P1.223: Community-Level Vulnerability and NICU Utilization: A Nationwide Study of 4 Million U.S. Neonates, 2022-2024.

Background: Neonatal intensive care unit (NICU) utilization is a critical marker of neonatal morbidity, yet disparities in access and utilization persist. While prior studies have highlighted individual-level risk factors, few have examined the influence of community-level vulnerabilities on NICU utilization. This study aims to identify social and geographic vulnerability domains associated with NICU use. The Vizient Vulnerability Index™ (VVI) was used to identify geographic ZIP-codes with barriers to care, as an actionable public access framework that is timely, healthcare focused, and predictive of life expectancy.

Methods: A retrospective cohort study of 4,004,017 neonates born between 01/2022-12/2024 was obtained from the Vizient® Clinical Data Base from 1,111 continuously reporting institutions, about 40% of total U.S. births for the time-period. NICU utilization was defined as any NICU stay during the birth encounter. Demographic characteristics included sex, race/ethnicity, primary payer, and hospital-level teaching and rural status. Community-level geographic vulnerabilities were assessed using the VVI, which leverages nine domains at the ZIP-code level: clean environment, economic, education, healthcare access, housing, neighborhood, public safety, social, and transportation. Chi-square tests and multivariable logistic regression models were used to assess unadjusted and adjusted associations with NICU utilization.

Results: Among 4,004,017 neonates, 326,476 (8.2%) had a NICU stay. NICU patients were more likely to be male (aOR 1.20, 95% CI 1.19-1.21), Black (aOR 1.19, 95% CI 1.18-1.20), and Medicaid insured (aOR 1.31, 95% CI 1.30-1.32) (Table 1). Teaching hospitals and urban settings were more likely to have patients with NICU utilization. High vulnerability in multiple domains of the VVI was significantly associated with NICU utilization (Table 2). Neonates from communities with high vulnerability in the transportation domain had 22% higher adjusted odds of NICU utilization (aOR 1.22, 95% CI 1.12–1.34). Similarly, those from highly vulnerable educational areas had 38% higher odds (aOR 1.38, 95% CI 1.34–1.42) and those from highly vulnerable social domains had 27% higher odds of NICU utilization (aOR 1.27, 95% CI 1.25-1.29). Conversely, high vulnerability in clean environment was associated with lower odds of NICU use (aOR 0.68, 95% CI 0.66–0.70), likely reflective of rurality and lack of NICU access.

Conclusion: NICU utilization is significantly associated with individual demographic characteristics and with multiple domains of structural community-level vulnerability. We highlight that transportation access, educational outreach, and social services may be most impactful in addressing NICU utilization among vulnerable populations. These findings underscore the importance of incorporating structural, social, and geographic context into maternal-child health care risk assessment frameworks. Domain-level vulnerability insights can inform prenatal care outreach strategies, clinical resource allocation, and highlight vulnerable geographies with greatest obstacles to health care.