Improved Referral of Very Low Birthweight Infants to High-Risk Infant Follow-Up in California

Background
A statewide initiative was implemented in California in June 2013 to address disparities in referral of very low birthweight (VLBW, birthweight less than 1500 grams) infants to high-risk infant follow-up programs. We examined the change in high-risk infant follow-up referral rates and identified risk factors associated with non-referral in the pre- and post-initiative periods.

Methods
We included VLBW infants born 2010-2016 in the population-based California Perinatal Quality Care Collaborative who survived to discharge home. We used multivariable logistic regression to examine factors associated with referral and derive risk-adjusted referral rates by NICU and region.

Results
83% of VLBW infants were referred in the pre-initiative period (January 2010-June 2013); 95% were referred in the post-initiative period (July 2013-December 2016). Referral rates improved the most (greater than or equal to 15%) for infants born at greater than 33 weeks gestation, with birthweight 1251-1500 grams, and born in intermediate and lower-volume NICUs. Post-intervention, Hispanic race-ethnicity, small for gestational age status, congenital anomaly, and major morbidity were no longer associated with decreased odds of referral. Lower birthweight, outborn status and higher NICU volume were no longer associated with increased referral. African-American race-ethnicity was associated with lower odds of referral, and higher NICU level with higher odds, during both time periods. Referral improved in many previously poor-performing NICUs and regions.

Conclusion
High-risk infant follow-up referral of VLBW infants improved significantly and disparities decreased following the statewide improvement initiative. Our results demonstrate the benefit of a targeted initiative in California, which may be applicable to other quality collaboratives.