STRUCTURED REVIEW OF NEONATAL DEATHS IN A MANAGED CARE ORGANIZATION

We sought to quantify neonatal mortality (< 28 days) in a 10-hospital system, determine what proportion was associated with suboptimal neona tal care and make recommendations on how neonatal mortality rates (NMR s) could be used in quality improvement efforts. Deaths were identifie d using electronic linkage to the State of California Death Certificat e Tapes. Individual fatalities were reviewed by a minimum of two physi cians who did not care for the infant. Deaths were classified as eithe r being associated with suboptimal care or not. For deaths where subop timal care was an issue, emphasis was on delineating the process invol ved in the death. Subjects were all neonatal deaths among 64 469 babie s born in 1990-91 in the 10 birth facilities of the Kaiser Permanente Medical Care Program, Northern California Region. A total of 241 neona tal deaths were identified. Adjusting for prematurity by increasing th e follow-up period in preterm babies (included as neonatal deaths if t hey died up to 40 weeks corrected gestational age + 27.9 days) increas ed overall mortality rates by 5%. Birthweight-specific NMRs in Kaiser Permanents are similar to those of other published reports. Among the 198 deaths in babies weighing greater than or equal to 500 g at birth, only 14 (7%) were possibly associated with suboptimal care. In popula tions with access to health insurance, reporting only aggregate NMRs i s of limited use. The number of deaths that could be ascribed to subop timal neonatal care is very small and measuring variations in rates of such deaths is difficult. Future measurements of quality of care will require more sophisticated measures.