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    Original Investigation
    June 10, 2020

    Racial/Ethnic Disparities Among Extremely Preterm Infants in the United States From 2002 to 2016

    Author Affiliations
    • 1Department of Pediatrics, University of Alabama at Birmingham, Birmingham
    • 2Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina
    • 3Statistics and Epidemiology Unit, RTI International, Rockville, Maryland
    • 4Department of Pediatrics, University of Iowa, Iowa City
    • 5Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus
    • 6Children’s Healthcare of Atlanta, Grady Memorial Hospital, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
    • 7Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
    • 8Women and Infants’ Hospital, Department of Pediatrics, Brown University, Providence, Rhode Island
    • 9Division of Neonatal and Developmental Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
    • 10Department of Pediatrics, Duke University, Durham, North Carolina
    • 11University of Rochester School of Medicine and Dentistry, Rochester, New York
    • 12Department of Pediatrics, Wayne State University, Detroit, Michigan
    • 13The Children’s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania, Philadelphia
    • 14Rainbow Babies and Children’s Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
    • 15Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
    • 16Department of Global and Community Health, George Mason University, Fairfax, Virginia
    JAMA Netw Open. 2020;3(6):e206757. doi:10.1001/jamanetworkopen.2020.6757
    Key Points español 中文 (chinese)

    Question  Are racial/ethnic disparities in care practices and major outcomes increasing or decreasing among extremely preterm infants in the US?

    Findings  In this cohort study of 20 092 extremely preterm infants, racial/ethnic disparities in rates of antenatal corticosteroids and cesarean delivery decreased over time. Changes in rates of mortality and most major morbidities did not differ among white, black, and Hispanic infants, and while mortality decreased over time from 2002 to 2016, rates of moderate-severe neurodevelopmental impairment increased over time in all groups.

    Meaning  Racial/ethnic disparities in rates of potentially life-saving care practices decreased over time in the US, with reductions in mortality but increases in neurodevelopmental impairment in all racial/ethnic groups.


    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.