Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Demonstrating the relationships of length of stay, cost and clinical outcomes in a simulated NICU



Health-care leaders place significant focus on reducing the average length of stay (ALOS). We examined the relationships among ALOS, cost and clinical outcomes using a neonatal intensive care unit (NICU) simulation model.

Study Design:

A discrete-event NICU simulation model based on the Duke NICU was created. To identify the relationships among ALOS, cost and clinical outcomes, we replaced the standard probability distributions with composite distributions representing the best and worst outcomes published by the National Institutes of Health Neonatal Research Network.


Both average cost per patient and average cost per 28 week patient were lower in the best NICU ($16,400 vs $19,700 and $56,800 vs $76,700, respectively), while LOS remained higher (27 vs 24 days).


Our model demonstrates that reducing LOS does not uniformly reduce hospital resource utilization. These results suggest that health-care leaders should not simply rely on initiatives to reduce LOS without clear line-of-sight on clinical outcomes as well.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Rent or buy this article

Prices vary by article type



Prices may be subject to local taxes which are calculated during checkout


  1. Osnabrugge RL, Speir AM, Head SJ, Jones PG, Ailawadi G, Fonner CE et al. Cost, quality, and value in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2014; 148 (6): 2729–2735.

    Article  Google Scholar 

  2. Kaboli PJ, Go JT, Hockenberry J, Glasgow JM, Johnson SR, Rosenthal GE et al. Associations between reduced hospital length of stay and 30- day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med 2012; 157 (12): 837–845.

    Article  Google Scholar 

  3. Stambough JB, Nunley RM, Curry MC, Steger-May K, Clohisy JC . Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. J Arthroplasty 2015; 30: 521–526.

    Article  Google Scholar 

  4. Tadros RO, Faries PL, Malik R, Vouyouka AG, Ting W, Dunn A et al. The effect of a hospitalist comanagement service on vascular surgery inpatients. J Vasc Surg 2015; 61: 1550–1555.

    Article  Google Scholar 

  5. Nordstrom P, Gustafson Y, Michaelsson K, Nordstrom A . Length of hospital stay after hip fracture and short term risk of death after discharge: a total cohort study in Sweden. BMJ (Clin Res Ed) 2015; 350: h696.

    Google Scholar 

  6. Hintz SR, Bann CM, Ambalavanan N, Cotten CM, Das A, Higgins RD . Predicting time to hospital discharge for extremely preterm infants. Pediatrics 2010; 125 (1): e146–e154.

    Article  Google Scholar 

  7. Bender G . Neonatal intensive care unit: predictive models for length of stay. J Perinatol. 2013; 33 (2): 147–153.

    Article  CAS  Google Scholar 

  8. Lee HC, Bennett MV, Schulman J, Gould JB . Accounting for variation in length of NICU stay for extremely low birth weight infants. J Perinatol 2013; 33 (11): 872–876.

    Article  CAS  Google Scholar 

  9. Pepler P, Uys D, Nel D . Predicting mortality and length-of-stay for neonatal admissions to private hospital neonatal intensive care units: a Southern African retrospective study. Afr Health Sci 2012; 12 (2): 166–173.

    Article  CAS  Google Scholar 

  10. Bisquera JA, Cooper TR, Berseth CL . Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birth weight infants. Pediatrics 2002; 109 (3): 423–428.

    Article  Google Scholar 

  11. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 2002; 110 (2 Part 1): 285–291.

    Article  Google Scholar 

  12. Rogowski JA, Horbar JD, Plsek PE, Baker LS, Deterding J, Edwards WH et al. Economic implications of neonatal intensive care unit collaborative quality improvement. Pediatrics 2001; 107 (1): 23–29.

    Article  CAS  Google Scholar 

  13. Horbar JD, Rogowski J, Plsek PE, Delmore P, Edwards WH, Hocker J et al. Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network. Pediatrics 2001; 107 (1): 14–22.

    Article  CAS  Google Scholar 

  14. Cotten CM, Oh W, McDonald S, Carlo W, Fanaroff AA, Duara S et al. Prolonged hospital stay for extremely premature infants: risk factors, center differences, and the impact of mortality on selecting a best-performing center. J Perinatol 2005; 25 (10): 650–655.

    Article  Google Scholar 

  15. SAS Institute Inc SAS Simulation Studio 14.1: User’s Guide. SAS Institute: Cary, NC, 2015.

  16. DeRienzo C, Shaw RJ, Meanor P, Lada E, Ferranti MJ, Tanaka D . A simulation tool to support and predict hospital and clinic staffing. Health Informatics J 2016 (e-pub ahead of print 29 February 2016; doi:10.1177/1460458216628314).

  17. DeRienzo C, Tanaka D, Lada E, Meanor P Creating a SimNICU: Using SAS Simulation Studio to Model Staffing Needs in Clinical Environments. Proceedings of the SAS Global Conference, Washington, DC, 2014.

  18. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126 (3): 443–456.

    Article  Google Scholar 

  19. SAS Institute Inc JMP Pro 12: User’s Guide. SAS Institute: Cary, NC, 2015.

  20. Russell RB, Green NS, Steiner CA, Meikle S, Howse JL, Poschman K et al. Cost of hospitalization for preterm and low birth weight infants in the United States. Pediatrics 2007; 120 (1): e1–e9.

    Article  Google Scholar 

  21. Johnson TJ, Patel AL, Jegier BJ, Engstrom JL, Meier PP . Cost of morbidities in very low birth weight infants. J Pediatr 2013; 162 (2): 243–249.

    Article  Google Scholar 

  22. Schulman J . Studying determinants of length of hospital stay. J Perinatol 2006; 26: 243–245.

    Article  CAS  Google Scholar 

  23. Levit K, Ryan K, Elixhauser A, Stranges E, Kassed C, Coffey R . HCUP Facts and Figures: Statistics on Hospital-based Care in the United States in 2005. Agency for Healthcare Research and Quality: Rockville, MD, 2007. Available at

  24. Bolisetty S, Dhawan A, Abdel-Latif M, Bajuk B, Stack J . Intraventricular hemorrhage and neurodevelopmental outcomes in extreme preterm infants. Pediatrics 2014; 133 (1): 55–62.

    Article  Google Scholar 

  25. Lee HC, Bennet MV, Schulman J, Gould JB . Accounting for variation in length of NICU stay for extremely low birth weight infants. J Perinatol 2013; 33 (11): 872–876.

    Article  CAS  Google Scholar 

  26. St. John E, Nelson K, Cliver S, Bishnoi R, Goldenberg R . Cost of neonatal care according to gestational age at birth and survival status. Am J Obstet Gyncol 2000; 182 (1): 170–175.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to C DeRienzo.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

DeRienzo, C., Kohler, J., Lada, E. et al. Demonstrating the relationships of length of stay, cost and clinical outcomes in a simulated NICU. J Perinatol 36, 1128–1131 (2016).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:

This article is cited by


Quick links