS: Substantial variability in perinatal risk factors and outcomes exists across AANHPI groups. Aggregation into "AANHPI" is not appropriate for outcome reporting.

    View details for DOI 10.1016/j.annepidem.2022.09.004

    View details for PubMedID 36115627

  • Emotional Exhaustion Among US Health Care Workers Before and During the COVID-19 Pandemic, 2019-2021. JAMA network open Sexton, J. B., Adair, K. C., Proulx, J., Profit, J., Cui, X., Bae, J., Frankel, A. 2022; 5 (9): e2232748


    Importance: Extraordinary strain from COVID-19 has negatively impacted health care worker (HCW) well-being.Objective: To determine whether HCW emotional exhaustion has increased during the pandemic, for which roles, and at what point.Design, Setting, and Participants: This survey study was conducted in 3 waves, with an electronic survey administered in September 2019, September 2020, and September 2021 through January 2022. Participants included hospital-based HCWs in clinical and nonclinical (eg, administrative support) roles at 76 community hospitals within 2 large health care systems in the US.Exposures: Safety, Communication, Organizational Reliability, Physician, and Employee Burnout and Engagement (SCORE) survey domains of emotional exhaustion and emotional exhaustion climate.Main Outcomes and Measures: The percentage of respondents reporting emotional exhaustion (%EE) in themselves and a climate of emotional exhaustion (%EEclim) in their colleagues. Survey items were answered on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree); neutral or higher scores were counted as "percent concerning" for exhaustion.Results: Electronic surveys were returned by 37 187 (of 49 936) HCWs in 2019, 38 460 (of 45 268) in 2020, and 31 475 (of 41 224) in 2021 to 2022 for overall response rates of 74.5%, 85.0%, and 76.4%, respectively. The overall sample comprised 107 122 completed surveys. Nursing was the most frequently reported role (n=43 918 [40.9%]). A total of 17 786 respondents (16.9%) reported less than 1 year at their facility, 59 226 (56.2%) reported 1 to 10 years, and 28 337 (26.9%) reported 11 years or more. From September 2019 to September 2021 through January 2022, overall %EE increased from 31.8% (95% CI, 30.0%-33.7%) to 40.4% (95% CI, 38.1%-42.8%), with a proportional increase in %EE of 26.9% (95% CI, 22.2%-31.8%). Physicians had a decrease in %EE from 31.8% (95% CI, 29.3%-34.5%) in 2019 to 28.3% (95% CI, 25.9%-31.0%) in 2020 but an increase during the second year of the pandemic to 37.8% (95% CI, 34.7%-41.3%). Nurses had an increase in %EE during the pandemic's first year, from 40.6% (95% CI, 38.4%-42.9%) in 2019 to 46.5% (95% CI, 44.0%-49.1%) in 2020 and increasing again during the second year of the pandemic to 49.2% (95% CI, 46.5%-51.9%). All other roles showed a similar pattern to nurses but at lower levels. Intraclass correlation coefficients revealed clustering of exhaustion within work settings across the 3 years, with coefficients of 0.15 to 0.17 for emotional exhaustion and 0.22 to 0.24 for emotional exhaustion climate, higher than the .10 coefficient typical of organizational climate (a medium effect for shared variance), suggestive of a social contagion effect of HCW exhaustion.Conclusions and Relevance: This large-scale survey study of HCWs spanning 3 years offers substantial evidence that emotional exhaustion trajectories varied by role but have increased overall and among most HCW roles since the onset of the pandemic. These results suggest that current HCW well-being resources and programs may be inadequate and even more difficult to use owing to lower workforce capacity and motivation to initiate and complete well-being interventions.

    View details for DOI 10.1001/jamanetworkopen.2022.32748

    View details for PubMedID 36129705

  • Associations between maternal residential rurality and maternal health, access to care, and very low birthweight infant outcomes. Journal of perinatology : official journal of the California Perinatal Association Ondusko, D. S., Liu, J., Hatch, B., Profit, J., Carter, E. H. 2022


    OBJECTIVE: Infant mortality is increased in isolated rural areas. This study compares prenatal factors, access to care, and health outcomes for very-low birthweight (VLBW) infants by degree of maternal residential rurality.METHODS: This descriptive population-based retrospective cohort study used the California Perinatal Quality Care Collaborative registry to study VLBW infants. Rurality was assigned as urban, large rural, and small rural/isolated using the Rural Urban Commuting Area codes. We used hierarchical random effect models to test the association of rurality with survival without major morbidity.RESULTS: The study included 38 614 dyads. VLBW survival without major morbidity decreased with increasing rurality and the relationship remained significant for small rural/isolated areas (OR 0.79, p=0.03) after adjustment. Birth weight, gestational age, and infant sex were similar across geographic groups.CONCLUSION: A rural urban disparity exists for VLBW survival without major morbidity. Our findings generate hypotheses about factors that may be driving these disparities.

    View details for DOI 10.1038/s41372-022-01456-9

    View details for PubMedID 35821103

  • Implementation of a Bedside Point-of-Care Ultrasound Program in a Large Academic Neonatal Intensive Care Unit. American journal of perinatology Pai, V. V., Noh, C. Y., Dasani, R., Vallandingham, S., Manipon, C., Haileselassie, B., Profit, J., Balasundaram, M., Davis, A. S., Bhombal, S. 2022


     In the adult and pediatric critical care population, point-of-care ultrasound (POCUS) can aid in diagnosis, patient management, and procedural accuracy. For neonatal providers, training in ultrasound and the use of ultrasound for diagnosis and management is increasing, but use in the neonatal intensive care unit (NICU) is still uncommon compared with other critical care fields. Our objective was to describe the process of implementing a POCUS program in a large academic NICU and evaluate the role of ultrasound in neonatal care during early adaption of this program. A POCUS program established in December 2018 included regular bedside scanning, educational sessions, and quality assurance, in collaboration with members of the cardiology, radiology, and pediatric critical care divisions. Core applications were determined, and protocols outlined guidelines for image acquisition. An online database included images and descriptive logs for each ultrasound. A total of 508 bedside ultrasounds (76.8% diagnostic and 23.2% procedural) were performed by 23 providers from December 2018 to December 2020 in five core diagnostic applications: umbilical line visualization, cardiac, lung, abdomen (including bladder), and cranial as well as procedural applications. POCUS guided therapy and influenced clinical management in all applications: umbilical line assessment (26%), cardiac (33%), lung (14%), abdomen (53%), and cranial (43%). With regard to procedural ultrasound, 74% of ultrasound-guided arterial access and 89% of ultrasound-guided lumbar punctures were successful. Implementation of a POCUS program is feasible in a large academic NICU and can benefit from a team approach. Establishing a program in any NICU requires didactic opportunities, a defined scope of practice, and imaging review with quality assurance. Bedside clinician performed ultrasound findings can provide valuable information in the NICU and impact clinical management.· Use of point-of-care ultrasound is increasing in neonatology and has been shown to improve patient care.. · Implementation of a point-of-care ultrasound program requires the definition of scope of practice and can benefit from the support of other critical care and imaging departments and providers.. · Opportunities for point-of-care ultrasound didactics, imaging review, and quality assurance can enhance the utilization of bedside ultrasound..

    View details for DOI 10.1055/s-0042-1750118

    View details for PubMedID 35691294

  • Disparities and early engagement associated with the 18-36 month high risk infant follow up visit among very low birthweight infants in California. The Journal of pediatrics Lakshmanan, A., Rogers, E. E., Lu, T., Gray, E., Vernon, L., Briscoe, H., Profit, J., Jocson, M. A., Hintz, S. R. 2022


    OBJECTIVE: To determine follow-up rates for the high-risk infant follow-up (HRIF) visit at 18-36 months among infants with very low birthweights (VLBW) and identify factors associated with completion.STUDY DESIGN: We completed a retrospective cohort study using linked California Perinatal Quality of Care Collaborative (CPQCC) neonatal intensive care unit (NICU), CPQCC California Children's Services HRIF, and Vital Statistics Birth Cohort databases. We identified maternal, sociodemographic, neonatal, clinical and HRIF program level factors associated with 18-36 month follow-up using multivariable Poisson regression.RESULT: From 2010-2015, among 19,284 infants with VLBW expected to attend at least one visit at 18-36 months, 10,249 (53%) attended. On multivariable analysis, factors independently associated with attendance at a 18-36 month visit included estimated gestational age (RR 1.21, 95% CI 1.15 -1.26; <26 weeks vs. 31+), maternal education (RR 1.09, 95% CI 1.06 -1.12; college degree or more vs. high school), distance from clinic (RR 0.92, 95% CI 0.89-0.97; 4th quartile vs 1st quartile), Black non-Hispanic race vs. White (RR 0.88, 95% CI 0.84-0.92). However, completion of an initial HRIF visit within the first 12 months was the factor most strongly associated with completion of a 18-36 month visit (RR 6.47, 95% CI 5.91-7.08).CONCLUSION: In a California VLBW cohort, maternal education, race and distance from the clinic were associated with sustained HRIF participation, but attendance at a visit by 12 months was the most significantly associated factor. These findings highlight the importance of early engagement with all families to ensure equitable follow-through for children born preterm.

    View details for DOI 10.1016/j.jpeds.2022.05.026

    View details for PubMedID 35597303

  • Increasing early exposure to mother's own milk in premature newborns. Journal of perinatology : official journal of the California Perinatal Association Balasundaram, M., Land, R., Miller, S., Profit, J., Porter, M., Arnold, C., Sivakumar, D. 2022


    OBJECTIVE: Increase the proportion of ≤33 weeks newborns exposed to mother's own milk (MOM) oral care by 12h of age by 20% over 2 years to support a healthier microbiome.STUDY DESIGN: We implemented interventions to support early expression of colostrum and reliable delivery of resultant MOM to premature newborns. Statistical process control charts were used to track progress and provide feedback to staff. Proportions of newborns exposed to MOM by 12h were compared relative to baseline.RESULTS: There were 46, 66, and 46 newborns in the baseline, implementation, and sustainability periods, respectively. The primary outcome improved from 48% to 61% in the implementation period (relative change 1.27, 95% CI 0.89, 1.81, p=0.2), to 69% in sustainability period (relative to baseline 1.45, 95% CI 1.02, 2.08, p=0.03).CONCLUSION: An interdisciplinary team-based, multicycle, quality improvement intervention resulted in increased rates of early exposure to MOM.

    View details for DOI 10.1038/s41372-022-01376-8

    View details for PubMedID 35396577

  • Purpose, Subject, and Consumer Comment on "Perceived Burden Due to Registrations for Quality Monitoring and Improvement in Hospitals: A Mixed Methods Study". International journal of health policy and management Hysong, S. J., O'Mahen, P., Profit, J., Petersen, L. A. 2022


    Zegers and colleagues' study codifies the perceived burden of quality monitoring and improvement stemming from the work by clinicians of registering (documenting) quality information in the medical record. We agree with Zegers and colleagues' recommendation that a smaller, more effective and curated set of measures is needed to reduce burden, confusion, and expense. We further note that focusing on validity of clinical evidence behind individual measures is critical, but insufficient. We therefore extend Zegers and colleagues' work through a pragmatic, tripartite heuristic. To assess the value of and curate a targeted set of performance measures, we propose concentrating on the relationships among three factors: (1) The purpose of the performance measure, (2) the subject being evaluated, and (3) the consumer using information for decision-making. Our proposed tripartite framework lays the groundwork for executing the evidence-based recommendations proposed by Zegers et al, and provides a path forward for more effective healthcare performance-measurement systems.

    View details for DOI 10.34172/ijhpm.2022.6495

    View details for PubMedID 35174682

  • Purpose, Subject, and Consumer: Comment on "Perceived Burden Due to Registrations for Quality Monitoring and Improvement in Hospitals: A Mixed Methods Study" INTERNATIONAL JOURNAL OF HEALTH POLICY AND MANAGEMENT Hysong, S. J., O'Mahen, P., Profit, J., Petersen, L. A. 2022
  • Disruptive Therapy Using a Nonsurgical Orthodontic Airway Plate for the Management of Neonatal Robin Sequence: 1-Year Follow-up. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Choo, H., Galera, R. I., Balakrishnan, K., Lin, H. C., Ahn, H., Lorenz, P., Khosla, R. K., Profit, J., Poets, C. F., Lee, J. S. 2022: 10556656221076980


    We recently published the 3-month follow-up of 2 neonates with Robin sequence whose mandibular hypoplasia and restricted airway were successfully treated with an orthodontic airway plate (OAP) without surgical intervention. Both infants were successfully weaned off the OAP after several months of continuous use. We present the course of OAP treatment in these patients with a focus on breathing, feeding, and facial growth during their first year of life. Both infants demonstrated stable mandibular projection, resolution of obstructive sleep apnea, and normal development.

    View details for DOI 10.1177/10556656221076980

    View details for PubMedID 35167404

  • Effectiveness of a bite-sized web-based intervention to improve healthcare worker wellbeing: A randomized clinical trial of WISER. Frontiers in public health Sexton, J. B., Adair, K. C., Cui, X., Tawfik, D. S., Profit, J. 2022; 10: 1016407


    Importance: Problems with the wellbeing of healthcare workers (HCWs) are widespread and associated with detrimental consequences for the workforce, organizations, and patients.Objective: This study tested the effectiveness of the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention, a positive psychology program, to improve six dimensions of the wellbeing of HCWs.Design: We conducted a randomized controlled trial of HCWs between 1 April 2018 and 22 July 2019. Cohort 1 received WISER daily for 10 days. Cohort 2 acted as a waitlist control before receiving WISER.Setting: Web-based intervention for actively employed HCWs across the United States.Participants: Eligibility criteria included being ≥18 years old and working as a HCW. Each participant was randomized to start the intervention or serve as a waitlist control for 14 days before starting the intervention.Interventions: Cohorts received links via 10 texts exposing them to introductory videos and positive psychology exercises (3 good things, cultivating awe, random acts of kindness, cultivating relationships, and gratitude letters).Main outcomes and measures: The primary outcome was emotional exhaustion; secondary outcomes included depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. All outcomes were assessed at baseline, 1-week post-intervention (primary endpoint), and 1, 6, and 12-month post-intervention. Outcomes were measured using six validated wellbeing instruments, rescaled to 100-point scales for comparison. Six items assessed participants' WISER experience. The analysis employed mixed-effects models.Results: In cohorts 1 and 2, 241 and 241 initiated WISER, and 178 (74%) and 186 (77%) completed the 6-month follow-up, respectively. Cohort populations were similar at baseline, mostly female (81; 76%) and nurses (34; 32%) or physicians (22; 23%), with 1-10 years of experience in their current position (54; 52%). Relative to control, WISER significantly improved depressive symptoms [-7.5 (95%CI: -11.0, -4.0), p < 0.001], work-life integration [6.5 (95%CI: 4.1, 8.9), p < 0.001], happiness [5.7 (95%CI: 3.0, 8.4), p < 0.001], emotional thriving [6.4 (95%CI: 2.5, 10.3), p = 0.001], and emotional recovery [5.3 (95%CI: 1.7, 8.9), p = 0.004], but not emotional exhaustion [-3.7 (95%CI: -8.2, 0.8), p = 0.11] at 1 week. Combined cohort results at 1, 6, and 12 months showed that all six wellbeing outcomes were significantly improved relative to baseline (p < 0.05 for all). Favorable impressions of WISER were reported by 87% of participants at the 6-month post-assessment.Conclusion and relevance: WISER improved HCW depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. Improvements in all HCW wellbeing outcomes endured at the 1-, 6-, and 12-month follow-ups. HCW's impressions of WISER were positive.Clinical trials number:, identifier: NCT02603133. Web-based Implementation for the Science of Enhancing Resilience Study (WISER).

    View details for DOI 10.3389/fpubh.2022.1016407

    View details for PubMedID 36568789

  • Does magnesium sulfate for hypertensive disease reduce the risk of neonatal hypoxic ischemic encephalopathy? Minor, K. C., Liu, J., El-Sayed, Y. Y., Druzin, M. L., Profit, J., Hintz, S., Bonifacio, S., Leonard, S. A., Karakash, S. MOSBY-ELSEVIER. 2022: S526
  • Hypoxic ischemic encephalopathy: Do peripartum risk factors account for observed changes in incidence? Minor, K. C., Liu, J., El-Sayed, Y. Y., Druzin, M. L., Profit, J., Hintz, S., Bonifacio, S., Karakash, S. MOSBY-ELSEVIER. 2022: S210
  • Evaluating Care in Safety Net Hospitals: Clinical Outcomes and NICU Quality of Care in California. The Journal of pediatrics Liu, J., Pang, E. M., Iacob, A., Simonian, A., Phibbs, C. S., Profit, J. 2021


    OBJECTIVES: To examine the characteristics of safety net (sn) and non-safety net neonatal intensive care units (NICUs) in California and whether the site of care is associated with clinical outcomes.STUDY DESIGN: This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22,081 infants born between 2014-2018 with birth weights of 401-1500g or gestational ages of 22-29 weeks. Quality of care as measured by Baby-MONITOR score and rates of survival without major morbidity were compared between snNICUs and non-snNICUs.RESULTS: Black and Hispanic infants were disproportionately cared for in snNICUs, where care and outcomes varied widely. We found no significant differences in Baby-MONITOR scores (snNICUs: z-score (SD) = -0.31 (1.3); non-snNICUs: 0.03 (1.1), P = 0.1). Among individual components, infants in snNICUs exhibited lower rates of human milk nutrition at discharge (-0.64 (1.0) vs. 0.27 (0.9)), lower rates of no healthcare associated infection (-0.27 (1.1) vs. 0.14 (0.9)) and higher rates of no hypothermia on admission (0.39 (0.7) vs. -0.25 (1.1)). We found small but significant differences in survival without major morbidity (Adjusted rate = 65.9% (63.9-67.9) for snNICUs vs. 68.3% (67.0-69.6) for non-snNICUs, p=0.02) and in some of its components; snNICUS had higher rates of necrotizing enterocolitis (3.8% (3.4-4.3) vs. 3.1% (2.8-3.4)) and mortality (7.1% (6.5-7.7) vs. 6.6% (6.2-7.0)).CONCLUSIONS: Safety net NICUs achieved similar performance to non-snNICUs in quality of care, except for small but significant differences in any human milk at discharge, infection, hypothermia, necrotizing enterocolitis, and mortality.

    View details for DOI 10.1016/j.jpeds.2021.12.003

    View details for PubMedID 34890584

  • Evaluation of trends in Bronchopulmonary Dysplasia and Respiratory Support Practice for Very Low Birth Weight Infants: A Population-Based Cohort Study. The Journal of pediatrics Lee, S. M., Sie, L., Liu, J., Profit, J., Lee, H. C. 2021


    OBJECTIVES: To characterize the incidence of bronchopulmonary dysplasia (BPD) over time and test the association of multi-level factors, including respiratory support, with the diagnosis of BPD.STUDY DESIGN: This population-based cohort study included 40,268 infants born between 22 and 32 weeks of gestation at hospitals in California between 2008 and 2017. BPD diagnosis was based on respiratory support at 36 weeks post-menstrual age. Tests for linear trend and multivariable logistic regression analyses were performed.RESULTS: The rate of BPD was consistent year over year, and the mortality rate declined. The incidence of BPD was 23.5% for the overall cohort, and was 44.9% for less than 28 weeks gestational age and 45.2% for extremely low birth weight infants. For infants >26 weeks gestational age, the incidence of BPD for the most recent three years significantly decreased compared with vthe earlier three years (odds ratio (OR) 0.91). Invasive ventilation during delivery room resuscitation (OR 2.64) and after leaving the delivery room (OR 10.02) conferred the highest risk of BPD compared with oxygen or no respiratory support. Non-invasive ventilation as maximum respiratory support at 36 weeks increased by 20% over time.CONCLUSIONS: Marked changes to non-invasive support care have occurred without an overall decline in BPD rates. Further research, quality improvement, and strategies in addition to non-invasive respiratory support are needed for reduction of BPD.

    View details for DOI 10.1016/j.jpeds.2021.11.049

    View details for PubMedID 34838581

  • Institutional Racism: A Key Contributor to Perinatal Health Inequity. Pediatrics Dhurjati, R., Main, E., Profit, J. 2021

    View details for DOI 10.1542/peds.2021-050768

    View details for PubMedID 34429337

  • Randomized controlled trial of the "WISER" intervention to reduce healthcare worker burnout JOURNAL OF PERINATOLOGY Profit, J., Adair, K. C., Cui, X., Mitchell, B., Brandon, D., Tawfik, D. S., Rigdon, J., Gould, J. B., Lee, H. C., Timpson, W. L., McCaffrey, M. J., Davis, A. S., Pammi, M., Matthews, M., Stark, A. R., Papile, L., Thomas, E., Cotten, M., Khan, A., Sexton, J. 2021
  • Quality of Care in US NICUs by Race and Ethnicity. Pediatrics Edwards, E. M., Greenberg, L. T., Profit, J., Draper, D., Helkey, D., Horbar, J. D. 2021


    BACKGROUND: Summary measures are used to quantify a hospital's quality of care by combining multiple metrics into a single score. We used Baby-MONITOR, a summary quality measure for NICUs, to evaluate quality by race and ethnicity across and within NICUs in the United States.METHODS: Vermont Oxford Network members contributed data from 2015 to 2019 on infants from 25 to 29 weeks' gestation or of 401 to 1500 g birth weight who were inborn or transferred to the reporting hospital within 28 days of birth. Nine Baby-MONITOR measures were individually risk adjusted, standardized, equally weighted, and averaged to derive scores for African American, Hispanic, Asian American, and American Indian infants, compared with white infants.RESULTS: This prospective cohort included 169400 infants at 737 hospitals. Across NICUs, Hispanic and Asian American infants had higher Baby-MONITOR summary scores, compared with those of white infants. African American and American Indian infants scored lower on process measures, and all 4 minority groups scored higher on outcome measures. Within NICUs, the mean summary scores for African American, Hispanic, and Asian American NICU subsets were higher, compared with those of white infants in the same NICU. American Indian summary NICU scores were not different, on average.CONCLUSIONS: With Baby-MONITOR, we identified differences in NICU quality by race and ethnicity. However, the summary score masked within-measure quality gaps that raise unanswered questions about the relationships between race and ethnicity and processes and outcomes of care.

    View details for DOI 10.1542/peds.2020-037622

    View details for PubMedID 34301773

  • Frustration With Technology and its Relation to Emotional Exhaustion Among Health Care Workers: Cross-sectional Observational Study. Journal of medical Internet research Tawfik, D. S., Sinha, A., Bayati, M., Adair, K. C., Shanafelt, T. D., Sexton, J. B., Profit, J. 2021; 23 (7): e26817


    BACKGROUND: New technology adoption is common in health care, but it may elicit frustration if end users are not sufficiently considered in their design or trained in their use. These frustrations may contribute to burnout.OBJECTIVE: This study aimed to evaluate and quantify health care workers' frustration with technology and its relationship with emotional exhaustion, after controlling for measures of work-life integration that may indicate excessive job demands.METHODS: This was a cross-sectional, observational study of health care workers across 31 Michigan hospitals. We used the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey to measure work-life integration and emotional exhaustion among the survey respondents. We used mixed-effects hierarchical linear regression to evaluate the relationship among frustration with technology, other components of work-life integration, and emotional exhaustion, with adjustment for unit and health care worker characteristics.RESULTS: Of 15,505 respondents, 5065 (32.7%) reported that they experienced frustration with technology on at least 3-5 days per week. Frustration with technology was associated with higher scores for the composite Emotional Exhaustion scale (r=0.35, P<.001) and each individual item on the Emotional Exhaustion scale (r=0.29-0.36, P<.001 for all). Each 10-point increase in the frustration with technology score was associated with a 1.2-point increase (95% CI 1.1-1.4) in emotional exhaustion (both measured on 100-point scales), after adjustment for other work-life integration items and unit and health care worker characteristics.CONCLUSIONS: This study found that frustration with technology and several other markers of work-life integration are independently associated with emotional exhaustion among health care workers. Frustration with technology is common but not ubiquitous among health care workers, and it is one of several work-life integration factors associated with emotional exhaustion. Minimizing frustration with health care technology may be an effective approach in reducing burnout among health care workers.

    View details for DOI 10.2196/26817

    View details for PubMedID 34255674

  • Safety Culture and Workforce Well-Being Associations with Positive Leadership WalkRounds JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Sexton, J., Adair, K. C., Profit, J., Bae, J., Rehder, K. J., Gosselin, T., Milne, J., Leonard, M., Frankel, A. 2021; 47 (7): 403-411


    Interventions to decrease burnout and increase well-being in health care workers (HCWs) and improve organizational safety culture are urgently needed. This study was conducted to determine the association between Positive Leadership WalkRounds (PosWR), an organizational practice in which leaders conduct rounds and ask staff about what is going well, and HCW well-being and organizational safety culture.This study was conducted in a large academic health care system in which senior leaders were encouraged to conduct PosWR. The researchers used data from a routine cross-sectional survey of clinical and nonclinical HCWs, which included a question about recall of exposure of HCWs to PosWR: "Do senior leaders ask for information about what is going well in this work setting (e.g., people who deserve special recognition for going above and beyond, celebration of successes, etc.)?"-along with measures of well-being and safety culture. T-tests compared work settings in the first and fourth quartiles for PosWR exposure across SCORE (Safety, Communication, Operational Reliability, and Engagement) domains of safety culture and workforce well-being.Electronic surveys were returned by 10,627 out of 13,040 possible respondents (response rate 81.5%) from 396 work settings. Exposure to PosWR was reported by 63.1% of respondents overall, with a mean of 63.4% (standard deviation = 20.0) across work settings. Exposure to PosWR was most commonly reported by HCWs in leadership roles (83.8%). Compared to work settings in the fourth (< 50%) quartile for PosWR exposure, those in the first (> 88%) quartile revealed a higher percentage of respondents reporting good patient safety norms (49.6% vs. 69.6%, p < 0.001); good readiness to engage in quality improvement activities (60.6% vs. 76.6%, p < 0.001); good leadership accessibility and feedback behavior (51.9% vs. 67.2%, p < 0.001); good teamwork norms (36.8% vs. 52.7%, p < 0.001); and good work-life balance norms (61.9% vs. 68.9%, p = 0.003). Compared to the fourth quartile, the first quartile had a lower percentage of respondents reporting emotional exhaustion in themselves (45.9% vs. 32.4%, p < 0.001), and in their colleagues (60.5% vs. 47.7%, p < 0.001).Exposure to PosWR was associated with better HCW well-being and safety culture.

    View details for DOI 10.1016/j.jcjq.2021.04.001

    View details for Web of Science ID 000665772900003

    View details for PubMedID 34024756

    View details for PubMedCentralID PMC8240670

  • Quantifying the variation in neonatal transport referral patterns using network analysis. Journal of perinatology : official journal of the California Perinatal Association Kunz, S. N., Helkey, D., Zitnik, M., Phibbs, C. S., Rigdon, J., Zupancic, J. A., Profit, J. 2021


    OBJECTIVE: Regionalized care reduces neonatal morbidity and mortality. This study evaluated the association of patient characteristics with quantitative differences in neonatal transport networks.STUDY DESIGN: We retrospectively analyzed prospectively collected data for infants <28 days of age acutely transported within California from 2008 to 2012. We generated graphs representing bidirectional transfers between hospitals, stratified by patient attribute, and compared standard network analysis metrics.RESULT: We analyzed 34,708 acute transfers, representing 1594 unique transfer routes between 271 hospitals. Density, centralization, efficiency, and modularity differed significantly among networks drawn based on different infant attributes. Compared to term infants and to those transported for medical reasons, network metrics identify greater degrees of regionalization for preterm and surgical patients (more centralized and less dense, respectively [p<0.001]).CONCLUSION: Neonatal interhospital transport networks differ by patient attributes as reflected by differences in network metrics, suggesting that regionalization should be considered in the context of a multidimensional system.

    View details for DOI 10.1038/s41372-021-01091-w

    View details for PubMedID 34035453

  • Personal and Professional Factors Associated With Work-Life Integration Among US Physicians. JAMA network open Tawfik, D. S., Shanafelt, T. D., Dyrbye, L. N., Sinsky, C. A., West, C. P., Davis, A. S., Su, F., Adair, K. C., Trockel, M. T., Profit, J., Sexton, J. B. 2021; 4 (5): e2111575


    Importance: Poor work-life integration (WLI) occurs when career and personal responsibilities come in conflict and may contribute to the ongoing high rates of physician burnout. The characteristics associated with WLI are poorly understood.Objective: To identify personal and professional factors associated with WLI in physicians and identify factors that modify the association between gender and WLI.Design, Setting, and Participants: This cross-sectional study was based on electronic and paper surveys administered October 2017 to March 2018 at private, academic, military, and veteran's practices across the US. It used a population-based sample of US physicians across all medical specialties. Data analysis was performed from November 2019 to July 2020.Main Outcomes and Measures: WLI was assessed using an 8-item scale (0-100 point scale, with higher scores indicating favorable WLI), alongside personal and professional factors. Multivariable linear regressions evaluated independent associations with WLI as well as factors that modify the association between gender and WLI.Results: Of 5197 physicians completing surveys, 4370 provided complete responses. Of the physicians who provided complete responses, 2719 were men, 3491 were White/Caucasian (80.8%), 3560 were married (82.4%), and the mean (SD) age was 52.3 (12.0) years. The mean (SD) WLI score was 55 (23). Women reported lower (worse) mean (SD) WLI scores than men overall (52 [22] vs 57 [23]; mean difference, -5 [-0.2 SDs]; P<.001). In multivariable regression, lower WLI was independently associated with being a woman (linear regression coefficient, -6; SE, 0.7; P<.001) as well as being aged 35 years or older (eg, aged 35 to 44 years: linear regression coefficient, -7; SE, 1.4; P<.001), single (linear regression coefficient, -3 vs married; SE, 1.1; P=.003), working more hours (eg, 50 to 59 hours per week vs less than 40 hours per week: linear regression coefficient, -9; SE, 1.0; P<.001) and call nights (linear regression coefficient, -1 for each call night per week; SE, 0.2; P<.001), and being in emergency medicine (linear regression coefficient, -18; SE, 1.6, P<.001), urology (linear regression coefficient, -11; SE, 4.0; P=.009), general surgery (linear regression coefficient, -4; SE, 2.0; P=.04), anesthesiology (linear regression coefficient, -4; SE, 1.7; P=.03), or family medicine (linear regression coefficient, -3; SE, 1.4; P=.04) (reference category, internal medicine subspecialties). In interaction modeling, physician age, youngest child's age, and hours worked per week modified the associations between gender and WLI, such that the largest gender disparities were observed in physicians who were aged 45 to 54 years (estimated WLI score for women, 49; 95% CI, 47-51; estimated WLI score for men, 57, 95% CI, 55-59; P<.001), had youngest child aged 23 years or older (estimated WLI score for women, 51; 95% CI, 48-54; estimated WLI score for men, 60; 95% CI, 58-62; P<.001), and were working less than 40 hours per week (estimated WLI score for women, 61; 95% CI, 59-63; estimated WLI score for men; 70; 95% CI, 68-72; P<.001).Conclusions and Relevance: This study found that lower WLI was reported by physicians who are women, single, aged 35 years or older, and who work more hours and call nights. These findings suggest that systemic change is needed to improve WLI among physicians.

    View details for DOI 10.1001/jamanetworkopen.2021.11575

    View details for PubMedID 34042994

  • Perceptions of Institutional Support for "Second Victims" Are Associated with Safety Culture and Workforce Well-Being JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Sexton, J., Adair, K. C., Profit, J., Milne, J., McCulloh, M., Scott, S., Frankel, A. 2021; 47 (5): 306–12


    This study was performed to determine whether health care worker (HCW) assessments of good institutional support for second victims were associated with institutional safety culture and workforce well-being.HCWs' awareness of work colleagues emotionally traumatized by an unanticipated clinical event (second victims), their perceptions of level of institutional support for such colleagues, safety culture, and workforce well-being were assessed using a cross-sectional survey (SCORE [Safety, Communication, Operational Reliability, and Engagement] survey). Safety culture scores and workforce well-being scores were compared across work settings with high (top quartile) and low (bottom quartile) perceptions of second victim support.Of the 10,627 respondents (81.5% response rate), 36.3% knew at least one work colleague who had been traumatized by an unanticipated clinical event. Across 396 work settings, the percentage of respondents agreeing (slightly or strongly) that second victims receive appropriate support ranged from 0% to 100%. Across all respondents, significant correlations between perceived support for second victims and all SCORE domains (Improvement Readiness, Local Leadership, Teamwork Climate, Safety Climate, Emotional Exhaustion, Burnout Climate, and Work-Life Balance) were found. The 24.9% of respondents who knew an actual second victim and reported inadequate institutional support were significantly more negative in their assessments of safety culture and well-being than the 42.2% who reported adequate institutional support.Perceived institutional support for second victims was associated with a better safety culture and lower emotional exhaustion. Investment in programs to support second victims may improve overall safety culture and HCW well-being.

    View details for DOI 10.1016/j.jcjq.2020.12.001

    View details for Web of Science ID 000645092800008

    View details for PubMedID 33563556

  • COVID-19 preparedness-a survey among neonatal care providers in low- and middle-income countries. Journal of perinatology : official journal of the California Perinatal Association Klingenberg, C., Tembulkar, S. K., Lavizzari, A., Roehr, C. C., Ehret, D. E., Vain, N. E., Mariani, G. L., Erdeve, O., Lara-Diaz, V. J., Velaphi, S., Cheong, H. K., Bisht, S. S., Waheed, K. A., Stevenson, A. G., Al-Kafi, N., Roue, J., Barrero-Castillero, A., Molloy, E. J., Zupancic, J. A., Profit, J., International Neonatal COVID-19 Consortium 2021


    OBJECTIVE: To evaluate COVID-19 pandemic preparedness, available resources, and guidelines for neonatal care delivery among neonatal health care providers in low- and middle-income countries (LMICs) across all continents.STUDY DESIGN: Cross-sectional, web-based survey administered between May and June, 2020.RESULTS: Of 189 invited participants in 69 LMICs, we received 145 (77%) responses from 58 (84%) countries. The pandemic provides significant challenges to neonatal care, particularly in low-income countries. Respondents noted exacerbations of preexisting shortages in staffing, equipment, and isolation capabilities. In Sub-Saharan Africa, 9/35 (26%) respondents noted increased mortality in non-COVID-19-infected infants. Clinical practices on cord clamping, isolation, and breastfeeding varied widely, often not in line with World Health Organization guidelines. Most respondents noted family access restrictions, and limited shared decision-making.CONCLUSIONS: Many LMICs face an exacerbation of preexisting resource challenges for neonatal care during the pandemic. Variable approaches to care delivery and deviations from guidelines provide opportunities for international collaborative improvement.

    View details for DOI 10.1038/s41372-021-01019-4

    View details for PubMedID 33850282

  • PretermConnect: Leveraging mobile technology to mitigate social disadvantage in the NICU and beyond. Seminars in perinatology Jani, S. G., Nguyen, A. D., Abraham, Z., Scala, M., Blumenfeld, Y. J., Morton, J., Nguyen, M., Ma, J., Hsing, J. C., Moiwa-Grant, M., Profit, J., Wang, C. J. 2021: 151413


    Preterm birth (PTB) - delivery prior to 37-weeks gestation - disproportionately affects low-income and minority populations and leads to substantial infant morbidity and mortality. The time following a PTB represents an optimal window for targeted interventions that encourage mothers to prioritize their own health and that of their babies. Healthcare teams can leverage digital strategies to address maternal and infant needs in this postpartum period, both in the neonatal intensive care unit and beyond. We therefore developed PretermConnect, a mobile app designed to educate, engage, and empower women at risk for PTB. This article describes the participant-centered design approach of PretermConnect, with preliminary findings from focus groups and co-design sessions in different community settings and suggested future directions for mobile technologies in population health. Apps such as PretermConnect can mitigate social disadvantage by serving as remote monitoring tools, providing social support, preventing recurrent PTB and lowering infant mortality rates.

    View details for DOI 10.1016/j.semperi.2021.151413

    View details for PubMedID 33888330

  • Unequal care: Racial/ethnic disparities in neonatal intensive care delivery. Seminars in perinatology Ravi, D., Iacob, A., Profit, J. 2021: 151411


    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.

    View details for DOI 10.1016/j.semperi.2021.151411

    View details for PubMedID 33902931

  • Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations. Seminars in perinatology Lorch, S. A., Rogowski, J., Profit, J., Phibbs, C. S. 2021: 151409


    Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to present theimportance of delivery hospitals on neonatal outcomes, discuss variation in access to these hospitals for high-risk infants and their mothers, and to provide insight into drivers for differences in access to high-quality perinatal care using the available literature.This review also illustrates the lack of information on a number of topics that are crucial to the development of evidence-based interventions to improve access to appropriate delivery hospital services and thus optimize the outcomes of high-risk mothers and their newborns.

    View details for DOI 10.1016/j.semperi.2021.151409

    View details for PubMedID 33931237

  • Introduction. Seminars in perinatology Ravi, D., Profit, J. 2021: 151406

    View details for DOI 10.1016/j.semperi.2021.151406

    View details for PubMedID 33902930

  • Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic. Journal of perinatology : official journal of the California Perinatal Association Haidari, E., Main, E. K., Cui, X., Cape, V., Tawfik, D. S., Adair, K. C., Sexton, B. J., Profit, J. 2021


    OBJECTIVE: To assess maternal and neonatal healthcare workers (HCWs) perspectives on well-being and patient safety amid the COVID-19 pandemic.STUDY DESIGN: Anonymous survey of HCW well-being, burnout, and patient safety over the prior conducted in June 2020. Results were analyzed by job position and burnout status.RESULT: We analyzed 288 fully completed surveys. In total, 66% of respondents reported symptoms of burnout and 73% felt burnout among their co-workers had significantly increased. Workplace strategies to address HCW well-being were judged by 34% as sufficient. HCWs who were "burned out" reported significantly worse well-being and patient safety attributes. Compared to physicians, nurses reported higher rates of unprofessional behavior (37% vs. 14%, p=0.027) and difficulty focusing on work (59% vs. 36%, p=0.013).CONCLUSION: Three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.

    View details for DOI 10.1038/s41372-021-01014-9

    View details for PubMedID 33727700

  • Choosing wisely for the other 80%: What we need to know about the more mature newborn and NICU care. Seminars in perinatology Braun, D. n., Edwards, E. M., Schulman, J. n., Profit, J. n., Pursley, D. M., Goodman, D. C. 2021: 151395


    Although neonatal intensive unit (NICU) care is envisioned as the care of very immature infants, more than 95% of births and 80% of NICU admissions are of more mature newborns-infants born at 34 or more weeks' gestation. In spite of the size of this population there are important gaps in the understanding of their needs and optimal management as reflected by remarkably large unexplained variation in their care. The goal of this article is to describe what is known about the more mature, higher birth weight newborn population's use of NICU care and highlight important gaps in knowledge and obstacles to research. Research priorities are identified: including (1) the need for birth population based rather than NICU based studies, and (2) population specific data elements. Summary: More mature newborns-infants of 34 or more weeks' gestation-account for most NICU admissions. There are large gaps in the understanding of their needs and optimal management as reflected by large unexplained variation in their care. We enumerate these gaps in current knowledge and suggest research priorities to address them.

    View details for DOI 10.1016/j.semperi.2021.151395

    View details for PubMedID 33573773

  • The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care JOURNAL OF PATIENT SAFETY Profit, J., Sharek, P. J., Cui, X., Nisbet, C. C., Thomas, E. J., Tawfik, D. S., Lee, H. C., Draper, D., Sexton, J. 2020; 16 (4): E310–E316
  • Changing safety culture. Journal of perinatology : official journal of the California Perinatal Association Ravi, D., Tawfik, D. S., Sexton, J. B., Profit, J. 2020


    Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.

    View details for DOI 10.1038/s41372-020-00839-0

    View details for PubMedID 33024255

  • Birth Hospital and Racial/Ethnic Differences in Severe Maternal Morbidity in the State of California. American journal of obstetrics and gynecology Mujahid, M. S., Kan, P., Leonard, S. A., Hailu, E. M., Wall-Wieler, E., Abrams, B., Main, E., Profit, J., Carmichael, S. L. 2020


    BACKGROUND: Birth hospital has recently emerged as a potentially key contributor to disparities in severe maternal morbidity, but investigations remain limited.OBJECTIVES: We leveraged state-wide data from California to examine whether birth hospital explained racial/ethnic differences in severe maternal morbidity.METHODS: This cohort study used data on all births ≥20 weeks in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least one of 21 diagnoses and procedures (e.g. eclampsia, blood transfusion, hysterectomy). Mixed effects logistic regression models (i.e. women nested within hospitals) were used to compare racial/ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, co-morbidities, and hospital characteristics. We also estimated risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percent reduction in severe maternal morbidity if each group of racially/ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic White women.RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian/Pacific Islander; 1.1% White; 1.6% American Indian/Alaska Native and Mixed Race referred to as "Other"). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, odds of severe maternal morbidity was greater among non-White women compared to Whites in a given hospital (Odds Ratios and 95% Confidence Intervals; Black =1.25 (1.19-1.31), US-born Hispanic=1.25 (1.20-1.29), Foreign-born Hispanic=1.17 (1.11-1.24), Asian/Pacific Islander=1.26 (1.21-1.32), "Other"=1.31 (1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of White women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared to 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and White women and accounted for 16.1-24.2% of the differences for all other racial/ethnic groups.CONCLUSION: In California, excess odds of severe maternal morbidity among racially/ethnically minoritized women was not fully explained by birth hospital. Structural causes of racial/ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

    View details for DOI 10.1016/j.ajog.2020.08.017

    View details for PubMedID 32798461

  • Neonates in the COVID-19 pandemic. Pediatric research Molloy, E. J., Lavizzari, A., Klingenberg, C., Profit, J., Zupancic, J. A., Davis, A. S., Mosca, F., Bearer, C. F., Roehr, C. C., International Neonatal COVID-19 Consortium, Bassler, D., Burn-Murdoch, J., Danhaive, O., Davis, J., Ferri, W. A., Fuchs, H., Ge, H., Gupta, A., Gupta, M., van Kaam, A., Diaz, V. J., Trevino-Perez, R., Mariani, G. L., Naver, L., Patel, A., Shah, P., Szczapa, T., Vento, M., Wellman, S., Zangen, S. 2020

    View details for DOI 10.1038/s41390-020-1096-y

    View details for PubMedID 32746446

  • Former NICU Families Describe Gaps in Family-Centered Care. Qualitative health research Sigurdson, K., Profit, J., Dhurjati, R., Morton, C., Scala, M., Vernon, L., Randolph, A., Phan, J. T., Franck, L. S. 2020: 1049732320932897


    Care and outcomes of infants admitted to neonatal intensive care vary and differences in family-centered care may contribute. The objective of this study was to understand families' experiences of neonatal care within a framework of family-centered care. We conducted focus groups and interviews with 18 family members whose infants were cared for in California neonatal intensive care units (NICUs) using a grounded theory approach and centering the accounts of families of color and/or of low socioeconomic status. Families identified the following challenges that indicated a gap in mutual trust and power sharing: conflict with or lack of knowledge about social work; staff judgment of, or unwillingness to address barriers to family presence at bedside; need for nurse continuity and meaningful relationship with nurses and inconsistent access to translation services. These unmet needs for partnership in care or support were particularly experienced by parents of color or of low socioeconomic status.

    View details for DOI 10.1177/1049732320932897

    View details for PubMedID 32713256

  • Racial/Ethnic Disparities Among Extremely Preterm Infants in the United States From 2002 to 2016. JAMA network open Travers, C. P., Carlo, W. A., McDonald, S. A., Das, A., Ambalavanan, N., Bell, E. F., Sanchez, P. J., Stoll, B. J., Wyckoff, M. H., Laptook, A. R., Van Meurs, K. P., Goldberg, R. N., D'Angio, C. T., Shankaran, S., DeMauro, S. B., Walsh, M. C., Peralta-Carcelen, M., Collins, M. V., Ball, M. B., Hale, E. C., Newman, N. S., Profit, J., Gould, J. B., Lorch, S. A., Bann, C. M., Bidegain, M., Higgins, R. D., Generic Database and Follow-up Subcommittees of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network 2020; 3 (6): e206757


    Importance: Racial/ethnic disparities in quality of care among extremely preterm infants are associated with adverse outcomes.Objective: To assess whether racial/ethnic disparities in major outcomes and key care practices were changing over time among extremely preterm infants.Design, Setting, and Participants: This observational cohort study used prospectively collected data from 25 US academic medical centers. Participants included 20 092 infants of 22 to 27 weeks' gestation with a birth weight of 401 to 1500 g born at centers participating in the National Institute of Child Health and Human Development Neonatal Research Network from 2002 to 2016. Of these infants, 9316 born from 2006 to 2014 were eligible for follow-up at 18 to 26 months' postmenstrual age (excluding 5871 infants born before 2006, 2594 infants born after 2014, and 2311 ineligible infants including 64 with birth weight >1000 g and 2247 infants with gestational age >26 6/7 weeks), of whom 745 (8.0%) did not have known follow-up outcomes at 18 to 26 months.Main Outcomes and Measures: Rates of mortality, major morbidities, and care practice use over time were evaluated using models adjusted for baseline characteristics, center, and birth year. Data analyses were conducted from 2018 to 2019.Results: In total, 20 092 infants with a mean (SD) gestational age of 25.1 (1.5) weeks met the inclusion criteria and were available for the primary outcome: 8331 (41.5%) black infants, 3701 (18.4%) Hispanic infants, and 8060 (40.1%) white infants. Hospital mortality decreased over time in all groups. The rate of improvement in hospital mortality over time did not differ among black and Hispanic infants compared with white infants (black infants went from 35% to 24%, Hispanic infants went from 32% to 27%, and white infants went from 30% to 22%; P=.59 for race*year interaction). The rates of late-onset sepsis among black infants (went from 37% to 24%) and Hispanic infants (went from 45% to 23%) were initially higher than for white infants (went from 36% to 25%) but decreased more rapidly and converged during the most recent years (P=.02 for race*year interaction). Changes in rates of other major morbidities did not differ by race/ethnicity. Death before follow-up decreased over time (from 2006 to 2014: black infants, 14%; Hispanic infants, 39%, white infants, 15%), but moderate-severe neurodevelopmental impairment increased over time in all racial/ethnic groups (increase from 2006 to 2014: black infants, 70%; Hispanic infants, 123%; white infants, 130%). Rates of antenatal corticosteroid exposure (black infants went from 72% to 90%, Hispanic infants went from 73% to 83%, and white infants went from 86% to 90%; P=.01 for race*year interaction) and of cesarean delivery (black infants went from 45% to 59%, Hispanic infants went from 49% to 59%, and white infants went from 62% to 63%; P=.03 for race*year interaction) were initially lower among black and Hispanic infants compared with white infants, but these differences decreased over time.Conclusions and Relevance: Among extremely preterm infants, improvements in adjusted rates of mortality and most major morbidities did not differ by race/ethnicity, but rates of neurodevelopmental impairment increased in all groups. There were narrowing racial/ethnic disparities in important care practices, including the use of antenatal corticosteroids and cesarean delivery.

    View details for DOI 10.1001/jamanetworkopen.2020.6757

    View details for PubMedID 32520359

  • Provider burnout: Implications for our perinatal patients. Seminars in perinatology Tawfik, D. S., Profit, J. 2020: 151243


    OBJECTIVE: To describe the syndrome of physician burnout within neonatology, its relation to neonatal quality of care, and outline potential solutions.FINDINGS: Burnout affects up to half of physicians, including up to one-third of neonatologists, at any given time. It is linked to suicidality, substance abuse, and intent to leave practice, and it is strongly associated with reduced quality of care in the published literature. Resilience and mindfulness interventions rooted in positive psychology may reduce burnout among individual providers. Because burnout is largely driven by organizational factors, system-level attention to leadership, teamwork, and practice efficiency can reduce burnout at the level of the organization.CONCLUSIONS: Burnout is common among neonatologists and consistently relates to decreased quality of patient care in a variety of dimensions. Personal resilience training and system-wide organizational interventions are needed to reverse burnout and promote high-quality neonatal care.

    View details for DOI 10.1016/j.semperi.2020.151243

    View details for PubMedID 32248955

  • The changing landscape of perinatal regionalization. Seminars in perinatology Kunz, S. N., Phibbs, C. S., Profit, J. 2020: 151241


    Regionalization, which emphasizes matching patient needs with the capabilities of the hospital in which care is provided, has long been a recommended approach to reducing neonatal morbidity and mortality. Over the past decade, research methods surrounding the measurement and evaluation of such programs have improved, thus strengthening arguments for implementation of these strategies. However, regionalization policies vary widely across regions and between countries, with potential impacts on neonatal outcomes as well as costs of care. It is important to account for geographic and other regional differences when determining the feasibility of regionalization for a specific region, as certain areas and populations may need particular consideration in order for regionalization policies to be successful.

    View details for DOI 10.1016/j.semperi.2020.151241

    View details for PubMedID 32248957

  • Multilevel social factors and NICU quality of care in California. Journal of perinatology : official journal of the California Perinatal Association Padula, A. M., Shariff-Marco, S., Yang, J., Jain, J., Liu, J., Conroy, S. M., Carmichael, S. L., Gomez, S. L., Phibbs, C., Oehlert, J., Gould, J. B., Profit, J. 2020


    OBJECTIVE: Our objective was to incorporate social and built environment factors into a compendium of multilevel factors among a cohort of very low birth weight infants to understand their contributions to inequities in NICU quality of care and support providers and NICUs in addressing these inequitiesvia development of a health equity dashboard.STUDY DESIGN: We examined bivariate associations between NICU patient pool and NICU catchment area characteristics and NICU quality of care with data from a cohort of 15,901 infants from 119 NICUs in California, born 2008-2011.RESULT: NICUs with higher proportion of minority racial/ethnic patients and lower SES patients had lower quality scores. NICUs with catchment areas of lower SES, higher composition of minority residents, and more household crowding had lower quality scores.CONCLUSION: Multilevel social factors impact quality of care in the NICU. Their incorporation into a health equity dashboard can inform providers of their patients' potential resource needs.

    View details for DOI 10.1038/s41372-020-0647-8

    View details for PubMedID 32157221

  • The risk of small for gestational age in very low birth weight infants born to Asian or Pacific Islander mothers in California. Journal of perinatology : official journal of the California Perinatal Association Lee, S. M., Sie, L., Liu, J., Profit, J., Lee, H. C. 2020


    OBJECTIVE: To evaluate potential differences and to show the risk associated with small for gestational age (SGA) at birth and discharge among infants born to mothers of various Asian/Pacific islander (PI) races.STUDY DESIGN: In this retrospective cohort study, infants with weight <1500g or 23-28 weeks gestation, born in California during 2008-2012 were included. Logistic regression models were used.RESULTS: Asian and PI infants in ten groups had significant differences in growth parameters, socioeconomic factors, and some morbidities. Overall incidences of SGA at birth and discharge were 21% and 50%, respectively; Indian race had the highest numbers (29%, 63%). Infants of parents with the same race were at increased risk of SGA at birth and discharge compared with mixed race parents.CONCLUSION: Specific Asian race should be considered when evaluating preterm growth. Careful consideration for the appropriateness of grouping Asian/PI races together in perinatal studies is warranted.

    View details for DOI 10.1038/s41372-020-0601-9

    View details for PubMedID 32051543

  • Reduction in Racial Disparities in Severe Maternal Morbidity from Hemorrhage in a Large-scale Quality Improvement Collaborative. American journal of obstetrics and gynecology Main, E. K., Chang, S. C., Dhurjati, R. n., Cape, V. n., Profit, J. n., Gould, J. B. 2020


    Eliminating persistent racial/ethnic disparities in maternal mortality and morbidity is a public health priority. National strategies to improve maternal outcomes are increasingly focused on quality improvement collaboratives. However, the effectiveness of quality collaboratives for reducing racial disparities in maternity care is understudied.To evaluate the impact of a hemorrhage quality improvement collaborative on racial disparities in severe maternal morbidity (SMM) from hemorrhage.We conducted a cross-sectional study from 2011 to 2016 among 99 hospitals that participated in a hemorrhage quality improvement collaborative in California. The focus of the quality collaborative was to implement the national maternal hemorrhage safety bundle consisting of 17 evidence-based recommendations for practice and care processes known to improve outcomes. This analysis included 54,311 women from the baseline period (January 2011 through December 2014) and 19,165 women from the post-intervention period (October 2015 through December 2016) with a diagnosis of obstetric hemorrhage during delivery hospitalization. We examined whether racial/ethnic-specific SMM rates in these women with obstetric hemorrhage were reduced from the baseline to the post-intervention period. In addition, we conducted Poisson Generalized Estimating Equation models to estimate relative risks (RRs) and 95% confidence intervals (CIs) for SMM comparing each racial/ethnic group to White.During the baseline period, the rate of SMM among women with hemorrhage was 22.1% (12,002/54,311) with the highest rate observed among Blacks (28.6%, 973/3,404), and the lowest among Whites (19.8%, 3,124/15,775). The overall rate fell to 18.5% (3,553/19,165) in the post-intervention period. Both Black and White mothers benefited from the intervention, but the benefit among Blacks exceeded that of Whites (9.0% vs. 2.1% absolute rate reduction). The baseline risk of SMM was 1.34 times higher among Black mothers compared to Whites (RR: 1.34, 95% CI: 1.27-1.42), and it was reduced to 1.22 (1.05-1.40) in the post-intervention period. Sociodemographic and clinical factors explained a part of the Black-White differences. After controlling for these factors, the Black-White RR was 1.22 (95% CI: 1.15-1.30) at baseline and narrowed to 1.07 (1.92-1.24) in the post-intervention period. Results were similar when excluding SMM cases with transfusion alone. After accounting for maternal risk factors, the Black-White RR for SMM excluding transfusion alone was reduced from a baseline of 1.33 (95% CI: 1.16-1.52) to 0.99 (0.76-1.29) in the post-intervention period. The most important clinical risk factor for disparate Black rates for both SMM and SMM excluding transfusion alone was cesarean delivery, potentially providing another opportunity for quality improvement.A large-scale quality improvement collaborative reduced rates of SMM due to hemorrhage in all races and reduced the performance gap between Blacks and Whites. Improving access to highly effective treatments has the potential to decrease disparities for care-sensitive acute hospital-focused morbidities.

    View details for DOI 10.1016/j.ajog.2020.01.026

    View details for PubMedID 31978432

  • International comparison of guidelines for managing neonates at the early phase of the SARS-CoV-2 pandemic. Pediatric research Lavizzari, A. n., Klingenberg, C. n., Profit, J. n., Zupancic, J. A., Davis, A. S., Mosca, F. n., Molloy, E. J., Roehr, C. C. 2020


    The COVID-19 pandemic threatens global newborn health. We describe the current state of national and local protocols for managing neonates born to SARS-CoV-2-positive mothers.Care providers from neonatal intensive care units on six continents exchanged and compared protocols on the management of neonates born to SARS-CoV-2-positive mothers. Data collection was between March 14 and 21, 2020. We focused on central protocol components, including triaging, hygiene precautions, management at delivery, feeding protocols, and visiting policies.Data from 20 countries were available. Disease burden varied between countries at the time of analysis. In most countries, asymptomatic infants were allowed to stay with the mother and breastfeed with hygiene precautions. We detected discrepancies between national guidance in particular regarding triaging, use of personal protection equipment, viral testing, and visitor policies. Local protocols deviated from national guidance.At the start of the pandemic, lack of evidence-based guidance on the management of neonates born to SARS-CoV-2-positive mothers has led to ad hoc creation of national and local guidance. Compliance between collaborators to share and discuss protocols was excellent and may lead to more consensus on management, but future guidance should be built on high-level evidence, rather than expert consensus.At the rapid onset of the COVID19 pandemic, all countries presented protocols in place for managing infants at risk of COVID19, with a certain degree of variations among regions. A detailed review of ad hoc guidelines is presented, similarities and differences are highlighted. We provide a broad overview of currently applied recommendations highlighting the need for international context-relevant coordination.

    View details for DOI 10.1038/s41390-020-0976-5

    View details for PubMedID 32541844

  • Racial/ethnic disparities and human milk use in necrotizing enterocolitis. Pediatric research Goldstein, G. P., Pai, V. V., Liu, J. n., Sigurdson, K. n., Vernon, L. B., Lee, H. C., Sylvester, K. G., Shaw, G. M., Profit, J. n. 2020; 88 (Suppl 1): 3–9


    The impact of human milk use on racial/ethnic disparities in necrotizing enterocolitis (NEC) incidence is unknown.Trends in NEC incidence and human milk use at discharge were evaluated by race/ethnicity among 47,112 very low birth weight infants born in California from 2008 to 2017. We interrogated the association between race/ethnicity and NEC using multilevel regression analysis, and evaluated the effect of human milk use at discharge on the relationship between race/ethnicity and NEC using mediation analysis.Annual NEC incidence declined across all racial/ethnic groups from an aggregate average of 4.8% in 2008 to 2.6% in 2017. Human milk use at discharge increased over the time period across all racial groups, and non-Hispanic (NH) black infants received the least human milk each year. In multivariable analyses, Hispanic ethnicity (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.02-1.57) and Asian or Pacific Islander race (OR 1.35, 95% CI 1.01-1.80) were each associated with higher odds of NEC, while the association of NH black race with NEC was attenuated after adding human milk use at discharge to the model. Mediation analysis revealed that human milk use at discharge accounted for 22% of the total risk of NEC in non-white vs. white infants, and 44% in black vs. white infants.Although NEC incidence has declined substantially over the past decade, a sizable racial/ethnic disparity persists. Quality improvement initiatives augmenting human milk use may further reduce the incidence of NEC in vulnerable populations.

    View details for DOI 10.1038/s41390-020-1073-5

    View details for PubMedID 32855505

  • Disparities in Health Care-Associated Infections in the NICU AMERICAN JOURNAL OF PERINATOLOGY Liu, J., Sakarovitch, C., Sigurdson, K., Lee, H. C., Profit, J. 2020; 37 (2): 166–73
  • The COVID-19 Pandemic as a Catalyst for More Integrated Maternity Care. American journal of public health Profit, J. n., Edmonds, B. T., Shah, N. n., Cheyney, M. n. 2020; 110 (11): 1663–65

    View details for DOI 10.2105/AJPH.2020.305935

    View details for PubMedID 33026864

  • Survival Without Major Morbidity Among Very Low Birth Weight Infants in California. Pediatrics Lee, H. C., Liu, J. n., Profit, J. n., Hintz, S. R., Gould, J. B. 2020


    To examine trends in survival without major morbidity and its individual components among very low birth weight infants across California and assess remaining gaps that may be opportune targets for improvement efforts.The study population included infants born between 2008 and 2017 with birth weights of 401 to 1500 g or a gestational age of 22 to 29 weeks. Risk-adjusted trends of survival without major morbidity and its individual components were analyzed. Survival without major morbidity was defined as the absence of death during birth hospitalization, chronic lung disease, severe peri-intraventricular hemorrhage, nosocomial infection, necrotizing enterocolitis, severe retinopathy of prematurity or related surgery, and cystic periventricular leukomalacia. Variations in adjusted rates and/or interquartile ranges were examined. To assess opportunities for additional improvement, all hospitals were reassigned to perform as if in the top quartile, and recalculation of predicted numbers were used to estimate potential benefit.In this cohort of 49 333 infants across 142 hospitals, survival without major morbidity consistently increased from 62.2% to 66.9% from 2008 to 2017. Network variation decreased, with interquartile ranges decreasing from 21.1% to 19.2%. The largest improvements were seen for necrotizing enterocolitis and nosocomial infection. Bronchopulmonary dysplasia rates did not change significantly. Over the final 3 years, if all hospitals performed as well as the top quartile, an additional 621 infants per year would have survived without major morbidity, accounting for an additional 6.6% annual improvement.Although trends are promising, bronchopulmonary dysplasia remains a common and persistent major morbidity, remaining a target for continued quality-improvement efforts.

    View details for DOI 10.1542/peds.2019-3865

    View details for PubMedID 32554813

  • Racial and Ethnic Disparities in Human Milk Intake at Neonatal Intensive Care Unit Discharge among Very Low Birth Weight Infants in California. The Journal of pediatrics Liu, J., Parker, M. G., Lu, T., Conroy, S. M., Oehlert, J., Lee, H. C., Gomez, S. L., Shariff-Marco, S., Profit, J. 2019


    OBJECTIVES: To examine how infant and maternal factors, hospital factors, and neighborhood-level factors impact or modify racial/ethnic disparities in human milk intake at hospital discharge among very low birth weight infants.STUDY DESIGN: We studied 14 422 infants from 119 California Perinatal Quality Care Collaborative neonatal intensive care units born from 2008 to 2011. Maternal addresses were linked to 2010 census tract data, representing neighborhoods. We tested for associations with receiving no human milk at discharge, using multilevel cross-classified models.RESULTS: Compared with non-Hispanic whites, the adjusted odds of no human milk at discharge was higher among non-Hispanic blacks (aOR 1.33 [1.16-1.53]) and lower among Hispanics (aOR 0.83 [0.74-0.93]). Compared with infants of more educated white mothers, infants of less educated white, black, and Asian mothers had higher odds of no human milk at discharge, and infants of Hispanic mothers of all educational levels had similar odds as infants of more educated white mothers. Country of birth and neighborhood socioeconomic was also associated with disparities in human milk intake at discharge.CONCLUSIONS: Non-Hispanic blacks had the highest and Hispanic infants the lowest odds of no human milk at discharge. Maternal education and country of birth were the biggest drivers of disparities in human milk intake, suggesting the need for targeted approaches of breastfeeding support.

    View details for DOI 10.1016/j.jpeds.2019.11.020

    View details for PubMedID 31843218

  • Improving Quality of Care Can Mitigate Persistent Disparities. Pediatrics Ravi, D., Sigurdson, K., Profit, J. 2019

    View details for DOI 10.1542/peds.2019-2002

    View details for PubMedID 31405886

  • Patient- and Family-Centered Care as a Dimension of Quality AMERICAN JOURNAL OF MEDICAL QUALITY Dhurjati, R., Sigurdson, K., Profit, J. 2019; 34 (3): 307–8
  • Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants JAMA PEDIATRICS Horbar, J. D., Edwards, E. M., Greenberg, L. T., Profit, J., Draper, D., Helkey, D., Lorch, S. A., Lee, H. C., Phibbs, C. S., Rogowski, J., Gould, J. B., Firebaugh, G. 2019; 173 (5): 455–61
  • Racial and ethnic disparities in severe maternal morbidity prevalence and trends ANNALS OF EPIDEMIOLOGY Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., Carmichael, S. L. 2019; 33: 30–36
  • Stillbirth and Live Birth at Periviable Gestational Age: A Comparison of Prevalence and Risk Factors AMERICAN JOURNAL OF PERINATOLOGY Carmichael, S. L., Blumenfeld, Y. J., Mayo, J. A., Profit, J., Shaw, G. M., Hintz, S. R., Stevenson, D. K. 2019; 36 (5): 537–44
  • Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants. JAMA pediatrics Horbar, J. D., Edwards, E. M., Greenberg, L. T., Profit, J., Draper, D., Helkey, D., Lorch, S. A., Lee, H. C., Phibbs, C. S., Rogowski, J., Gould, J. B., Firebaugh, G. 2019


    Importance: Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear.Objective: To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States.Design, Setting, and Participants: This cohort study of 743 NICUs in the Vermont Oxford Network included 117 982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks' gestation from January 2014 to December 2016. Analysis began January 2018.Main Outcomes and Measures: The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index.Results: Infants (36 359 black [31%], 21 808 Hispanic [18%], 5920 Asian [5%], and 53 895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46-0.53], Hispanic: 0.58 [95% CI, 0.54-0.61], and Asian: 0.45 [95% CI, 0.40-0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02-0.13], Hispanic: -0.10 [95% CI, -0.17 to -0.04], and Asian: -0.26 [95% CI, -0.32 to -0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: -0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants.Conclusions and Relevance: Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.

    View details for PubMedID 30907924

  • Organizational factors affecting physician well-being. Current treatment options in pediatrics Tawfik, D. S., Profit, J., Webber, S., Shanafelt, T. D. 2019; 5 (1): 11–25


    Purpose of review: Symptoms of burnout affect approximately half of pediatricians and pediatric subspecialists at any given time, with similarly concerning prevalence of other aspects of physician distress, including fatigue, depressive symptoms, and suicidal ideation. Physician well-being affects quality of care, patient satisfaction, and physician turnover. Organizational factors influence well-being, stressing the need for organizations to address this epidemic.Recent findings: Organizational characteristics, policies, and culture influence physician well-being, and specific strategies may support an environment where physicians thrive. We highlight four organizational opportunities to improve physician well-being: developing leaders, cultivating community and organizational culture, improving practice efficiency, and optimizing administrative policies. Leaders play a key role in aligning organizational and individual values, promoting professional fulfillment, and fostering a culture of collegiality and social support among physicians. Reducing documentation burden and improving practice efficiency may help balance job demands and resources. Finally, reforming administrative policies may reduce work-home conflict, support physician's efforts to attend to their own well-being, and normalize use of supportive resources.Summary: Physician well-being is critical to organizational success, sustainment of an adequate workforce, and optimal patient outcomes. Because burnout is primarily influenced by organizational factors, organizational interventions are key to promoting well-being. Developing supportive leadership, fostering a culture of wellness, optimizing practice efficiency, and improving administrative policies are worthy of organizational action and further research.

    View details for DOI 10.1007/s40746-019-00147-6

    View details for PubMedID 31632895

  • Perinatal Risk Factors and Outcome Coding in Clinical and Administrative Databases PEDIATRICS Tawfik, D. S., Gould, J. B., Profit, J. 2019; 143 (2)
  • Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health services research Tawfik, D. S., Profit, J. n., Lake, E. T., Liu, J. B., Sanders, L. M., Phibbs, C. S. 2019


    To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs).Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression.We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients.An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality.Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

    View details for DOI 10.1111/1475-6773.13249

    View details for PubMedID 31869865

  • Measuring aspects of high-reliability culture in healthcare settings J Pt Saf Risk Manag Etchegaray, J., Thomas, E. J., Profit, J. 2019

    View details for DOI 10.1177/2516043519838185

  • Disparities in Health Care-Associated Infections in the NICU. American journal of perinatology Liu, J. n., Sakarovitch, C. n., Sigurdson, K. n., Lee, H. C., Profit, J. n. 2019


     This study aimed to examine multilevel risk factors for health care-associated infection (HAI) among very low birth weight (VLBW) infants with a focus on race/ethnicity and its association with variation in infection across hospitals. This is a population-based cohort study of 20,692 VLBW infants born between 2011 and 2015 in the California Perinatal Quality Care Collaborative. Risk-adjusted infection rates varied widely across neonatal intensive care units (NICUs), ranging from 0 to 24.6% across 5 years. Although Hispanic infants had higher odds of HAI overall, race/ethnicity did not affect the variation in infection rates. Non-Hispanic black mothers were more likely to receive care in NICUs within the top tertile of infection risk. Yet, among NICUs in this tertile, infants across all races and ethnicities suffered similar high rates of infection. Hispanic infants had higher odds of infection. We found significant variation in infection across NICUs, even after accounting for factors usually associated with infection.

    View details for PubMedID 31039596

  • "Following through": addressing the racial inequality for preterm infants and their families. Pediatric research Stevenson, D. K., Wong, R. J., Profit, J. n., Shaw, G. M., Jason Wang, C. n., Lee, H. C. 2019

    View details for DOI 10.1038/s41390-019-0602-6

    View details for PubMedID 31581171

  • Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Annals of epidemiology Leonard, S. A., Main, E. K., Scott, K. A., Profit, J. n., Carmichael, S. L. 2019


    Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors.We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997-2014 (n = 8,252,025).The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics.The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.

    View details for PubMedID 30928320

  • Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis. Annals of internal medicine Tawfik, D. S., Scheid, A. n., Profit, J. n., Shanafelt, T. n., Trockel, M. n., Adair, K. C., Sexton, J. B., Ioannidis, J. P. 2019


    Whether health care provider burnout contributes to lower quality of patient care is unclear.To estimate the overall relationship between burnout and quality of care and to evaluate whether published studies provide exaggerated estimates of this relationship.MEDLINE, PsycINFO, Health and Psychosocial Instruments (EBSCO), Mental Measurements Yearbook (EBSCO), EMBASE (Elsevier), and Web of Science (Clarivate Analytics), with no language restrictions, from inception through 28 May 2019.Peer-reviewed publications, in any language, quantifying health care provider burnout in relation to quality of patient care.2 reviewers independently selected studies, extracted measures of association of burnout and quality of care, and assessed potential bias by using the Ioannidis (excess significance) and Egger (small-study effect) tests.A total of 11 703 citations were identified, from which 123 publications with 142 study populations encompassing 241 553 health care providers were selected. Quality-of-care outcomes were grouped into 5 categories: best practices (n = 14), communication (n = 5), medical errors (n = 32), patient outcomes (n = 17), and quality and safety (n = 74). Relations between burnout and quality of care were highly heterogeneous (I2 = 93.4% to 98.8%). Of 114 unique burnout-quality combinations, 58 indicated burnout related to poor-quality care, 6 indicated burnout related to high-quality care, and 50 showed no significant effect. Excess significance was apparent (73% of studies observed vs. 62% predicted to have statistically significant results; P = 0.011). This indicator of potential bias was most prominent for the least-rigorous quality measures of best practices and quality and safety.Studies were primarily observational; neither causality nor directionality could be determined.Burnout in health care professionals frequently is associated with poor-quality care in the published literature. The true effect size may be smaller than reported. Future studies should prespecify outcomes to reduce the risk for exaggerated effect size estimates.Stanford Maternal and Child Health Research Institute.

    View details for DOI 10.7326/M19-1152

    View details for PubMedID 31590181

  • Safety climate, safety climate strength, and length of stay in the NICU. BMC health services research Tawfik, D. S., Thomas, E. J., Vogus, T. J., Liu, J. B., Sharek, P. J., Nisbet, C. C., Lee, H. C., Sexton, J. B., Profit, J. n. 2019; 19 (1): 738


    Safety climate is an important marker of patient safety attitudes within health care units, but the significance of intra-unit variation of safety climate perceptions (safety climate strength) is poorly understood. This study sought to examine the standard safety climate measure (percent positive response (PPR)) and safety climate strength in relation to length of stay (LOS) of very low birth weight (VLBW) infants within California neonatal intensive care units (NICUs).Observational study of safety climate from 2073 health care providers in 44 NICUs. Consistent perceptions among a NICU's respondents, i.e., safety climate strength, was determined via intra-unit standard deviation of safety climate scores. The relation between safety climate PPR, safety climate strength, and LOS among VLBW (< 1500 g) infants was evaluated using log-linear regression. Secondary outcomes were infections, chronic lung disease, and mortality.NICUs had safety climate PPRs of 66 ± 12%, intra-unit standard deviations 11 (strongest) to 23 (weakest), and median LOS 60 days. NICUs with stronger climates had LOS 4 days shorter than those with weaker climates. In interaction modeling, NICUs with weak climates and low PPR had the longest LOS, NICUs with strong climates and low PPR had the shortest LOS, and NICUs with high PPR (both strong and weak) had intermediate LOS. Stronger climates were associated with lower odds of infections, but not with other secondary outcomes.Safety climate strength is independently associated with LOS and moderates the association between PPR and LOS among VLBW infants. Strength and PPR together provided better prediction than PPR alone, capturing variance in outcomes missed by PPR. Evaluations of NICU safety climate consider both positivity (PPR) and consistency of responses (strength) across individuals.

    View details for DOI 10.1186/s12913-019-4592-1

    View details for PubMedID 31640679

  • Racial/Ethnic Disparities in Neonatal Intensive Care: A Systematic Review. Pediatrics Sigurdson, K. n., Mitchell, B. n., Liu, J. n., Morton, C. n., Gould, J. B., Lee, H. C., Capdarest-Arest, N. n., Profit, J. n. 2019


    Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear.To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting.Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care."English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected.Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities.Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included.Quantitative meta-analysis was not possible because of study heterogeneity.Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.

    View details for DOI 10.1542/peds.2018-3114

    View details for PubMedID 31358664

  • Newborn Antibiotic Exposures and Association With Proven Bloodstream Infection. Pediatrics Schulman, J. n., Benitz, W. E., Profit, J. n., Lee, H. C., Dueñas, G. n., Bennett, M. V., Jocson, M. A., Schutzengel, R. n., Gould, J. B. 2019


    To estimate the percentage of hospital births receiving antibiotics before being discharged from the hospital and efficiency diagnosing proven bloodstream infection.We conducted a cross-sectional study of 326 845 live births in 2017, with a 69% sample of all California births involving 121 California hospitals with a NICU, of which 116 routinely served inborn neonates. Exposure included intravenous or intramuscular antibiotic administered anywhere in the hospital during inpatient stay associated with maternal delivery. The main outcomes were the percent of newborns with antibiotic exposure and counts of exposed newborns per proven bloodstream infection. Units of observation and analysis were the individual hospitals. Correlation analyses included infection rates, surgical case volume, NICU inborn admission rates, and mortality rates.The percent of newborns with antibiotic exposure varied from 1.6% to 42.5% (mean 8.5%; SD 6.3%; median 7.3%). Across hospitals, 11.4 to 335.7 infants received antibiotics per proven early-onset sepsis case (mean 95.1; SD 71.1; median 69.5), and 2 to 164 infants received antibiotics per proven late-onset sepsis case (mean 19.6; SD 24.0; median 12.2). The percent of newborns with antibiotic exposure correlated neither with proven bloodstream infection nor with the percent of patient-days entailing antibiotic exposure.The percent of newborns with antibiotic exposure varies widely and is unexplained by proven bloodstream infection. Identification of sepsis, particularly early onset, often is extremely inefficient. Knowledge of the numbers of newborns receiving antibiotics complements evaluations anchored in days of exposure because these are uncorrelated measures.

    View details for DOI 10.1542/peds.2019-1105

    View details for PubMedID 31641017

  • The Improvement Readiness scale of the SCORE survey: a metric to assess capacity for quality improvement in healthcare. BMC health services research Adair, K. C., Quow, K., Frankel, A., Mosca, P. J., Profit, J., Hadley, A., Leonard, M., Bryan Sexton, J. 2018; 18 (1): 975


    BACKGROUND: Quality improvement efforts are inextricably linked to the readiness of healthcare workers to take them on. The current study aims to clarify the nature and measurement of Improvement Readiness (IR) by 1) examining the psychometric properties of a novel IR scale, 2) assessing relationships between IR and other safety culture domains 3) exploring whether IR differs by healthcare worker demographic factors, and 4) examining linguistic differences in word type use between high and low scoring IR work settings from their free text responses.METHODS: Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate 81%) completed the 5-item IR scale, demographics, safety culture scales, and two open-ended questions. Psychometric analyses, correlations and ANOVAs tested the properties of IR. Linguistic Inquiry Word Count software assessed comments from open-ended questions.RESULTS: The IR scale exhibited strong psychometric properties and a one factor model fit the data well (Cronbach's alpha=.93; RMSEA=.07; CFI=99; TLI=.99). IR scores differed significantly by role, shift, shift length, and years in specialty. IR correlated significantly and in expected directions with safety culture scales. Linguistic analyses revealed that people in low versus high IR work settings used significantly more words in their responses, and specifically more past tense verbs (e.g., "ignored"), negative emotion words (e.g., "upset"), and first person singular ("I"). Workers from high IR work settings used significantly more positive emotions words (e.g., "grateful") and social words (e.g., "team").CONCLUSION: The IR scale exhibits strong psychometric properties, is associated with better safety and teamwork climate, lower burnout, and predicts linguistic differences in high versus low IR groups.

    View details for PubMedID 30558593

  • Patient- and Family-Centered Care as a Dimension of Quality. American journal of medical quality : the official journal of the American College of Medical Quality Dhurjati, R., Sigurdson, K., Profit, J. 2018: 1062860618814312

    View details for PubMedID 30501498

  • The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care. Journal of patient safety Profit, J., Sharek, P. J., Cui, X., Nisbet, C. C., Thomas, E. J., Tawfik, D. S., Lee, H. C., Draper, D., Sexton, J. B. 2018


    OBJECTIVES: Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture.STUDY DESIGN: Cross-sectional study of 6253 very low-birth-weight infants in 44 NICUs. We measured clinical quality via the Baby-MONITOR and its nine risk-adjusted and standardized subcomponents (antenatal corticosteroids, hypothermia, pneumothorax, healthcare-associated infection, chronic lung disease, retinopathy screen, discharge on any human milk, growth velocity, and mortality). A voluntary sample of 2073 of 3294 eligible professional caregivers provided ratings of safety and teamwork climate using the Safety Attitudes Questionnaire. We examined NICU-level variation across clinical and safety culture ratings and conducted correlation analysis of these dimensions.RESULTS: We found significant variation in clinical and safety culture metrics across NICUs. Neonatal intensive care unit teamwork and safety climate ratings were correlated with absence of healthcare-associated infection (r = 0.39 [P = 0.01] and r = 0.29 [P = 0.05], respectively). None of the other clinical metrics, individual or composite, were significantly correlated with teamwork or safety climate.CONCLUSIONS: Neonatal intensive care unit teamwork and safety climate were correlated with healthcare-associated infections but not with other quality metrics. Linkages to clinical measures of quality require additional research.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

    View details for PubMedID 30407963

  • In Reply-Burnout Is Not Associated With Increased Medical Errors MAYO CLINIC PROCEEDINGS Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C., Dyrbye, L., Tutty, M., West, C. P., Shanafelt, T. D. 2018; 93 (11): 1683–84
  • In Reply-Burnout Is Not Associated With Increased Medical Errors. Mayo Clinic proceedings Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C., Dyrbye, L., Tutty, M., West, C. P., Shanafelt, T. D. 2018; 93 (11): 1683–84

    View details for PubMedID 30392548

  • Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011. The Journal of pediatrics Phibbs, C. S., Schmitt, S. K., Cooper, M., Gould, J. B., Lee, H. C., Profit, J., Lorch, S. A. 2018


    OBJECTIVE: To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.STUDY DESIGN: We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212.RESULTS: The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.CONCLUSIONS: Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.

    View details for PubMedID 30297293

  • Predicting Successful Neonatal Retro-Transfer to a Lower Level of Care. The Journal of pediatrics Kunz, S. N., Dukhovny, D., Profit, J., Mao, W., Miedema, D., Zupancic, J. A. 2018


    Up to 20% of newborn infants retro-transferred to a lower level of care require readmission to a higher-level facility. In this study, we developed and validated a prediction rule (The Rule for Elective Transfer between Units for Recovering Neonates [RETURN]) to identify clinical characteristics of infants at risk for failing retro-transfer.

    View details for PubMedID 30291023

  • Stillbirth and Live Birth at Periviable Gestational Age: A Comparison of Prevalence and Risk Factors. American journal of perinatology Carmichael, S. L., Blumenfeld, Y. J., Mayo, J. A., Profit, J., Shaw, G. M., Hintz, S. R., Stevenson, D. K. 2018


    OBJECTIVE: We compared the prevalence of and risk factors for stillbirth and live birth at periviable gestational age (20-25 weeks).STUDY DESIGN: This is a cohort study of 2.5 million singleton births in California from 2007 to 2011. We estimated racial-ethnic prevalence ratios and used multivariable logistic regression for risk factor comparisons.RESULTS: In this study, 42% of deliveries at 20 to 25 weeks' gestation were stillbirths, and 22% were live births who died within 24 hours. The prevalence of delivery at periviable gestation was 3.4 per 1,000 deliveries among whites, 10.9 for blacks, 3.5 for Asians, and 4.4 for Hispanics. Nonwhite race-ethnicity, lower education, uninsured status, being U.S. born, older age, obesity, smoking, pre-pregnancy hypertension, nulliparity, interpregnancy interval, and prior preterm birth or stillbirth were all associated with increased risk of both stillbirth and live birth at 20 to 25 weeks' gestation, compared with delivery of a live birth at 37 to 41 weeks.CONCLUSION: Inclusion of stillbirths and live births in studies of deliveries at periviable gestations is important.

    View details for PubMedID 30208499

  • Variations in Neonatal Antibiotic Use PEDIATRICS Schulman, J., Profit, J., Lee, H. C., Duenas, G., Bennett, M. V., Parucha, J., Jocson, M. L., Gould, J. B. 2018; 142 (3)


    We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens.In a retrospective cohort study of >54 000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts.By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%-22.0%), reflecting 42 960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%-28.8%) compared with 16.2% (95% CI 16.1%-16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume (ρ = 0.53; P = .01), mortality rate (ρ = 0.57; P = .004), and average length of stay (ρ = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%-57%).Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.

    View details for PubMedID 30177514

  • Correction: Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of perinatology : official journal of the California Perinatal Association Sigurdson, K., Morton, C., Mitchell, B., Profit, J. 2018


    The original HTML version of this Article incorrectly showed the copyright holder to be 'Nature America, Inc., part of Springer Nature', when the correct copyright holder is 'The Authors 2018'. This has been corrected in the HTML version of the Article. The PDF version was correct from the time of publication.

    View details for PubMedID 30042468

  • Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic proceedings Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., Tutty, M. A., West, C. P., Shanafelt, T. D. 2018


    OBJECTIVE: To evaluate physician burnout, well-being, and work unit safety grades in relationship to perceived major medical errors.PARTICIPANTS AND METHODS: From August 28, 2014, to October 6, 2014, we conducted a population-based survey of US physicians in active practice regarding burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors. Multivariate logistic regression and mixed-effects hierarchical models evaluated the associations among burnout, well-being measures, work unit safety grades, and medical errors.RESULTS: Of 6695 responding physicians in active practice, 6586 provided information on the areas of interest: 3574 (54.3%) reported symptoms of burnout, 2163 (32.8%) reported excessive fatigue, and 427 (6.5%) reported recent suicidal ideation, with 255 of 6563 (3.9%) reporting a poor or failing patient safety grade in their primary work area and 691 of 6586 (10.5%) reporting a major medical error in the prior 3 months. Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P<.001), fatigue (46.6% vs 31.2%; P<.001), and recent suicidal ideation (12.7% vs 5.8%; P<.001). In multivariate modeling, perceived errors were independently more likely to be reported by physicians with burnout (odds ratio [OR], 2.22; 95% CI, 1.79-2.76) or fatigue (OR, 1.38; 95% CI, 1.15-1.65) and those with incrementally worse work unit safety grades (OR, 1.70; 95% CI, 1.36-2.12; OR, 1.92; 95% CI, 1.48-2.49; OR, 3.12; 95% CI, 2.13-4.58; and OR, 4.37; 95% CI, 2.06-9.28 for grades of B, C, D, and F, respectively), adjusted for demographic and clinical characteristics.CONCLUSION: In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors. Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.

    View details for PubMedID 30001832

  • Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care. Journal of perinatology : official journal of the California Perinatal Association Dhurjati, R., Wahid, N., Sigurdson, K., Morton, C. H., Kaplan, H. C., Gould, J. B., Profit, J. 2018


    OBJECTIVE: To identify key features in the NICU care delivery context that influence quality of care delivery.STUDY DESIGN: Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory.RESULTS: Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital.CONCLUSIONS: Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.

    View details for PubMedID 29593356

  • Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives. Clinics in perinatology Pai, V. V., Lee, H. C., Profit, J. n. 2018; 45 (2): 165–80


    Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.

    View details for DOI 10.1016/j.clp.2018.01.013

    View details for PubMedID 29747881

  • Work-life balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis. BMJ quality & safety Schwartz, S. P., Adair, K. C., Bae, J. n., Rehder, K. J., Shanafelt, T. D., Profit, J. n., Sexton, J. B. 2018


    Healthcare is approaching a tipping point as burnout and dissatisfaction with work-life integration (WLI) in healthcare workers continue to increase. A scale evaluating common behaviours as actionable examples of WLI was introduced to measure work-life balance.(1) Explore differences in WLI behaviours by role, specialty and other respondent demographics in a large healthcare system. (2) Evaluate the psychometric properties of the work-life climate scale, and the extent to which it acts like a climate, or group-level norm when used at the work setting level. (3) Explore associations between work-life climate and other healthcare climates including teamwork, safety and burnout.Cross-sectional survey study completed in 2016 of US healthcare workers within a large academic healthcare system.10 627 of 13 040 eligible healthcare workers across 440 work settings within seven entities of a large healthcare system (81% response rate) completed the routine safety culture survey. The overall work-life climate scale internal consistency was α=0.830. WLI varied significantly among healthcare worker role, length of time in specialty and work setting. Random effects analyses of variance for the work-life climate scale revealed significant between-work setting and within-work setting variance and intraclass correlations reflected clustering at the work setting level. T-tests of top versus bottom WLI quartile work settings revealed that positive work-life climate was associated with better teamwork and safety climates, as well as lower personal burnout and burnout climate (p<0.001).Problems with WLI are common in healthcare workers and differ significantly based on position and time in specialty. Although typically thought of as an individual difference variable, WLI appears to operate as a climate, and is consistently associated with better safety culture norms.

    View details for PubMedID 30309912

  • Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of perinatology : official journal of the California Perinatal Association Sigurdson, K. n., Morton, C. n., Mitchell, B. n., Profit, J. n. 2018


    To identify how family advocates and clinicians describe disparities in NICU quality of care in narrative accounts.Qualitative analysis of a survey requesting disparity stories at the 2016 VON Quality Congress. Accounts (324) were from a sample of RNs (n = 114, 35%), MDs (n = 109, 34%), NNPs (n = 55, 17%), RN other (n = 4, 1%), clinical other (n = 25, 7%), family advocates (n = 16, 5%), and unspecified (n = 1, <1%).Accounts (324) addressed non-exclusive disparities: 151 (47%) language; 97 (30%) culture or ethnicity; 72 (22%) race; 41 (13%) SES; 28 (8%) drug use; 18 (5%) immigration status or nationality; 16 (4%) sexual orientation or family status; 14 (4%) gender; 10 (3%) disability. We identified three types of disparate care: neglectful care 85 (26%), judgmental care 85 (26%), or systemic barriers to care 139 (44%).Nearly all accounts described differential care toward families, suggesting the lack of equitable family-centered care.

    View details for PubMedID 29622778

  • Do trials reduce uncertainty? Assessing impact through cumulative meta-analysis of neonatal RCTs. Journal of perinatology : official journal of the California Perinatal Association Hay, S. C., Kirpalani, H., Viner, C., Soll, R., Dukhovny, D., Mao, W. Y., Profit, J., DeMauro, S. B., Zupancic, J. A. 2017


    To assess the impact of the latest randomized controlled trial (RCT) to each systematic review (SR) in Cochrane Neonatal Reviews.We selected meta-analyses reporting the typical point estimate of the risk ratio for the primary outcome of the latest study (n=130), mortality (n=128) and the mean difference for the primary outcome (n=44). We employed cumulative meta-analysis to determine the typical estimate after each trial was added, and then performed multivariable logistic regression to determine factors predictive of study impact.For the stated primary outcome, 18% of latest RCTs failed to narrow the confidence interval (CI), and 55% failed to decrease the CI by ⩾20%. Only 8% changed the typical estimate directionality, and 11% caused a change to or from significance. Latest RCTs did not change the typical estimate in 18% of cases, and only 41% changed the typical estimate by at least 10%. The ability to narrow the CI by >20% was negatively associated with the number of previously published RCTs (odds ratio 0.707). Similar results were found in analysis of typical estimates for the outcomes of mortality and mean difference.Across a broad range of clinical questions, the latest RCT failed to substantially narrow the CI of the typical estimate, to move the effect estimate or to change its statistical significance in a majority of cases. Investigators and grant peer review committees should consider prioritizing less-studied topics or requiring formal consideration of optimal information size based on extant evidence in power calculations.Journal of Perinatology advance online publication, 7 September 2017; doi:10.1038/jp.2017.126.

    View details for DOI 10.1038/jp.2017.126

    View details for PubMedID 28880258

  • Context in Quality of Care: Improving Teamwork and Resilience. Clinics in perinatology Tawfik, D. S., Sexton, J. B., Adair, K. C., Kaplan, H. C., Profit, J. 2017; 44 (3): 541-552


    Quality improvement in health care is an ongoing challenge. Consideration of the context of the health care system is of paramount importance. Staff resilience and teamwork climate are key aspects of context that drive quality. Teamwork climate is dynamic, with well-established tools available to improve teamwork for specific tasks or global applications. Similarly, burnout and resilience can be modified with interventions such as cultivating gratitude, positivity, and awe. A growing body of literature has shown that teamwork and burnout relate to quality of care, with improved teamwork and decreased burnout expected to produce improved patient quality and safety.

    View details for DOI 10.1016/j.clp.2017.04.004

    View details for PubMedID 28802338

  • Network analysis: a novel method for mapping neonatal acute transport patterns in California. Journal of perinatology Kunz, S. N., Zupancic, J. A., Rigdon, J., Phibbs, C. S., Lee, H. C., Gould, J. B., Leskovec, J., Profit, J. 2017; 37 (6): 702-708


    The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network.This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically derived sub-networks were compared with state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression.Empirical sub-networks showed significant overlap with regulatory regions (P<0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (P<0.001), need for surgery (P=0.01) and insurance as the reason for transfer (P<0.001).Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.Journal of Perinatology advance online publication, 23 March 2017; doi:10.1038/jp.2017.20.

    View details for DOI 10.1038/jp.2017.20

    View details for PubMedID 28333155

  • Factors Associated With Provider Burnout in the NICU PEDIATRICS Tawfik, D. S., Phibbs, C. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Trockel, M., Profit, J. 2017; 139 (5)


    NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.

    View details for DOI 10.1542/peds.2016-4134

    View details for Web of Science ID 000400371500040

    View details for PubMedID 28557756

  • Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants. American journal of perinatology Profit, J., Sharek, P. J., Kan, P., Rigdon, J., Desai, M., Nisbet, C. C., Tawfik, D. S., Thomas, E. J., Lee, H. C., Sexton, J. B. 2017


    Background and Objective Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p = 0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion Improving teamwork may be an important element in infection control efforts.

    View details for DOI 10.1055/s-0037-1601563

    View details for PubMedID 28395366

  • Variation in quality report viewing by providers and correlation with NICU quality metrics. Journal of perinatology Wahid, N., Bennett, M. V., Gould, J. B., Profit, J., Danielsen, B., Lee, H. C. 2017


    To examine variation in quality report viewing and assess correlation between provider report viewing and neonatal intensive care unit (NICU) quality.Variation in report viewing sessions for 129 California Perinatal Quality Care Collaborative NICUs was examined. NICUs were stratified into tertiles based on their antenatal steroid (ANS) use and hospital-acquired infection (HAI) rates to compare report viewing session counts.The number of report viewing sessions initiated by providers varied widely over a 2-year period (median=11; mean=25.5; s.d.=45.19 sessions). Report viewing was not associated with differences in ANS use. Facilities with low HAI rates had less frequent report viewing. Facilities with high report views had significant improvements in HAI rates over time.Available audit and feedback reports are utilized inconsistently across California NICUs despite evidence that report viewing is associated with improvements in quality of care delivery. Further studies are needed for reports to reach their theoretical potential.Journal of Perinatology advance online publication, 6 April 2017; doi:10.1038/jp.2017.44.

    View details for DOI 10.1038/jp.2017.44

    View details for PubMedID 28383536

  • Trends in Patent Ductus Arteriosus Diagnosis and Management for Very Low Birth Weight Infants PEDIATRICS Ngo, S., Profit, J., Gould, J. B., Lee, H. C. 2017; 139 (4)


    To examine yearly trends of patent ductus arteriosus (PDA) diagnosis and treatment in very low birth weight infants.In this retrospective cohort study of very low birth weight infants (<1500 g) between 2008 and 2014 across 134 California hospitals, we evaluated PDA diagnosis and treatment by year of birth. Infants were either inborn or transferred in within 2 days after delivery and had no congenital abnormalities. Intervention levels for treatment administered to achieve ductal closure were categorized as none, pharmacologic (indomethacin or ibuprofen), both pharmacologic intervention and surgical ligation, or ligation only. Multivariable logistic regression was used to assess risk factors for PDA diagnosis and treatment.PDA was diagnosed in 42.8% (12 002/28 025) of infants, with a decrease in incidence from 49.2% of 4205 infants born in 2008 to 38.5% of 4001 infants born in 2014. Pharmacologic and/or surgical treatment was given to 30.5% of patients. Between 2008 and 2014, the annual rate of infants who received pharmacologic intervention (30.5% vs 15.7%) or both pharmacologic intervention and surgical ligation (6.9% vs 2.9%) decreased whereas infants who were not treated (60.5% vs 78.3%) or received primary ligation (2.2% vs 3.0%) increased.There is an increasing trend toward not treating patients diagnosed with PDA compared with more intensive treatments: pharmacologic intervention or both pharmacologic intervention and surgical ligation. Possible directions for future study include the impact of these trends on hospital-based and long-term outcomes.

    View details for DOI 10.1542/peds.2016-2390

    View details for Web of Science ID 000398602400016

    View details for PubMedID 28562302

  • Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. Journal of perinatology Tawfik, D. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Lee, H. C., Profit, J. 2017; 37 (3): 315-320


    To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500 g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.Journal of Perinatology advance online publication, 17 November 2016; doi:10.1038/jp.2016.211.

    View details for DOI 10.1038/jp.2016.211

    View details for PubMedID 27853320

  • Got spirit? The spiritual climate scale, psychometric properties, benchmarking data and future directions. BMC health services research Doram, K., Chadwick, W., Bokovoy, J., Profit, J., Sexton, J. D., Sexton, J. B. 2017; 17 (1): 132-?


    Organizations that encourage the respectful expression of diverse spiritual views have higher productivity and performance, and support employees with greater organizational commitment and job satisfaction. Within healthcare, there is a paucity of studies which define or intervene on the spiritual needs of healthcare workers, or examine the effects of a pro-spirituality environment on teamwork and patient safety. Our objective was to describe a novel survey scale for evaluating spiritual climate in healthcare workers, evaluate its psychometric properties, provide benchmarking data from a large faith-based healthcare system, and investigate relationships between spiritual climate and other predictors of patient safety and job satisfaction.Cross-sectional survey study of US healthcare workers within a large, faith-based health system.Seven thousand nine hundred twenty three of 9199 eligible healthcare workers across 325 clinical areas within 16 hospitals completed our survey in 2009 (86% response rate). The spiritual climate scale exhibited good psychometric properties (internal consistency: Cronbach α = .863). On average 68% (SD 17.7) of respondents of a given clinical area expressed good spiritual climate, although assessments varied widely (14 to 100%). Spiritual climate correlated positively with teamwork climate (r = .434, p < .001) and safety climate (r = .489, p < .001). Healthcare workers reporting good spiritual climate were less likely to have intentions to leave, to be burned out, or to experience disruptive behaviors in their unit and more likely to have participated in executive rounding (p < .001 for each variable).The spiritual climate scale exhibits good psychometric properties, elicits results that vary widely by clinical area, and aligns well with other culture constructs that have been found to correlate with clinical and organizational outcomes.

    View details for DOI 10.1186/s12913-017-2050-5

    View details for PubMedID 28189142

  • Relationship of Hospital Staff Coverage and Delivery Room Resuscitation Practices to Birth Asphyxia. American journal of perinatology Tu, J. H., Profit, J., Melsop, K., Brown, T., Davis, A., Main, E., Lee, H. C. 2017; 34 (3): 259-263


    Objective The objective of this study was to assess utilization of specialist coverage and checklists in perinatal settings and to examine utilization by birth asphyxia rates. Design This is a survey study of California maternity hospitals concerning checklist use to prepare for delivery room resuscitation and 24-hour in-house specialist coverage (pediatrician/neonatologist, obstetrician, and obstetric anesthesiologist) and results linked to hospital birth asphyxia rates (preterm and low weight births were excluded). Results Of 253 maternity hospitals, 138 responded (55%); 59 (43%) indicated checklist use, and in-house specialist coverage ranged from 38% (pediatrician/neonatologist) to 54% (anesthesiology). In-house coverage was more common in urban versus rural hospitals for all specialties (p < 0.0001), but checklist use was not significantly different (p = 0.88). Higher birth volume hospitals had more specialist coverage (p < 0.0001), whereas checklist use did not differ (p = 0.3). In-house obstetric coverage was associated with lower asphyxia rates (odds ratio: 0.34; 95% confidence interval [CI]: 0.20, 0.58) in a regression model accounting for other providers. Checklist use was not associated with birth asphyxia (odds ratio: 1.12; 95% CI: 0.75, 1.68). Conclusion Higher birth volume and urban hospitals demonstrated greater in-house specialist coverage, but checklist use was similar across all hospitals. Current data suggest that in-house obstetric coverage has greater impact on asphyxia than other specialist coverage or checklist use.

    View details for DOI 10.1055/s-0036-1586505

    View details for PubMedID 27487231

  • If Health Care Teams Had to Win Championships. American journal of medical quality Dhurjati, R., Salas, E., Profit, J. 2017: 1062860616686684-?

    View details for DOI 10.1177/1062860616686684

    View details for PubMedID 28064518

  • Racial/Ethnic Disparity in NICU Quality of Care Delivery. Pediatrics Profit, J. n., Gould, J. B., Bennett, M. n., Goldstein, B. A., Draper, D. n., Phibbs, C. S., Lee, H. C. 2017


    Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs.We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents.Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.

    View details for PubMedID 28847984

  • Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity. JAMA pediatrics Schulman, J. n., Braun, D. n., Lee, H. C., Profit, J. n., Duenas, G. n., Bennett, M. V., Dimand, R. J., Jocson, M. n., Gould, J. B. 2017


    Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission.To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care.Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity.Live birth at GA of 34 weeks or more.Inborn NICU admission rate.Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41).Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

    View details for PubMedID 29181499

  • The associations between work-life balance behaviours, teamwork climate and safety climate: cross-sectional survey introducing the work-life climate scale, psychometric properties, benchmarking data and future directions. BMJ quality & safety Sexton, J. B., Schwartz, S. P., Chadwick, W. A., Rehder, K. J., Bae, J., Bokovoy, J., Doram, K., Sotile, W., Adair, K. C., Profit, J. 2016


    Improving the resiliency of healthcare workers is a national imperative, driven in part by healthcare workers having minimal exposure to the skills and culture to achieve work-life balance (WLB). Regardless of current policies, healthcare workers feel compelled to work more and take less time to recover from work. Satisfaction with WLB has been measured, as has work-life conflict, but how frequently healthcare workers engage in specific WLB behaviours is rarely assessed. Measurement of behaviours may have advantages over measurement of perceptions; behaviours more accurately reflect WLB and can be targeted by leaders for improvement.1. To describe a novel survey scale for evaluating work-life climate based on specific behavioural frequencies in healthcare workers.2. To evaluate the scale's psychometric properties and provide benchmarking data from a large healthcare system.3. To investigate associations between work-life climate, teamwork climate and safety climate.Cross-sectional survey study of US healthcare workers within a large healthcare system.7923 of 9199 eligible healthcare workers across 325 work settings within 16 hospitals completed the survey in 2009 (86% response rate). The overall work-life climate scale internal consistency was Cronbach α=0.790. t-Tests of top versus bottom quartile work settings revealed that positive work-life climate was associated with better teamwork climate, safety climate and increased participation in safety leadership WalkRounds with feedback (p<0.001). Univariate analysis of variance demonstrated differences that varied significantly in WLB between healthcare worker role, hospitals and work setting.The work-life climate scale exhibits strong psychometric properties, elicits results that vary widely by work setting, discriminates between positive and negative workplace norms, and aligns well with other culture constructs that have been found to correlate with clinical outcomes.

    View details for DOI 10.1136/bmjqs-2016-006032

    View details for PubMedID 28008006

  • Comparing NICU teamwork and safety climate across two commonly used survey instruments BMJ QUALITY & SAFETY Profit, J., Lee, H. C., Sharek, P. J., Kan, P., Nisbet, C. C., Thomas, E. J., Etchegaray, J. M., Sexton, B. 2016; 25 (12): 954-961


    Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)).Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearman's rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance.We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments.Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

    View details for DOI 10.1136/bmjqs-2014-003924

    View details for PubMedID 26700545

  • Characteristics of neonatal transports in California JOURNAL OF PERINATOLOGY Akula, V. P., Gould, J. B., Kan, P., Bollman, L., Profit, J., Lee, H. C. 2016; 36 (12): 1122-1127


    To describe the current scope of neonatal inter-facility transports.California databases were used to characterize infants transported in the first week after birth from 2009 to 2012.Transport of the 22 550 neonates was classified as emergent 9383 (41.6%), urgent 8844 (39.2%), scheduled 2082 (9.2%) and other 85 (0.4%). In addition, 2152 (9.5%) were initiated for delivery attendance. Most transports originated from hospitals without a neonatal intensive care unit (68%), with the majority transferred to regional centers (66%). Compared with those born and cared for at the birth hospital, the odds of being transported were higher if the patient's mother was Hispanic, <20 years old, or had a previous C-section. An Apgar score <3 at 10 min of age, cardiac compressions in the delivery room, or major birth defect were also risk factors for neonatal transport.As many neonates receive transport within the first week after birth, there may be opportunities for quality improvement activities in this area.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.102.

    View details for DOI 10.1038/jp.2016.102

    View details for Web of Science ID 000389735700019

    View details for PubMedID 27684413

  • Opportunities for maternal transport for delivery of very low birth weight infants. Journal of perinatology Robles, D., Blumenfeld, Y. J., Lee, H. C., Gould, J. B., Main, E., Profit, J., Melsop, K., Druzin, M. 2016


    To assess frequency of very low birth weight (VLBW) births at non-level III hospitals.Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500 g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models.Of the 1 508 143 births, 13 919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24 h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively.Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.174.

    View details for DOI 10.1038/jp.2016.174

    View details for PubMedID 27684426

  • Estimating Length of Stay by Patient Type in the Neonatal Intensive Care Unit AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Bennett, M. V., Schulman, J., Gould, J. B., Profit, J. 2016; 33 (8): 751-757


    Objective Develop length of stay prediction models for neonatal intensive care unit patients. Study Design We used data from 2008 to 2010 to construct length of stay models for neonates admitted within 1 day of age to neonatal intensive care units and surviving to discharge home. Results Our sample included 23,551 patients. Median length of stay was 79 days when birth weight was < 1,000 g, 46 days for 1,000 to 1,500 g, 21 days for 1,500 to 2,500 g, and 8 days for ≥2,500 g. Risk factors for longer length of stay varied by weight. Units with shorter length of stay for one weight group had shorter lengths of stay for other groups. Conclusion Risk models for comparative assessments of length of stay need to appropriately account for weight, particularly considering the cutoff of 1,500 g. Refining prediction may benefit counseling of families and health care systems to efficiently allocate resources.

    View details for DOI 10.1055/s-0036-1572433

    View details for PubMedID 26890437

  • Impact of antenatal steroids on intraventricular hemorrhage in very-low-birth weight infants JOURNAL OF PERINATOLOGY Wei, J. C., Catalano, R., Profit, J., Gould, J. B., Lee, H. C. 2016; 36 (5): 352-356


    To determine the association between antenatal steroids administration and intraventricular hemorrhage rates.We used cross-sectional data from the California Perinatal Quality Care Collaborative during 2007 to 2013 for infants ⩽32 weeks gestational age. Using multivariable logistic regression, we evaluated the effect of antenatal steroids on intraventricular hemorrhage, stratified by gestational age.In 25 979 very-low-birth weight infants, antenatal steroid use was associated with a reduction in incidence of any grade of intraventricular hemorrhage (odds ratio=0.68, 95% confidence interval: 0.62, 0.75) and a reduction in incidence of severe intraventricular hemorrhage (odds ratio=0.51, 95% confidence interval: 0.45, 0.58). This association was seen across gestational ages ranging from 22 to 29 weeks.Although current guidelines recommend coverage for preterm birth at 24 to 34 weeks gestation, our results suggest that treatment with antenatal steroids may be beneficial even before 24 weeks of gestational age.

    View details for DOI 10.1038/jp.2016.38

    View details for Web of Science ID 000374914900006

    View details for PubMedID 27010109

  • The Association of Level of Care With NICU Quality. Pediatrics Profit, J., Gould, J. B., Bennett, M., Goldstein, B. A., Draper, D., Phibbs, C. S., Lee, H. C. 2016; 137 (3): 1-9


    Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.We conducted a cross-sectional analysis of 21 051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.

    View details for DOI 10.1542/peds.2014-4210

    View details for PubMedID 26908663

  • Postnatal growth failure in very low birthweight infants born between 2005 and 2012. Archives of disease in childhood. Fetal and neonatal edition Griffin, I. J., Tancredi, D. J., Bertino, E., Lee, H. C., Profit, J. 2016; 101 (1): 50-55


    Postnatal growth restriction is common in preterm infants and is associated with long-term neurodevelopmental impairment. Recent trends in postnatal growth restriction are unclear.Birth and discharge weights from 25 899 Californian very low birthweight infants (birth weight 500-1500 g, gestational age 22-32 weeks) who were born between 2005 and 2012 were converted to age-specific Z-scores and analysed using multivariable modelling.Birthweight Z-score did not change between 2005 and 2012. However, the adjusted discharge weight Z-score increased significantly by 0.168 Z-scores (0.154, 0.182) over the study period, and the adjusted fall in weight Z-score between birth and discharge decreased significantly between those dates (by 0.016 Z-scores/year). The proportion of infants who were discharged home below the 10th weight-for-age centile or had a fall in weight Z-score between birth and discharge of >1 decreased significantly over time. The comorbidities most associated with poorer postnatal growth were medical or surgical necrotising enterocolitis, isolated gastrointestinal perforation and severe retinopathy of prematurity, which were associated with an adjusted mean reduction in discharge weight Z-score of 0.24, 0.57, 0.46 and 0.32, respectively. Chronic lung disease was not a risk factor after accounting for length of stay.Postnatal, but not prenatal, growth improved among very low birthweight infants between 2005 and 2012. Neonatal morbidities including necrotising enterocolitis, gastrointestinal perforations and severe retinopathy of prematurity have significant negative effects on postnatal growth.

    View details for DOI 10.1136/archdischild-2014-308095

    View details for PubMedID 26201534

  • Optimal Criteria Survey for Preresuscitation Delivery Room Checklists. American journal of perinatology Brown, T., Tu, J., Profit, J., Gupta, A., Lee, H. C. 2016; 33 (2): 203-207


    Objective To investigate the optimal format and content of delivery room reminder tools, such as checklists. Study Design Voluntary, anonymous web-based surveys on checklists and reminder tools for neonatal resuscitation were sent to clinicians at participating hospitals. Summary statistics including the mean and standard deviation of the survey items were calculated. Several key comparisons between groups were completed using Student t-test. Results Fifteen hospitals were surveyed and 299 responses were collected. Almost all (96%) respondents favored some form of a reminder tool. Specific reminders such as "check and prepare all equipment" (mean 3.69, SD 0.81) were ranked higher than general reminders and personnel reminders such as "introduction and assigning roles" (mean 3.23, SD 1.08). Rankings varied by profession, institution, and deliveries attended per month. Conclusions Clinicians perceive a benefit of a checklist for neonatal resuscitation in the delivery room. Preparation of equipment was perceived as the most important use for checklists.

    View details for DOI 10.1055/s-0035-1564064

    View details for PubMedID 26368913

  • Neonatal networks: clinical research and quality improvement SEMINARS IN FETAL & NEONATAL MEDICINE Profit, J., Soll, R. F. 2015; 20 (6): 410-415


    Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.

    View details for DOI 10.1016/j.siny.2015.09.001

    View details for Web of Science ID 000367484300006

  • Neonatal networks: clinical research and quality improvement. Seminars in fetal & neonatal medicine Profit, J., Soll, R. F. 2015


    Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.

    View details for DOI 10.1016/j.siny.2015.09.001

    View details for PubMedID 26453046

  • Needs assessment to improve neonatal intensive care in Mexico PAEDIATRICS AND INTERNATIONAL CHILD HEALTH Weiss, K. J., Kowalkowski, M. A., Trevino, R., Cabrera-Meza, G., Thomas, E. J., KAPLAN, H. C., Profit, J. 2015; 35 (3): 213-219
  • Regional variation in antenatal corticosteroid use: a network-level quality improvement study. Pediatrics Profit, J., Goldstein, B. A., TAMARESIS, J., Kan, P., Lee, H. C. 2015; 135 (2): e397-404


    Examination of regional care patterns in antenatal corticosteroid use (ACU) rates may be salient for the development of targeted interventions. Our objective was to assess network-level variation using California perinatal care regions as a proxy. We hypothesized that (1) significant variation in ACU exists within and between California perinatal care regions, and (2) lower performing regions exhibit greater NICU-level variability in ACU than higher performing regions.We undertook cross-sectional analysis of 33 610 very low birth weight infants cared for at 120 hospitals in 11 California perinatal care regions from 2005 to 2011. We computed risk-adjusted median ACU rates and interquartile ranges (IQR) for each perinatal care region. The degree of variation was assessed using hierarchical multivariate regression analysis with NICU as a random effect and region as a fixed effect.From 2005 to 2011, mean ACU rates across California increased from 82% to 87.9%. Regional median (IQR) ACU rates ranged from 68.4% (24.3) to 92.9% (4.8). We found significant variation in ACU rates among regions (P < .0001). Compared with Level IV NICUs, care in a lower level of care was a strongly significant predictor of lower odds of receiving antenatal corticosteroids in a multilevel model (Level III, 0.65 [0.45-0.95]; Level II, 0.39 [0.24-0.64]; P < .001). Regions with lower performance in ACU exhibited greater variability in performance.We found significant variation in ACU rates among California perinatal regions. Regional quality improvement approaches may offer a new avenue to spread best practice.

    View details for DOI 10.1542/peds.2014-2177

    View details for PubMedID 25601974

  • Hospital variation and risk factors for bronchopulmonary dysplasia in a population-based cohort. JAMA pediatrics Lapcharoensap, W., Gage, S. C., Kan, P., Profit, J., Shaw, G. M., Gould, J. B., Stevenson, D. K., O'Brodovich, H., Lee, H. C. 2015; 169 (2)


    Bronchopulmonary dysplasia (BPD) remains a serious morbidity in very low-birth-weight (VLBW) infants (<1500 g). Deregionalization of neonatal care has resulted in an increasing number of VLBW infants treated in community hospitals with unknown impact on the development of BPD.To identify individual risk factors for BPD development and hospital variation of BPD rates across all levels of neonatal intensive care units (NICUs) within the California Perinatal Quality Care Collaborative.Retrospective cohort study (January 2007 to December 2011) from the California Perinatal Quality Care Collaborative including more than 90% of California's NICUs. Eligible VLBW infants born between 22 to 29 weeks' gestational age.Varying levels of intensive care.Bronchopulmonary dysplasia was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age. A combined outcome of BPD or mortality prior to 36 weeks was used. Multivariable logistic regression accounting for hospital as a random effect and gestational age as a risk factor was used to assess individual risk factors for BPD. This model was applied to determine risk-adjusted rates of BPD across hospitals and assess associations between levels of care and BPD rates.The study cohort included 15 779 infants, of which 1534 infants died prior to 36 weeks' postmenstrual age. A total of 7081 infants, or 44.8%, met the primary outcome of BPD or death prior to 36 weeks. Combined BPD or death rates across 116 NICUs varied from 17.7% to 73.4% (interquartile range, 38.7%-54.1%). Compared with level IV NICUs, the risk for developing BPD was higher for level II NICUs (odds ratio, 1.23; 95% CI, 1.02-1.49) and similar for level III NICUs (odds ratio, 1.04; 95% CI, 0.95-1.14).Bronchopulmonary dysplasia or death prior to 36 weeks' postmenstrual age affects approximately 45% of VLBW infants across California. The wide variability in BPD occurrence across hospitals could offer insights into potential risk or preventive factors. Additionally, our findings suggest that increased regionalization of NICU care may reduce BPD among VLBW infants.

    View details for DOI 10.1001/jamapediatrics.2014.3676

    View details for PubMedID 25642906

  • Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis. JAMA pediatrics Kastenberg, Z. J., Lee, H. C., Profit, J., Gould, J. B., Sylvester, K. G. 2015; 169 (1): 26-32


    There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization.To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals.A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30 566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth.Level and volume of neonatal intensive care at the hospital of birth.In-hospital mortality.There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life.These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.

    View details for DOI 10.1001/jamapediatrics.2014.2085

    View details for PubMedID 25383940

  • Postnatal growth failure in very low birthweight infants born between 2005 and 2012 ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Griffin, I. J., Tancredi, D. J., Bertino, E., Lee, H. C., Profit, J. 2015; 101 (1): 50-55
  • The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants. Journal of perinatology : official journal of the California Perinatal Association Griffin, I. J., Lee, H. C., Profit, J. n., Tancedi, D. J. 2015


    Objective:Survival of preterm and very low birth weight (VLBW) infants has steadily improved. However, the rates of mortality and morbidity among the very smallest infants are poorly characterized.Study Design:Data from the California Perinatal Quality Care Collaborative for the years 2005 to 2012 were used to compare the mortality and morbidity of profoundly low birth weight (ProLBW, birth weight 300 to 500 g) and profoundly small for gestational age (ProSGA, <1st centile for weight-for-age) infants with very low birth weight (VLBW, birth weight 500 to 1500 g) and appropriate for gestational age (AGA, 5th to 95th centile for weight-for-age) infants, respectively.Result:Data were available for 44 561 neonates of birth weight <1500 g. Of these, 1824 were ProLBW and 648 were ProSGA. ProLBW and ProSGA differed in their antenatal risk factors from the comparison groups and were less likely to receive antenatal steroids or to be delivered by cesarean section. Only 14% of ProSGA and 21% of ProLBW infants survived to hospital discharge, compared with >80% of AGA and VLBW infants. The largest increase in mortality in ProSGA and ProLBW infants occurred prior to 12 h of age, and most mortality happened in this time period. Survival of the ProLBW and ProSGA infants was positively associated with higher gestational age, receipt of antenatal steroids, cesarean section delivery and singleton birth.Conclusion:Survival of ProLBW and ProSGA infants is uncommon, and survival without substantial morbidity is rare. Survival is positively associated with receipt of antenatal steroids and cesarean delivery.Journal of Perinatology advance online publication, 15 January 2015; doi:10.1038/jp.2014.233.

    View details for PubMedID 25590218

  • Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout BMJ QUALITY & SAFETY Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. 2014; 23 (10): 814-822


    Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown.This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas.WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.

    View details for DOI 10.1136/bmjqs-2013-002042

    View details for Web of Science ID 000342375400004

  • Burnout in the NICU setting and its relation to safety culture BMJ QUALITY & SAFETY Profit, J., Sharek, P. J., Amspoker, A. B., Kowalkowski, M. A., Nisbet, C. C., Thomas, E. J., Chadwick, W. A., Sexton, J. B. 2014; 23 (10): 806-813


    Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes.(1) Test the psychometric properties of a brief four-item burnout scale, (2) Provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types, (3) Examine the relationships between caregiver burnout and patient safety culture.Cross-sectional survey study.Nurses, nurse practitioners, respiratory care providers and physicians in 44 NICUs.Caregiver assessments of burnout and safety culture.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. The percentage of respondents in each NICU reporting burnout ranged from 7.5% to 54.4% (mean=25.9%, SD=10.8). The four-item burnout scale was reliable (α=0.85) and appropriate for aggregation (intra-class correlation coefficient-2=0.95). Burnout varied significantly between NICUs, p<0.0001, but was less prevalent in physicians (mean=15.1%, SD=19.6) compared with non-physicians (mean=26.9%, SD=11.4, p=0.0004). NICUs with more burnout had lower teamwork climate (r=-0.48, p=0.001), safety climate (r=-0.40, p=0.01), job satisfaction (r=-0.64, p<0.0001), perceptions of management (r=-0.50, p=0.0006) and working conditions (r=-0.45, p=0.002).NICU caregiver burnout appears to have 'climate-like' features, is prevalent, and associated with lower perceptions of patient safety culture.

    View details for DOI 10.1136/bmjqs-2014-002831

    View details for Web of Science ID 000342375400003

  • Baby-MONITOR: A Composite Indicator of NICU Quality. Pediatrics Profit, J., Kowalkowski, M. A., Zupancic, J. A., Pietz, K., Richardson, P., Draper, D., Hysong, S. J., Thomas, E. J., Petersen, L. A., Gould, J. B. 2014; 134 (1): 74-82


    NICUs vary in the quality of care delivered to very low birth weight (VLBW) infants. NICU performance on 1 measure of quality only modestly predicts performance on others. Composite measurement of quality of care delivery may provide a more comprehensive assessment of quality. The objective of our study was to develop a robust composite indicator of quality of NICU care provided to VLBW infants that accurately discriminates performance among NICUs.We developed a composite indicator, Baby-MONITOR, based on 9 measures of quality chosen by a panel of experts. Measures were standardized, equally weighted, and averaged. We used the California Perinatal Quality Care Collaborative database to perform across-sectional analysis of care given to VLBW infants between 2004 and 2010. Performance on the Baby-MONITOR is not an absolute marker of quality but indicates overall performance relative to that of the other NICUs. We used sensitivity analyses to assess the robustness of the composite indicator, by varying assumptions and methods.Our sample included 9023 VLBW infants in 22 California regional NICUs. We found significant variations within and between NICUs on measured components of the Baby-MONITOR. Risk-adjusted composite scores discriminated performance among this sample of NICUs. Sensitivity analysis that included different approaches to normalization, weighting, and aggregation of individual measures showed the Baby-MONITOR to be robust (r = 0.89-0.99).The Baby-MONITOR may be a useful tool to comprehensively assess the quality of care delivered by NICUs.

    View details for DOI 10.1542/peds.2013-3552

    View details for PubMedID 24918221

  • Consequences of the Affordable Care Act for Sick Newborns. Pediatrics Profit, J. n., Wise, P. H., Lee, H. C. 2014

    View details for PubMedID 25311609

  • Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care A Randomized Trial JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Petersen, L. A., Simpson, K., Pietz, K., Urech, T. H., Hysong, S. J., Profit, J., Conrad, D. A., Dudley, R. A., Woodard, L. D. 2013; 310 (10): 1042-1050


    Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory.To test the effect of explicit financial incentives to reward guideline-recommended hypertension care.Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists).Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports.Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension.Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout.Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these Identifier: NCT00302718.

    View details for DOI 10.1001/jama.2013.276303

    View details for Web of Science ID 000324133400021

    View details for PubMedID 24026599

  • Variations in Definitions of Mortality Have Little Influence on Neonatal Intensive Care Unit Performance Ratings JOURNAL OF PEDIATRICS Profit, J., Gould, J. B., Draper, D., Zupancic, J. A., Kowalkowski, M. A., Woodard, L., Pietz, K., Petersen, L. A. 2013; 162 (1): 50-U320


    To measure the influence of varying mortality time frames on performance rankings among regional neonatal intensive care units (NICUs) in a large state.We performed a cross-sectional data analysis of very low birth weight infants receiving care at 24 level 3 NICUs. We tested the effect of 4 definitions of mortality: (1) death between admission and end of birth hospitalization or up to 366 days; (2) death between 12 hours of age and the end of birth hospitalization or up to 366 days; (3) death between admission and 28 days; and (4) death between 12 hours of age and 28 days. NICUs were ranked by quantifying their deviation from risk-adjusted expected mortality and dividing them into 3 tiers: top 6, bottom 6, and in between.There was wide interinstitutional variation in risk-adjusted mortality for each definition (observed minus expected z-score range, -6.08 to 3.75). However, mortality-based NICU rankings and classification into performance tiers were very similar for all institutions in each of our time frames. Among all 4 definitions, NICU rank correlations were high (>0.91). Few NICUs changed relative to a neighboring tier with changes in definitions, and none changed by more than one tier.The time frame used to ascertain mortality had little effect on comparative NICU performance.

    View details for DOI 10.1016/j.jpeds.2012.06.002

    View details for Web of Science ID 000312915900012

    View details for PubMedID 22854328

  • Nurse-to-Patient Ratios and Neonatal Outcomes: A Brief Systematic Review NEONATOLOGY Sherenian, M., Profit, J., Schmidt, B., Suh, S., Xiao, R., Zupancic, J. A., DeMauro, S. B. 2013; 104 (3): 179-183


    Higher patient-to-nurse ratios and nursing workload are associated with increased mortality in the adult intensive care unit (ICU). Most neonatal ICUs (NICUs) in the United Kingdom do not meet national staffing recommendations. The impact of staffing on outcomes in the NICU is unknown.To determine how nurse-to-patient ratios or nursing workload affects outcomes in the NICU.Two authors (M.S., S.S.) searched PubMed, Medline, and EMBASE for eligible studies. Included studies reported on both the outcomes of infants admitted to a NICU and nurse-to-patient ratios or workload, and were published between 1/1990 and 4/2010 in any language. The primary outcome was mortality before discharge, relative to nurse-to-patient ratios. Secondary outcomes were intraventricular hemorrhage, daily weight gain, days on assisted ventilation, days on oxygen and nosocomial infection. Study quality was assessed with the STROBE checklist.Seven studies met the inclusion criteria. Three reported on the same group of patients. Only four studies reported death before discharge from the NICU relative to nurse-to-patient ratios. Three reported an association between lower nurse-to-patient ratios and higher mortality, and one reported just the opposite. Because each study used a different definition of nurse staffing, a meta-analysis could not be performed.Nurse-to-patient ratios appear to affect outcomes of neonatal intensive care, but limitations of the existing literature prevent clear conclusions about optimal staffing strategies. Evidence-based standards for staffing could impact public policy and lead to improvements in patient safety and decreased rates of adverse outcomes. More research on this subject, including a standard and valid measure of nursing workload, is urgently needed.

    View details for DOI 10.1159/000353458

    View details for Web of Science ID 000325241900005

    View details for PubMedID 23941740

  • Correlation of Neonatal Intensive Care Unit Performance Across Multiple Measures of Quality of Care JAMA PEDIATRICS Profit, J., Zupancic, J. A., Gould, J. B., Pietz, K., Kowalkowski, M. A., Draper, D., Hysong, S. J., Petersen, L. A. 2013; 167 (1): 47-54


    To examine whether high performance on one measure of quality is associated with high performance on others and to develop a data-driven explanatory model of neonatal intensive care unit (NICU) performance.We conducted a cross-sectional data analysis of a statewide perinatal care database. Risk-adjusted NICU ranks were computed for each of 8 measures of quality selected based on expert input. Correlations across measures were tested using the Pearson correlation coefficient. Exploratory factor analysis was used to determine whether underlying factors were driving the correlations.Twenty-two regional NICUs in California.In total, 5445 very low-birth-weight infants cared for between January 1, 2004, and December 31, 2007.Pneumothorax, growth velocity, health care-associated infection, antenatal corticosteroid use, hypothermia during the first hour of life, chronic lung disease, mortality in the NICU, and discharge on any human breast milk.The NICUs varied substantially in their clinical performance across measures of quality. Of 28 unit-level correlations, 6 were significant (ρ < .05). Correlations between pairs of measures of quality of care were strong (ρ ≥ .5) for 1 pair, moderate (range, ρ ≥ .3 to ρ < .5) for 8 pairs, weak (range, ρ ≥ .1 to ρ < .3) for 5 pairs, and negligible (ρ < .1) for 14 pairs. Exploratory factor analysis revealed 4 underlying factors of quality in this sample. Pneumothorax, mortality in the NICU, and antenatal corticosteroid use loaded on factor 1; growth velocity and health care-associated infection loaded on factor 2; chronic lung disease loaded on factor 3; and discharge on any human breast milk loaded on factor 4.In this sample, the ability of individual measures of quality to explain overall quality of neonatal intensive care was modest.

    View details for DOI 10.1001/jamapediatrics.2013.418

    View details for Web of Science ID 000316797500010

    View details for PubMedID 23403539

  • Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures? JOURNAL OF PERINATOLOGY Kowalkowski, M., Gould, J. B., Bose, C., Petersen, L. A., Profit, J. 2012; 32 (4): 247-252


    To assess the level of agreement when selecting quality measures for inclusion in a composite index of neonatal intensive care quality (Baby-MONITOR) between two panels: one comprised of academic researchers (Delphi) and another comprised of academic and clinical neonatologists (clinician).In a modified Delphi process, a panel rated 28 quality measures. We assessed clinician agreement with the Delphi panel by surveying a sample of 48 neonatal intensive care practitioners. We asked the clinician group to indicate their level of agreement with the Delphi panel for each measure using a five-point scale (much too high, slightly too high, reasonable, slightly too low and much too low). In addition, we asked clinicians to select measures for inclusion in the Baby-MONITOR based on a yes or no vote and a pre-specified two-thirds majority for inclusion.In all, 23 (47.9%) of the clinicians responded to the survey. We found high levels of agreement between the Delphi and clinician panels, particularly across measures selected for the Baby-MONITOR. Clinicians selected the same nine measures for inclusion in the composite as the Delphi panel. For these nine measures, 74% of clinicians indicated that the Delphi panel rating was 'reasonable'.Practicing clinicians agree with an expert panel on the measures that should be included in the Baby-MONITOR, enhancing face validity.

    View details for DOI 10.1038/jp.2011.199

    View details for Web of Science ID 000302189200002

    View details for PubMedID 22241483

  • The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Profit, J., Etchegaray, J., Petersen, L. A., Sexton, J. B., Hysong, S. J., Mei, M., Thomas, E. J. 2012; 97 (2): F127-F132


    Neonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unit setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting.To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure.Cross-sectional survey of caregivers in 12 NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman rank correlation coefficients were used to test for consistency in scale performance. The authors then examined whether performance in the top four NICUs in one scale predicted top four performance in others.There were 547 respondents in 12 NICUs. Of 15 NICU-level correlations in performance ranking, two were >0.7, seven were between 0.4 and 0.69, and the six remaining were <0.4. The authors found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p=0.051, indicating generally consistent performance across dimensions of safety culture.A culture of safety permeates many aspects of patient care and organisational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.

    View details for DOI 10.1136/archdischild-2011-300612

    View details for Web of Science ID 000301633800010

    View details for PubMedID 22337935

  • Neonatal intensive care unit safety culture varies widely ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Profit, J., Etchegaray, J., Petersen, L. A., Sexton, J. B., Hysong, S. J., Mei, M., Thomas, E. J. 2012; 97 (2): F120-F126


    Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture.To describe NICU care giver assessments of safety culture, explore variability within and between NICUs on safety culture domains, and test for association with care giver characteristics.NICU care givers in 12 hospitals were surveyed using the Safety Attitudes Questionnaire (SAQ), which has six scales: teamwork climate, safety climate, job satisfaction, stress recognition, perception of management and working conditions. Scale means, SDs and percent positives (percent agreement) were calculated for each NICU.There was substantial variation in safety culture domains among NICUs. Composite mean score across the six domains ranged from 56.3 to 77.8 on a 100-point scale and NICUs in the top four NICUs were significantly different from the bottom four (p<0.001). Across the six domains, respondent assessments varied widely, but were least positive on perceptions of management (3%-80% positive; mean 33.3%) and stress recognition (18%-61% positive; mean 41.3%). Comparisons of SAQ scale scores between NICUs and a previously published adult ICU cohort generally revealed higher scores for NICUs. Composite scores for physicians were 8.2 (p=0.04) and 9.5 (p=0.02) points higher than for nurses and ancillary personnel.There is significant variation and scope for improvement in safety culture among these NICUs. The NICU variation was similar to variation in adult ICUs, but NICU scores were generally higher. Future studies should validate whether safety culture measured with the SAQ correlates with clinical and operational outcomes in NICUs.

    View details for DOI 10.1136/archdischild-2011-300635

    View details for Web of Science ID 000301633800009

    View details for PubMedID 21930691

    View details for PubMedCentralID PMC3845658

  • Perils and Opportunities of Comparative Performance Measurement ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Profit, J., Woodard, L. D. 2012; 166 (2): 191-194

    View details for Web of Science ID 000301211000015

    View details for PubMedID 22312179

  • Treating Chronically Ill People with Diabetes Mellitus with Limited Life Expectancy: Implications for Performance Measurement JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Woodard, L. D., Landrum, C. R., Urech, T. H., Profit, J., Virani, S. S., Petersen, L. A. 2012; 60 (2): 193-201


    To develop an algorithm to identify individuals with limited life expectancy and examine the effect of limited life expectancy on glycemic control and treatment intensification in individuals with diabetes mellitus.Individuals with diabetes mellitus and coexisting congestive heart failure, chronic obstructive pulmonary disease, dementia, end-stage liver disease, and/or primary or metastatic cancer with limited life expectancy were identified. To validate the algorithm, 5-year mortality was assessed in individuals identified as having limited life expectancy. Rates of meeting performance measures for glycemic control between individuals with and without limited life expectancy were compared. In individuals with uncontrolled glycosylated hemoglobin (HbA(1c) ) levels, the effect of limited life expectancy on treatment intensification within 90 days was examined.One hundred ten Department of Veterans Affairs facilities; October 2006 to September 2007.Eight hundred eighty-eight thousand six hundred twenty-eight individuals with diabetes mellitus.HbA(1c) ; treatment intensification within 90 days of index HbA(1c) reading.Twenty-nine thousand sixteen (3%) participants had limited life expectancy. Adjusting for age, 5-year mortality was five times as high in participants with limited life expectancy than in those without. Participants with limited life expectancy had poorer glycemic control than those without (glycemic control: 77.1% vs 78.1%; odds ratio (OR) = 0.84, 95% confidence interval (CI) = 0.81-0.86) and less-frequent treatment intensification (treatment intensification: 20.9% vs 28.6%; OR = 0.71, 95% CI = 0.67-0.76), even after controlling for patient-level characteristics.Participants with limited life expectancy were less likely than those without to have controlled HbA(1c) levels and to receive treatment intensification, suggesting that providers treat these individuals less aggressively. Quality measurement and performance-based reimbursement systems should acknowledge the different needs of this population.

    View details for DOI 10.1111/j.1532-5415.2011.03784.x

    View details for Web of Science ID 000300677400001

    View details for PubMedID 22260627

  • Formal selection of measures for a composite index of NICU quality of care: Baby-MONITOR JOURNAL OF PERINATOLOGY Profit, J., Gould, J. B., Zupancic, J. A., Stark, A. R., WALL, K. M., Kowalkowski, M. A., Mei, M., Pietz, K., Thomas, E. J., Petersen, L. A. 2011; 31 (11): 702-710


    To systematically rate measures of care quality for very low birth weight infants for inclusion into Baby-MONITOR, a composite indicator of quality.Modified Delphi expert panelist process including electronic surveys and telephone conferences. Panelists considered 28 standard neonatal intensive care unit (NICU) quality measures and rated each on a 9-point scale taking into account pre-defined measure characteristics. In addition, panelists grouped measures into six domains of quality. We selected measures by testing for rater agreement using an accepted method.Of 28 measures considered, 13 had median ratings in the high range (7 to 9). Of these, 9 met the criteria for inclusion in the composite: antenatal steroids (median (interquartile range)) 9(0), timely retinopathy of prematurity exam 9(0), late onset sepsis 9(1), hypothermia on admission 8(1), pneumothorax 8(2), growth velocity 8(2), oxygen at 36 weeks postmenstrual age 7(2), any human milk feeding at discharge 7(2) and in-hospital mortality 7(2). Among the measures selected for the composite, the domains of quality most frequently represented included effectiveness (40%) and safety (30%).A panel of experts selected 9 of 28 routinely reported quality measures for inclusion in a composite indicator. Panelists also set an agenda for future research to close knowledge gaps for quality measures not selected for the Baby-MONITOR.

    View details for DOI 10.1038/jp.2011.12

    View details for Web of Science ID 000296590600003

    View details for PubMedID 21350429

    View details for PubMedCentralID PMC3205234

  • Clinical Benefits, Costs, and Cost-Effectiveness of Neonatal Intensive Care in Mexico PLOS MEDICINE Profit, J., Lee, D., Zupancic, J. A., Papile, L., Gutierrez, C., Goldie, S. J., Gonzalez-Pier, E., Salomon, J. A. 2010; 7 (12)


    Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico.A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24-26, 27-29, and 30-33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24-26, 27-29, and 30-33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses.Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis. Please see later in the article for the Editors' Summary.

    View details for DOI 10.1371/journal.pmed.1000379

    View details for Web of Science ID 000285499600006

    View details for PubMedID 21179496

    View details for PubMedCentralID PMC3001895

  • Improving benchmarking by using an explicit framework for the development of composite indicators: an example using pediatric quality of care IMPLEMENTATION SCIENCE Profit, J., Typpo, K. V., Hysong, S. J., Woodard, L. D., Kallen, M. A., Petersen, L. A. 2010; 5


    The measurement of healthcare provider performance is becoming more widespread. Physicians have been guarded about performance measurement, in part because the methodology for comparative measurement of care quality is underdeveloped. Comprehensive quality improvement will require comprehensive measurement, implying the aggregation of multiple quality metrics into composite indicators.To present a conceptual framework to develop comprehensive, robust, and transparent composite indicators of pediatric care quality, and to highlight aspects specific to quality measurement in children.We reviewed the scientific literature on composite indicator development, health systems, and quality measurement in the pediatric healthcare setting. Frameworks were selected for explicitness and applicability to a hospital-based measurement system.We synthesized various frameworks into a comprehensive model for the development of composite indicators of quality of care. Among its key premises, the model proposes identifying structural, process, and outcome metrics for each of the Institute of Medicine's six domains of quality (safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity) and presents a step-by-step framework for embedding the quality of care measurement model into composite indicator development.The framework presented offers researchers an explicit path to composite indicator development. Without a scientifically robust and comprehensive approach to measurement of the quality of healthcare, performance measurement will ultimately fail to achieve its quality improvement goals.

    View details for DOI 10.1186/1748-5908-5-13

    View details for Web of Science ID 000275430000001

    View details for PubMedID 20181129

    View details for PubMedCentralID PMC2831823

  • Patient-to-Nurse Ratios and Outcomes of Moderately Preterm Infants PEDIATRICS Profit, J., Petersen, L. A., McCormick, M. C., Escobar, G. J., Coleman-Phox, K., Zheng, Z., Pietz, K., Zupancic, J. A. 2010; 125 (2): 320-326


    Moderately preterm infants (30-34(6/7) weeks' gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the influence of patient-to-nurse ratios (PNRs) on outcomes of care provided to moderately preterm infants.Using data from a prospective, multicenter, observational cohort study of 850 moderately preterm infants from 10 NICUs in California and Massachusetts, we tested for associations between PNR and several important clinical outcomes by using multivariate random-effects models. To correct for the influence of NICU size, we dichotomized the sample into those with an average daily census of <20 or > or =20 infants.Overall, we found few clinically significant associations between PNR and clinical outcomes of care. Mean PNRs were higher in large compared with small NICUs (2.7 vs 2.1; P < .001). In bivariate analyses, an increase in PNR was associated with a slightly higher daily weight gain (5 g/day), greater gestational age at discharge, any intraventricular hemorrhage, and severe retinopathy of prematurity. After controlling for case mix, NICU size, and site of care, an additional patient per nurse was associated with a decrease in daily weight gain by 24%. Other variables were no longer independently associated with PNR.In this population of moderately preterm infants, the PNR was associated with a decrease in daily weight gain, but was not associated with other measures of quality. In contrast with findings in the adult intensive care literature, measured clinical outcomes were similar across the range of nurse-staffing arrangements among participating NICUs. We conclude that the PNR is not useful for profiling hospitals' quality of care delivery to moderately preterm infants.

    View details for DOI 10.1542/peds.2008-3140

    View details for Web of Science ID 000275942900017

    View details for PubMedID 20064868

    View details for PubMedCentralID PMC3151172

  • Delayed Pediatric Office Follow-up of Newborns After Birth Hospitalization PEDIATRICS Profit, J., Cambric-Hargrove, A. J., Tittle, K. O., Pietz, K., Stark, A. R. 2009; 124 (2): 548-554


    Key recommendations of the American Academy of Pediatrics guideline on management of severe hyperbilirubinemia in healthy infants of >or=35 weeks' gestation include predischarge screening for risk of subsequent hyperbilirubinemia, follow-up at 3 to 5 days of age, and lactation support. Little information is available on contemporary compliance with follow-up recommendations.To assess timing and content of the first newborn office visit after birth hospitalization in urban and suburban pediatric practices in Houston, Texas.We reviewed office records for the first visit within 4 weeks of birth during January through July 2006 for apparently healthy newborns with a gestational age of >or=35 weeks or birth weight of >or=2500 g seen within a pediatric provider network. For each pediatrician, we selected every fifth patient up to a total of 6.Of 845 records abstracted, 698 (83%) were eligible for analysis. Infants were seen by 136 pediatricians in 39 practices. They had vaginal (64%) or cesarean (36%) deliveries at 20 local hospitals, of which 17 had routine predischarge bilirubin screening policies. Only 37% of all infants, 44% of vaginally delivered infants, and 41% of exclusively breastfed infants were seen before 6 days of age. Thirty-five percent of the infants were seen after 10 days of age. Among 636 infants seen at

    View details for DOI 10.1542/peds.2008-2926

    View details for Web of Science ID 000268377000015

    View details for PubMedID 19651578

    View details for PubMedCentralID PMC3155409

  • Pay for performance is growing up ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Profit, J., Petersen, L. A. 2007; 161 (7): 713-714

    View details for Web of Science ID 000247699000016

    View details for PubMedID 17606837

  • Implementing pay-for-performance in the neonatal intensive care unit PEDIATRICS Profit, J., Zupancic, J. A., Gould, J. B., Petersen, L. A. 2007; 119 (5): 975-982


    Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-for-performance and the state of quality measurement science, experimentation with pay-for-performance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting.

    View details for DOI 10.1542/peds.2006-1565

    View details for Web of Science ID 000246153300014

    View details for PubMedID 17473099

    View details for PubMedCentralID PMC3151255

  • Neonatal intensive care unit census influences discharge of moderately preterm infants PEDIATRICS Profit, J., McCormick, M. C., Escobar, G. J., Richardson, D. K., Zheng, Z., Coleman-Phox, K., Roberts, R., Zupancic, J. A. 2007; 119 (2): 314-319


    The timely discharge of moderately premature infants has important economic implications. The decision to discharge should occur independent of unit census. We evaluated the impact of unit census on the decision to discharge moderately preterm infants.In a prospective multicenter cohort study, we enrolled 850 infants born between 30 and 34 weeks' gestation at 10 NICUs in Massachusetts and California. We divided the daily census from each hospital into quintiles and tested whether discharges were evenly distributed among them. Using logistic regression, we analyzed predictors of discharge within census quintiles associated with a greater- or less-than-expected likelihood of discharge. We then explored parental satisfaction and postdischarge resource consumption in relation to discharge during census periods that were associated with high proportions of discharge.There was a significant correlation between unit census and likelihood of discharge. When unit census was in the lowest quintile, patients were 20% less likely to be discharged when compared with all of the other quintiles of unit census. In the lowest quintile of unit census, patient/nurse ratio was the only variable associated with discharge. When census was in the highest quintile, patients were 32% more likely to be discharged when compared with all of the other quintiles of unit census. For patients in this quintile, a higher patient/nurse ratio increased the likelihood of discharge. Conversely, infants with prolonged lengths of stay, an increasing Score for Neonatal Acute Physiology II, and minor congenital anomalies were less likely to be discharged. Infants discharged at high unit census did not differ from their peers in terms of parental satisfaction, emergency department visits, home nurse visits, or rehospitalization rates.Discharges are closely correlated with unit census. Providers incorporate demand and case mix into their discharge decisions.

    View details for DOI 10.1542/peds.2005-2909

    View details for Web of Science ID 000243942000011

    View details for PubMedID 17272621

    View details for PubMedCentralID PMC3151170

  • Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Profit, J., Zupancic, J. A., McCormick, M. C., Richardson, D. K., Escobar, G. J., Tucker, J., Tarnow-Mordi, W., Parry, G. 2006; 91 (4): F245-F250


    To compare gestational age at discharge between infants born at 30-34(+6) weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom.Prospective observational cohort study.Fifty four United Kingdom, five California, and five Massachusetts NICUs.A total of 4359 infants who survived to discharge home after admission to an NICU.Gestational age at discharge home.The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p = 0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI -1.2 to 3.0) days earlier in Massachusetts.Infants of 30-34(+6) weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants.

    View details for DOI 10.1136/adc.2005.075093

    View details for Web of Science ID 000238845800003

    View details for PubMedID 16449257

    View details for PubMedCentralID PMC2672723