PC1061: Disentangling Disparities and Equity Dashboards in the Neonatal Intensive Care Unit: A Qualitative Exploration of Expert Perspectives

Background: Significant racial/ethnic disparities in quality of care and outcomes in the neonatal intensive care unit (NICU) setting have been documented. Perinatal quality collaboratives and healthcare organizations have focused on addressing these disparities through a variety of efforts, such as anti-bias trainings and quality improvement (QI) initiatives, including a health equity dashboard. However, it is unclear whether these QI approaches can adequately address the origins of disparities. Our aims were to understand perceived sources of disparities in NICU quality of care and outcomes and to explore the alignment of these sources with QI tactics based on audit and feedback.

Methods: We conducted qualitative interviews with 12 Advisory Board members of an National Institutes of Health-funded grant to develop a NICU health equity dashboard. Participants were purposively selected to achieve gender, racial/ethnic and occupational diversity. They identified as men and women, Black, White, Asian, and Hispanic, and represented neonatologists, nurses, health services researchers and parents of former NICU infants. We used grounded theory, an inductive and iterative method, to develop codes, shape interviews and conduct analysis.

Results: Participants identified the following overlapping sources of disparity in NICU quality of care: structural racism, interpersonal biases, and care process barriers. With regard to structural racism, experts noted systematic barriers related to social determinants of health, including transportation and low socioeconomic status, as well as access to health care services, including insurance coverage and care regionalization. Solutions included advocacy and health policy interventions. Interpersonal biases arose in part from racial/ethnic, socioeconomic status, cultural or language discordance between NICU staff and families. No definitive solutions emerged from the data. Experts shared examples of clinicians’ interpersonal biases allocating differential effort based on moral judgments of whether a particular family is deserving. Participants described care process barriers (parking, employment, sibling care, family-centered hospital policies) which intersect heavily with social determinants of health, affecting opportunities for parental engagement at bedside. Participants noted that some of these barriers are amenable to hospital-based solutions, such as increased support for social workers. A health equity dashboard was viewed as a useful tool to highlight unit-specific disparities in clinical outcomes. However, currently, no metrics exist for many of the aforementioned sources of disparities.

Conclusion: Expert responses highlighted many sources of disparate care, including structural racism, interpersonal biases, and care process barriers, especially as they affect the level of parental engagement at the bedside. Our findings suggest that while equity dashboards are useful to highlight disparity in clinical outcomes for NICU infants, they are currently limited in their ability to measure care processes, social determinants of health, and interpersonal bias that families experience. Future iterations may require different data sources to capture this information, presenting unique challenges to QI approaches.