Journal of Perinatology https://doi.org/10.1038/s41372-017-0036-0 ARTICLE Volume, size, professionals' specialization and nutrition management of NICUs and their association with treatment quality in VLBW infants Felix Miedaner 1 ● Kristina Langhammer 2 ● Christian Enke 3 ● Wolfgang Göpel 4 ● Angela Kribs 2 ● Anika Nitzsche 5 ● Rainer Riedel 6 ● Christiane Woopen 3 ● Ludwig Kuntz 1 ● Bernhard Roth 7 Received: 26 July 2017 / Revised: 2 November 2017 / Accepted: 16 November 2017 © Nature America, Inc., part of Springer Nature 2017 Abstract Objective To assess the association of volume, size, the availability of highly-specialized professionals and nutrition management of NICUs with treatment quality among VLBW infants. Study design A prospective multicenter study of 923 VLBW infants in 66 German NICUs, born between May and October 2013. Using multilevel modeling, we examined the association between the aforementioned organizational characteristics and treatment quality, measured via major morbidities (severe IVH, PVL, BPD, NEC, FIP, ROP, and discharge without severe complications) and medical process measures of VLBW infants. Results After risk-adjustment and accounting for other NICU characteristics, infants in low-volume NICUs were at higher risk of IVH, ROP and PVL. However, the initial effect of volume on process measures (growth velocity, administration of antenatal steroids) disappeared. Conclusion Volume can only partially explain differences in the treatment quality of VLBWs. The underlying organizational mechanisms should be considered to improve the quality of care. Introduction Over the past years, various studies have shown the positive association between a higher number of treated very low birth weight (VLBW) infants (hereinafter referred to as volume) and a reduced mortality rate in Neonatal Intensive Care Units (NICUs) [1–4]. However, recent findings of the effect of volume are mainly lacking in two broad areas: First, the investigated associations of NICU volume on patient outcomes remain incomplete, because such studies have mostly focused on mortality. Given that most VLBW infants survive to discharge [5], studies should focus on morbidities and medical process measures to examine the effect of the quality of NICU care. Second, few studies have addressed organizational fac- tors beyond volume and level of care [6–8], although recent findings have shown that variations in clinical practice among NICUs might explain differences in outcomes for VLBWs [9–11]. As volume and level of care are only proxy markers for the contextual processes that influence care delivery at the bedside, the major mechanisms behind the effect of volume remain unclear. * Felix Miedaner miedaner@wiso.uni-koeln.de 1 Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany 2 Department of Neonatology and Pediatric Intensive Care, University Hospital of Cologne, Cologne, Germany 3 Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (ceres) and Research Unit Ethics, Medical Faculty, University Clinic Cologne, Cologne, Germany 4 Department of Pediatrics, University of Lübeck, Lübeck, Germany 5 Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany 6 Institute for Medical Economics and Health Services Research, Rheinische Fachhochschule Cologne, Cologne, Germany 7 Department of Neonatology and Pediatric Intensive Care and Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany Electronic supplementary material The online version of this article (https://doi.org/10.1038/s41372-017-0036-0) contains supplementary material, which is available to authorized users. 1234567890();,: