April 13, 2021

The two hospitals have similar infant death rates — until you look at extremely premature babies

Photo illustration by Shoshana Gordon/ProPublica, source images: Shaun Griswold and Marjorie Childress/New Mexico in Depth, Ewingdo via Wikimedia Commons and Nathan Gibbs via Flickr

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It was morning shift change at Lovelace Women’s Hospital in Albuquerque, New Mexico. In the neonatal intensive care unit, the lights were dimmed, as usual. People spoke in hushed tones typical of the NICU. But an arriving clinician knew immediately that something had gone wrong.

A “crash cart” carrying resuscitation equipment was positioned next to a newborn incubator, the enclosed cribs that keep preterm babies warm. Nurses stood nearby with grim expressions.

The incubator light illuminated an infant’s swollen, discolored belly.

“I’ll never forget what this baby looked like,” recalled the Lovelace clinician, who asked not to be identified for fear of retribution. “His abdomen was black and taut and almost the size of a grapefruit.”

The day before, the infant had been a little cold and had spit up, which wasn’t particularly unusual. “It was something to watch, but nothing was horribly wrong,” the clinician said.

Overnight, the baby’s condition had worsened. Now, he was on a ventilator, his tiny heart’s contractions slowing. His swollen abdomen prevented staff from administering chest compressions.

“There was nothing we could do,” the clinician said. “He died.”

The infant’s gut had stopped functioning, clogging his feeding tube with undigested food. That is sometimes a sign of an inflammatory condition of the intestines, called necrotizing enterocolitis or NEC, that’s a leading cause of hospital deaths among extremely preterm babies.

These babies’ problems can spiral into life-threatening conditions in a matter of hours. There’s no indication that Lovelace improperly handled the infant’s treatment. But extremely preterm babies died at the hospital with striking frequency, according to an analysis of state health data by New Mexico In Depth and ProPublica.

A yearlong investigation by the news organizations found that at Lovelace, the tiniest, most premature babies died at up to twice the rate as they did a few miles away, at Presbyterian Hospital, another major maternity and newborn facility.

New Mexico In Depth and ProPublica also found that Lovelace transferred more than three times as many newborns as Presbyterian to the University of New Mexico Hospital, the state’s only top-tier, level-4 regional referral NICU, where the sickest of the state’s newborns are sent for care.

All told, between 2015 and 2019, close to half — 46% — of the 84 extremely preterm babies born at Lovelace either died at the hospital or were transferred to UNM, according to Health Department data and UNM NICU records. Twenty-one percent of the 170 extremely preterm babies born at Presbyterian died, and none was transferred to UNM during those years.

Experts said the findings should be investigated.

The disparity “should be of concern to families, the community, and the state of New Mexico,” said Dr. David C. Goodman, a professor at the Dartmouth Institute for Health Policy & Clinical Practice at Dartmouth College. Goodman, who was the lead author of the September 2019 report Dartmouth Atlas of Neonatal Intensive Care, has studied the track records of dozens of U.S. hospitals that care for extremely preterm babies.

It is also a concern to Albuquerque medical professionals who care for these babies. Three Lovelace and UNM Hospital clinicians who contacted New Mexico In Depth and ProPublica about Lovelace voiced concerns about extremely preterm babies’ outcomes and pointed to broader issues related to their care. Those issues included the lack of an on-site surgeon and other specialists, the timing of transfers to UNM when babies needed higher-level care, and disagreement over how best to care for these fragile newborns.

Lovelace and Presbyterian initially agreed to share detailed data on their neonatal outcomes with New Mexico In Depth and ProPublica, but ultimately refused to provide most of the promised information. To investigate the clinicians’ concerns, the news organizations obtained state Health Department data on these newborns’ deaths.

To better understand the disparity in outcomes between Lovelace and Presbyterian hospitals, New Mexico In Depth and ProPublica also obtained UNM hospital-transfer and intake logs, along with emails and other documents, and interviewed more than two dozen people, including current and former Albuquerque clinicians, neonatal transport team members, hospital officials and nationally recognized NICU experts. NICU administrators at Lovelace and Presbyterian spoke to the news organizations in early 2020. Since then, Lovelace has not made administrators available for comment.

Lovelace rejected any comparison that focused only on extremely preterm babies or that contrasted their death rates to Presbyterian’s.

“Comparing us to only one other hospital as opposed to national benchmarks is flawed and not an appropriate basis for drawing broad conclusions,” Lovelace Vice President for Marketing Serena Pettes wrote in an email.

Pettes said the news organizations were “seeking to undermine our quality of care” through a “misinterpretation of data.” Asked how the hospital’s data had been misinterpreted, she did not respond.

Three experts told New Mexico In Depth and ProPublica that it’s cause for concern when level 3 neonatal hospitals, a designation that covers both Lovelace and Presbyterian, have higher death and transfer rates than neighboring facilities. Without access to patient records, numbers for neighboring hospitals were the best proxy to use in gauging outcomes, they said.

“Anytime you have a hospital that is delivering a lot of tiny babies that it has to send out or that die before you can send them out, you really have to ask the question, ‘Are the mothers delivering at the right place?’” said Dr. Jeffrey B. Gould, a professor of pediatrics at Stanford University. A pioneer in NICU quality improvement, Gould is co-founder and chief executive of the California Perinatal Quality Care Collaborative.

Moreover, lax state oversight and a lack of hospital transparency about outcomes severely curtails the public’s ability to know just how well hospitals are serving this vulnerable population. The state’s loose regulations stand in sharp contrast to other states, like Texas and California, which mandate periodic inspections of neonatal intensive care hospitals and scrutiny of newborn outcomes.

The Lovelace clinician who witnessed the baby boy’s death said New Mexico’s lack of oversight is one reason families are in the dark about extremely preterm babies’ outcomes at the hospital. Another is a culture of silence at the hospital when things go wrong: “We don’t even talk about it within the NICU, but especially to the parents.”

Comparing Lovelace and Presbyterian

Lovelace delivered about 2,700 babies in 2019; nearby Presbyterian delivered about 3,000, making those two hospitals the state’s largest maternity centers. They are also the state’s only level 3 neonatal intensive care hospitals, according to the state Health Department. Together, they delivered 28% of babies born statewide between 2010 and 2019, and 37% of the state’s extremely preterm babies.

“If your pregnancy falls into the high-risk category, you can rest assured you’ll be getting the best medical care available anywhere in the region,” a Lovelace advertisement states.

Overall, Lovelace and Presbyterian had similar newborn death rates, the news organizations found — except when it came to the tiniest and most premature newborns.

Babies weighing less than about 2 pounds at birth are called extremely low birth weight, while those born before 28 weeks of pregnancy are labeled extremely preterm. While most extremely preterm babies are also extremely low birth-weight babies, that is not always the case. To account for all of these vulnerable infants, the news organizations evaluated death rates using both birth weight and gestational age.

Between 2015 and 2019, 34% of Lovelace’s 88 extremely low birth-weight infants died, compared to 17% of Presbyterian’s 197, according to the New Mexico in Depth and ProPublica analysis, which compared birth and death certificate data at the two hospitals. The calculations excluded babies who were born elsewhere and transferred to Lovelace or Presbyterian, and babies born weighing less than 350 grams, who are not considered viable.

The analysis also found a disparity in the death rate when calculated by gestational age, instead of by birth weight. Lovelace’s hospital-wide death rate for extremely preterm babies was 36%, compared to Presbyterian’s 21%.

“The differences are meaningful,” Goodman said of the hospitals’ death rates. “They’re not slight differences. These are large differences.”

“Thirty-six percent is higher than expected for this gestational age group,” Goodman said. “It raises the question as to whether the care provided meets the needs of the newborn patients.”

The news organizations also found that Lovelace transferred 66 infants, both full term and preterm, to the level 4 NICU between 2015 and 2019, while Presbyterian sent 17 babies, none of them preterm, UNM records showed.

“Every time we have a tiny baby, I cringe. We have a terrible track record with them,” said the Lovelace clinician who was present when the baby died.

Another Lovelace NICU clinician voiced similar concerns about extremely preterm babies’ outcomes, both in the delivery room and the NICU.

“They have only rudimentary policies in place for micropreemies, but not nearly as comprehensive as things that I’ve seen at other hospitals,” the second Lovelace clinician said. (A copy of Lovelace’s NICU infant care guidelines, reviewed by the news organizations and dated Feb. 1, 2017, briefly mentions extremely preterm and extremely low birth-weight babies’ care in sections about nurse-to-patient ratios, thermoregulation and water loss, skin care, and body positioning.)

The clinicians were two of eight current and former Lovelace care providers who spoke to New Mexico In Depth and ProPublica about newborn care at the facility on the condition that they remain anonymous because speaking publicly could hurt their employment within New Mexico’s small medical community. Not all of them were critical of the hospital.

“It’s a well-run unit,” a former Lovelace clinician said of the NICU. “I wouldn’t hesitate to have my own child in that unit.”

Pettes declined to respond to clinicians’ concerns and criticized the news organizations’ decision to grant them anonymity. “We are not able to respond to anonymous sources,” she wrote in an email, calling the clinicians’ comments “opinions, and not facts.”

New Mexico’s NICU hospitals face little regulatory scrutiny

The American Academy of Pediatrics defines level 3 NICU hospitals as facilities equipped to care for high-risk babies. Unlike lower-level hospital nurseries, they are staffed by specialists experienced in treating the most at-risk and medically complex newborns.

In New Mexico, however, there’s no legal definition of what constitutes a level 3 NICU. The state has no NICU-specific legal or regulatory oversight authority. Nor does the state have a role in certifying NICUs or monitoring newborn outcomes. The state has not conducted on-site inspections of any of the three Albuquerque NICU hospitals and has not analyzed neonatal death rates at the facilities, state Health Department spokesperson James Walton acknowledged.

The New Mexico Department of Health collects some details from the hospitals about mothers and newborns, including which mothers received infertility treatments to become pregnant, whether labor was induced and whether the delivery was by cesarean section. But the state cannot impose penalties on hospitals that fail to report such data, Health Department officials confirmed.

For example, New Mexico In Depth and ProPublica identified a discrepancy in Lovelace’s reporting of cases of NEC, the dangerous intestinal condition. Lovelace reported only four neonatal NEC cases to the Health Department between 2015 and 2019, but NICU intake records at UNM showed 11 babies who were transferred from Lovelace with NEC during those years, including four in 2019 alone.

Goodman helped New Mexico In Depth and ProPublica analyze the Health Department’s birth and death data.

The causes of disparities in outcomes between institutions are not always clear. Possibilities include a sicker patient population and less effective care, Goodman said.

Lovelace repeatedly declined to identify demographic or patient factors that might explain the disparity in the hospitals’ extremely preterm neonatal death rates.

Identifying those factors requires careful review of patients’ medical records, experts said. New Mexico In Depth and ProPublica did not have access to patient records. But the news organizations attempted to identify possible explanations using the data Lovelace and Presbyterian reported to the state Health Department from 2010 to 2019.

Babies born at 21 to 23 weeks’ gestation frequently die shortly after delivery, and resuscitation practices for the age group vary, which could lead to differing outcomes. But a 2-to-1 death-rate disparity persisted when the analysis included only babies born at 24-27 weeks’ gestation, who are less likely to die shortly after delivery. The number of extremely preterm twins and triplets, who often fare poorly, also did not explain the death-rate disparity. Nor did differences in maternal race or ethnicity, prenatal therapies or other potential risk factors for extremely preterm babies, including the proportion of boy births, teen mothers, mothers who underwent infertility treatment or induced labor, or mothers who had cesarean-section deliveries.

Pettes claimed that for all NICU-admitted newborns — including lower-risk full-term babies and premature babies — Lovelace’s neonatal death rate is “significantly lower than the national average,” and has declined over time. “As a whole, our mortality rate is less than half of the national NICU average.”

But according to the Health Department data, full-term babies make up a much larger proportion of the hospital’s NICU population than extremely preterm newborns, obscuring the death rate for the hospital’s most at-risk babies.

Pettes declined to share the national benchmark she cited from a neonatal intensive care unit research collaborative, the Vermont Oxford Network. The network discloses outcomes only to member hospitals and declined the news organizations’ request for extremely preterm babies’ mortality rates at Lovelace and Presbyterian.

Pettes also objected to the news organizations’ comparison of hospital-wide death rates.

Pettes disclosed that 22% of Lovelace’s extremely low birth-weight babies died after admission to the NICU during 2015-2019.

But Goodman said NICU-only rates are not a true reflection of a hospital’s outcomes.

“We include every extremely preterm baby who dies … in our research,” said Goodman. “They are cared for by the NICU team and are the responsibility of the NICU team whether or not they are administratively admitted to a hospital’s NICU.”

Lovelace did not provide a hospital-wide death rate for these fragile babies.

Hospital-wide death rates are important indicators because labor and delivery unit practices can also affect survival, and babies who die in the NICU are not always recorded as NICU deaths, a Lovelace clinician noted.

It was impossible for the news organizations to compare NICU-only data between the hospitals. Presbyterian would not provide its NICU-only death rate. In addition, birth and death certificate data showed discrepancies in the Health Department’s data on NICU admissions. Extremely preterm babies who survive delivery should always eventually be admitted to NICUs, experts said, but the news organizations found infants for whom there was no record of a NICU admission or a death certificate.

The hospitals did not acknowledge or explain the discrepancies.

“Lovelace specials”

Lovelace transferred more than three times as many newborns to UNM’s level 4 NICU as did Presbyterian, UNM intake logs show. Ten of the Lovelace transfers were extremely low birth-weight infants, three of whom died at UNM. None of Presbyterian’s transferred babies were extremely preterm or extremely low birth-weight infants.

Information about neonatal transfers can help regulators identify facilities that aren’t meeting babies’ needs or find problems that hospitals should address, experts say.

Comparing UNM NICU intake logs with state data showed that close to 90% of Lovelace and Presbyterian’s transfers to UNM were not captured in Health Department data, because the state only requires hospitals to report transfers occurring in the first 24 hours after delivery.

“If you don’t have the data, you can’t make change,” said Dr. Scott A. Lorch, a professor of pediatrics and associate chair of the Division of Neonatology at the Children’s Hospital of Philadelphia, and a leading authority on NICU outcomes.

At UNM Hospital, babies who arrived in dire condition were sometimes called “Lovelace Specials,” according to two former UNM NICU clinicians who asked not to be named for fear of retribution.

Some of the Lovelace babies who had NEC arrived at UNM without needed X-ray reports, or with X-rays taken from angles that can miss signs of a worsening condition, a UNM pediatric radiologist said.

“That’s what I’ve seen based on imaging: Patients often arrived at UNM in more advanced stages of NEC,” the radiologist said. Unlike UNM and Presbyterian, Lovelace does not have a pediatric radiologist on staff, the radiologist noted. Lovelace declined to comment.

One of the two former UNM clinicians said that when babies arrived from Lovelace, “you just had no idea what you were getting into.”

Clinicians questioned not only the number of newborn transfers but their timing.

Lovelace is sometimes too slow to send babies in crisis to UNM Hospital, where surgery can be performed if needed, four clinicians from both Lovelace and UNM said. Lovelace declined to respond to their allegation.

The pace of transfer matters because NEC can progress in a matter of hours from subtle symptoms to a life-threatening condition requiring emergency surgery. It is not unusual for level 3 NICUs to have surgeons on call or to have a transfer agreement with other hospitals. But if a surgeon cannot perform emergency procedures on-site, timely transfers to surgical hospitals can be a matter of life or death.

Of 18 babies with NEC who were transferred to UNM since 2012, 15 came from Lovelace. There isn’t a hard-and-fast rule about when to transfer a sick infant to a higher-level facility, but transfer logs showed that of the 15 Lovelace babies sent to UNM, 12 were in a condition that required surgery when they got there, and two — a 5-day-old girl and a 12-day-old boy — died within hours of their arrival. Only one Lovelace baby with NEC was transferred and survived without surgery.

When NEC is caught early, it can be treated with antibiotics, a former UNM clinician said. “But you don’t want to wait until they’re so, so, so, so sick and then try to send them,” the clinician said.

“They just wait too long,” said the Lovelace clinician who witnessed the boy’s death, referring to cases the clinician handled. “Babies that might otherwise have survived did not because they didn’t get them to a place where they could have a surgeon if they needed it.”

The former UNM clinician added a key explanation: “That’s really where we get a lot of the kids, especially from Lovelace, is not having those pediatric surgeons available.”

Does Lovelace have a pediatric surgeon?

The question of whether Lovelace does, in fact, have an on-site pediatric surgeon, as Presbyterian does, is subject to debate.

In March 2019, the New Mexico Health Department and the Centers for Disease Control and Prevention informed Lovelace that a survey of the state’s maternity and neonatal hospitals had concluded that Lovelace was not operating a level 3 NICU, but instead a level 2 special-care nursery. State officials based their conclusion on the lack of a pediatric surgeon and a pediatric anesthesiologist at Lovelace.

Hospital administrators successfully appealed that determination, claiming in an email obtained by the news organizations that among the “providers available” at Lovelace was a pediatric surgeon and other experts “on site 24/7.”

But Lovelace clinicians told New Mexico In Depth and ProPublica that the claim was misleading.

“They’ve been saying they’re going to have pediatric surgery for almost a decade,” one Lovelace clinician said.

In some states, hospitals are required to support such claims with documentation. But emails indicate the state Health Department’s chief medical officer, Dr. Thomas Massaro, prevented other Health Department staff from asking Lovelace to provide the names and board certifications of medical specialists. Massaro told New Mexico In Depth and ProPublica, “Neither we nor CDC required documentation of any of the hospital claims or submissions.”

There’s a reason hospitals fight for level 3 status.

Lovelace Women’s Hospital opened its $11 million NICU in September 2007, positioning itself to compete with Presbyterian and UNM in the state’s lucrative newborn acute health care market. Lovelace markets itself as a state-of-the-art maternal and newborn hospital. Expectant parents are told that should anything go wrong, maternal and neonatal medical specialists are available to provide expert care. Front and center in that promise is the “Level 3 Neonatal Intensive Care Unit.”

Extremely preterm babies cared for in the NICU are known as “million-dollar babies,” several clinicians said. That’s no exaggeration: Hospital price sheets suggest care for these babies may bring Lovelace more than $1.2 million per baby from insurers.

Newborn intensive care has brought a lot of money to Lovelace and its privately owned parent company, Nashville-based Ardent Health Services. Between 2015 and 2019, Lovelace Women’s 53-bed facility received more than $99 million in payments from Medicaid for NICU patient care, while Presbyterian’s 58-bed NICU received $75 million during the same period, according to state data.

“It is no secret that the NICU is Lovelace Women’s Hospital’s golden goose,” said Wendy Walter, a former adult ICU charge nurse at Lovelace who provided “helping hands” when the NICU was short-staffed. (Walter was fired by the hospital in January for working more hours than authorized. She contends that she worked additional hours at shift’s end to properly document patients’ treatments.)

Months after successfully defending its level 3 status, Lovelace went further, informing the state Health Department last year that the facility merited recognition as a level 4 NICU. That could put it in competition with UNM, where extremely preterm babies can bring in more than $2 million per infant.

In a Jan. 10, 2020, email to Massaro, Lovelace’s director of women’s services, Dr. Abraham Lichtmacher, wrote that the hospital now had “pediatric surgery, which is represented by the pediatric surgeons from UNM as they have finalized and obtained their privileges at Lovelace Women’s Hospital allowing them to perform their procedures on site.”

Three current and former Lovelace clinicians expressed dismay that an administrator at the hospital made such a claim.

“They don’t have surgical support staff, pediatric surgical nurses — or even a place to do baby surgeries,” one said.

A few weeks after Lichtmacher emailed the state, UNM pediatric surgeon Dr. Jason McKee contradicted Lichtmacher’s claim in an interview with New Mexico In Depth and ProPublica. Asked if he had surgical privileges at Lovelace, McKee told the news organizations in early 2020: “I have consulting privileges at Lovelace so I can go and see a child, but as of now we don’t do surgery over there.”

McKee was noncommittal when asked if that would change in the near future, but noted that it would require Lovelace to hire surgical support staff.

Lovelace recently declined to say if any pediatric surgeries have been performed at the hospital or if it has surgical support staff available to perform such operations.

“We have, and continue to maintain, pediatric surgeon availability for our patients but defer to the surgeon’s clinical judgement as to the best place for those surgeries to occur to achieve the best outcomes for the patient,” Pettes, the Lovelace vice president for marketing, wrote in an email. She declined to say if Lovelace employed a pediatric surgeon or pediatric surgery support staff, or if any neonatal surgeries have been conducted at Lovelace in recent years.

Job listings for Lovelace Women’s posted as recently as Feb. 27 stated that the hospital “hopes to establish Pediatric Surgery in the future.”

Lovelace last sought the Health Department’s acknowledgement of its NICU as a level 4 facility in August, according to Walton, the department spokesman.

Lovelace refused to comment on its efforts to be recognized as a level 4 neonatal hospital.

A November 2020 Health Department document still listed Lovelace as a level 3 neonatal facility.

Why Lovelace might lag

One situation that experts say can cause disparities in outcomes at neonatal facilities is the number of patients they treat, or what researchers call “patient volume.”

Hospitals that care for a larger number of high-risk babies have better outcomes, likely the product of their experience, said Lorch, the authority on NICU outcomes. Teams need practice working together to meet the needs of high-risk babies, experts said.

While it is unclear whether patient volume was a factor in higher death rates among the tiniest babies at Lovelace, the hospital had less than half the patient volume of extremely preterm babies that Presbyterian had. Each year, between 2010 and 2019, Lovelace delivered on average 16 extremely preterm babies, compared to 38 at Presbyterian.

Research by Lorch and others shows that patient volume can predict survival rates for more developed “very” preterm babies, those born at 28 to 32 weeks’ gestation.

“You need experience caring for those babies,” said Harvard Medical School professor Dr. Ann Stark, who pioneered the American Academy of Pediatrics’ guidelines for levels of neonatal care.

The role hospitals’ patient volumes plays in survival among extremely preterm babies — those born before 28 weeks of pregnancy — has not been studied. But research has shown that dedicating an expert clinical team to care for extremely preterm babies can improve outcomes. In that light, having three Albuquerque hospitals within a few miles of each other that each care for a relatively small number of extremely preterm babies might not make sense, some experts said.

“Maybe having one high-volume center is better than having two or three centers that take care of those same babies,” said Dr. José Antonio Perez, a clinical professor of pediatrics at the University of Washington in Seattle and the NICU medical director at Swedish Issaquah Medical Center.

One way neonatal hospitals improve the quality of care after things go wrong is by convening formal staff morbidity and mortality, or “M&M,” case reviews. New Mexico regulators do not require M&M case reviews, but NICU staff at both Presbyterian and UNM hold them anyway.

Lovelace officials repeatedly declined to say if they do.

New Mexico In Depth and ProPublica asked eight current and former clinicians who worked at the Lovelace NICU over the past decade if they had participated in M&M case reviews at Lovelace. None had. They spoke with the news organizations without the hospital’s permission.

It would be “egregious” for a facility to not conduct M&M case reviews, Goodman said.

“Each newborn with a significant event, be it death or a significant morbidity that could even possibly be related to the care administered, I think those all require careful discussion to see if there is any systemic cause,” Goodman said.