Open Access Research article

Assessment of surfactant use in preterm infants as a marker of neonatal intensive care unit quality

Heather C Kaplan134*, Scott A Lorch234, Jennifer Pinto-Martin45, Mary Putt4 and Jeffrey H Silber246

Author Affiliations

1 Perinatal Institute and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA

2 Center for Outcomes Research, The Children's Hospital of Philadelphia, 3535 Market Street, Philadelphia, PA, USA

3 Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, USA

4 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, USA

5 School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA, USA

6 Departments of Pediatrics, Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, USA

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BMC Health Services Research 2011, 11:22  doi:10.1186/1472-6963-11-22

Published: 31 January 2011



Proposed neonatal quality measures have included structural measures such as average daily census, and outcome measures such as mortality and rates of complications of prematurity. However, process measures have remained largely unexamined. The objective of this research was to examine variation in surfactant use as a possible process measure of neonatal quality.


We obtained data on infants 30 to 34 weeks gestation admitted with respiratory distress syndrome (RDS) within 48 hours of birth to 16 hospitals participating in the Pediatric Health Information Systems database from 2001-2006. Models were developed to describe hospital variation in surfactant use and identify patient and hospital predictors of use. Another cohort of all infants admitted within 24 hours of birth was used to obtain adjusted neonatal intensive care unit (NICU) mortality rates. To assess the construct validity of surfactant use as a quality metric, adjusted hospital rates of mortality and surfactant use were compared using Kendall's tau.


Of 3,633 infants, 46% received surfactant. For individual hospitals, the adjusted odds of surfactant use varied from 2.2 times greater to 5.9 times less than the hospital with the median adjusted odds of surfactant use. Increased annual admissions of extremely low birth weight infants to the NICU were associated with greater surfactant use (OR 1.80, 95% CI 1.02-3.19). The correlation between adjusted hospital rates of surfactant use and in-hospital mortality was 0.37 (Kendall's tau p = 0.051).


Though results were encouraging, efforts to examine surfactant use in infants with RDS as a process measure reflecting quality of care revealed significant challenges. Difficulties related to adequate measurement including defining RDS using administrative data, accounting for care received prior to transfer, and adjusting for severity of illness will need to be addressed to improve the utility of this measure.