Impact on Health Disparities: Secondary Analysis of an Unplanned Extubation Quality Improvement Study

Quality improvement (QI) initiatives have reduced unplanned extubation (UE) rates in neonatal intensive care units, but few studies have examined the equity of these improvements. An explicit equity focus in QI can reveal disparities that may otherwise remain unrecognized. This secondary analysis of a previously published UE prevention QI initiative aimed to identify baseline disparities in UE rates and determine whether these disparities narrowed following the implementation of a standardized best-practice bundle (BPB).

We reviewed 6 months of preintervention medical record data and stratified UE rates by race/ethnicity, preferred primary language, and socioeconomic status (insurance as a proxy). Using the Model for Improvement, the QI team implemented the BPB components sequentially and uniformly across the neonatal intensive care unit. Data collection continued throughout implementation. Statistical process control (U) charts were used to examine baseline disparities and assess changes over time.

At baseline, non-Hispanic Black infants, patients from English-speaking families, and Medicaid-insured patients had higher UE rates. Following the implementation of the BPB, UE rates decreased across all subgroups. Control charts showed special-cause variation beginning in December 2022. Differences in UE rates across racial/ethnic, language, and socioeconomic groups narrowed.

UE rates were higher among racial minority and lower socioeconomic status populations at baseline. A standardized QI approach was associated with lower UE rates across all subgroups and reduced baseline disparities.