Too Much Of A Good Thing

When it comes to having doctors who specialize in the medical problems of premature infants, a new study suggests that more is not necessarily better.

"There does not seem to be a reason to further expand the supply" of specialized doctors and hospital beds for sick and premature newborns, according to Dr. David Goodman, who supervised the study.

Only newborns in areas with the very fewest specialists die at a higher rate than elsewhere. Once a certain threshold of care is reached, more doctors offer no extra advantage, the study says.

The researchers said this oversupply is not just wasteful but may also be harmful, subjecting babies to unnecessary tests and treatments.

The researchers "raise disturbing issues regarding the nation's unquestioning acceptance that more is always better with respect to the supply of specialist physicians and hospital technology," said Dr. Kevin Grumbach, a public health researcher at the University of California at San Francisco.

He wrote an editorial to accompany the findings, published in Thursday's edition of The New England Journal of Medicine.

The researchers at Dartmouth Medical School in Hanover, N.H., knew of big disparities in the availability of specialized neonatal care from region to region. They wondered if places with more specialized doctors or beds relative to the number of births save more newborns.

The study found that, for the most part, they don't. Only newborns in areas with very few such doctors, 2.7 for every 10,000 births, show a higher death rate - 7 percent higher than in other areas.

Elsewhere, areas with a supply of doctors ranging from 4.3 to 11.6 neonatologists per 10,000 births all had about the same death rate. Even the most premature babies were found to die at roughly the same rate in these areas.

Moreover, the supply of neonatal intensive care hospital beds made no difference in death rates around the country.

"Enough may be enough," said Goodman.

The neonatal-care specialty has mushroomed since the 1970s, thanks to new technology and therapies, including ventilators designed for premature newborns and prenatal drugs that help lungs develop. Some babies born three months early, weighing barely over a pound, can now be rescued.

However, the researchers suggested that social and economic factors have expanded the field beyond pure medical need. For doctors, the specialty can be gratifying, exciting and well-paying. For hospitals, it a lucrative and prestigious business.

Grumbach warns that it's possible that babies can be harmed if they are subjected to too much specialized care.

"If I have a healthy full-term baby, I actually don't want anyone messing around with that baby," Grumbach said. "There's a downside where we meddle too much."

"Infants with less serious illness might be more likely to be admitted to a neonatal intensive care unit and might be subjected to more intensive diagnostic and therapeutic measures," and the risks they entail.

However, he said it would take deep changes in the medical system, with more government planning, to distribute neonatal doctors and beds much more uniformly.

An executive at a large for-profit neonatal doctors' group, Pediatrix Medical Group of Sunrise, Fla., agreed that the distribution of these specialized doctors "is not ideal."

"There are areas where there are perhaps more than we need and areas where there are perhaps less than we need," said Dr. Joyce Peabody, vice president of medical affairs at Pediatrix.

However, she cautioned against drawing broad conclusions from the study, since it considered only death rates. Many other factors, like a child's mental and physical development, also reflect quality of care, she said.