Ronald McDonald House accommodation and parental presence in the neonatal intensive care unit

Abstract

Parental presence in the neonatal intensive care unit (NICU) is associated with favorable developmental outcomes and improved parental wellbeing [1, 2]. Yet, distance from the hospital is a significant barrier to parental presence [2, 3], especially in rural areas [4]. The Ronald McDonald House (RMH) program helps families overcome distance and cost barriers to participating in the care of their hospitalized children by providing subsidized housing in close proximity to children’s hospitals [5]. We performed a propensity-matched analysis of RMH accommodation and parental presence in the NICU at our tertiary care referral center in a rural region of eastern North Carolina. We retrospectively analyzed data from infants admitted to the NICU at the James and Connie Maynard Children’s Hospital (MCH) in 2019. The RMH has one location inside MCH, and another, larger, location on the medical campus. The offsite location is specifically designated for families living >30 miles (48 km) away from the hospital, and families are accepted regardless of ability to make a donation for their stay. We calculated the distance to the hospital from the mother’s ZIP code at NICU admission [4]. Infants were excluded if they were admitted at >28 days of life or had length of stay (LOS) < 5 days, if their mother lived <48 km away, or if they had missing data on study variables. Parental presence was calculated as a percentage of days during the NICU stay when mother, father, or adoptive parents were present at the bedside [4]. Parental accommodation at RMH was determined from RMH records. Covariates measured at the time of NICU admission were identified as possible confounding factors and were used to construct a propensity model of RMH accommodation: maternal age, marital status, maternal employment, other children in the household (none, one, two or more), receipt of prenatal care, substance use during pregnancy, and distance to the hospital (with outlier distances >200 km recoded to missing) [4]. Infant characteristics included gestational age, mode of delivery, sex, birth weight, race and ethnicity (non-Hispanic Black, nonHispanic White, Hispanic, or other), and payor type. The propensity score (PS) of RMH accommodation was calculated using logistic regression and used to match families staying at RMH (cases) with families that did not stay at RMH (controls) via nearest-neighbor matching without replacement [6]. A caliper set at 0.2 of the PS standard deviation was used to ensure that cases were matched to sufficiently similar controls. Covariate balance after matching was assessed using standardized differences (SD), with SD < 0.1 considered to represent adequate balance. Bivariate analysis of parental presence according to RMH accommodation was performed using sign-rank tests, and fixed effects linear regression was used to adjust for any covariates that did not attain sufficient balance between cases and controls. Data analysis was performed using Stata/SE 15.1 (College Station, TX, StataCorp, LP). P < 0.05 was considered statistically significant. Of the 394 cases meeting inclusion criteria, 64 were excluded due to missing data on covariates. Before matching, there were 93 cases compared to 237 controls (Table 1). After matching, 25 cases were excluded due to lack of adequately similar controls, and 169 controls were not used. Covariate balance in the matched sample (68 pairs of cases and controls) is summarized in Table 2. In the matched sample, the median percent of days with parental presence was 97% (interquartile range [IQR]: 87%, 100%) among infants whose families stayed at RMH and 86% (IQR: 53%, 100%) among controls (p < 0.001 on * John A. Kohler, Sr. [email protected]