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We're not using the HPV vaccine enough, and we may be using NICUs too much. This is Healthcare Triage News.
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We're not using the HPV vaccine enough, and we might be using NICUs too much.  This is Healthcare Triage News.


Let's start with the perennial favorite here on Healthcare Triage: The HPV vaccine.  New data on vaccination rates among 13-17 years olds have been released by the CDC.  Let's get right to it.  In 2014, more than 80% of adolescents had received at least one dose of T-DAP, more than 79% have received at least one dose of the meningococcal vaccine.  But only 60% of adolescent girls have received a dose of HPV vaccine, and only 42% of boys.  Granted, these numbers are up from 2013, when only 57% of girls and 34 of boys had received a dose of the HPV vaccine, but there's still a lot of room for improvement.  There are also some real geographic differences.  

Here's the percentage of adolescent females having received at least 1 dose of the vaccine by state.  As you can see, the differences are pretty wide.  Males have some pretty significant geographic differences as well.  

And let's talk about another more technical study that appeared recently in JAMA Pediatrics.  It's entitled "Epidemiologic trends in neo-natal intensive care, 2007-2012".  Almost no intervention is done as much to save young infants as the establishment of neo-natal intensive care units or NICUs.  Since the first one was opened in the United States in 1960, the neo-natal mortality rate has dropped from 18.73 per 1,000 live births to 4.01 per 1,000 live births in 2012.  But they're expensive and intense.  So researchers looked at how, at a population level, the admission rates to NICUs in the United States has changed over time.  

They exploited a change in the live birth certificates that allowed them to measure these rates and stratify them by birth weight, gestational age, weight at birth, and whether or not infants were receiving assisted ventilation, and what the study found could have implications for both current healthcare and future health policy.

Admission rates to NICUs increased during the six year period from 64 to almost 78 per 1,000 live births, and these increases occurred in all birth weight categories, not because there was an increase in the number of very premature or low birth weight infants born during the time.  In fact, during the study period, infants admitted to NICUs were larger and less premature overall.  
And look, there are limitations to a study like this that do warrant careful consideration.  The data don't allow researchers to account for the use of level 2 nurseries, so it may be that some or all of the increased admissions were not necessarily infants who had been transferred from newborn nurseries to NICUs.  Socioeconomic or other unmeasured factors could be causing these changes.  It's also possible that the increase in use of NICUs was warranted.  Perhaps this increased level of care led to better outcomes.  We can't really know for certain.  

But if we're gonna be serious and care about data and evidence, this study should give us pause.  Placing an infant in the NICU is not necessarily benign.  Many studies have shown that more intensive care carries a higher risk.  Moreover, NICU care is likely to cause a great deal of stress for parents, as well as interfere with mother-child bonding that would otherwise occur more naturally in a newborn nursery or at home.  NICU care is also very, very expensive.  

And let me stress loudly and clearly that this study doesn't prove that the increased NICU admissions are fraudulent or even merely wasteful.  It's entirely possible that the admissions are justified.  However, there's no doubt that they're expensive and carry potential harm.  If hospitals want to argue that NICUs are necessary, they're gonna need to prove that the need exists, especially in light of the increasing share of infants admitted who are at or near full-term.  If hospitals are unable to demonstrate that all these NICU admissions are as necessary as they think they are, then it's very likely that, at some point in the near future, policies will force them to reduce these admissions, which will have major implications for NICU and hospital finances.

Full disclosure, I wrote the editorial on this study in JAMA Pediatrics that said a lot of this already.  You should go read it.  Links down below.  

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