I have worked in both large and small NICU's and have enjoyed them both. I have been fortunate enough to work in units with good outcomes, where the babies have good survival rates and low rates of intracranial hemorrhage. In a large NICU you can be very busy and see all kinds of weird things. I suspect that the large NICU's have better outcomes because they are always in practice; some of the care becomes almost automatic. In a small NICU, though, it can be surprising how much interesting stuff you see. In my experience, I had a little more time to talk with the parents there, and the atmosphere was a little homier.
There are those who would say that health care payors, such as insurance companies, should require their babies to go to bigger NICU's, given the studies showing better outcomes in them. There was a time I would have agreed with that, but I no longer do. Could I be influenced by the fact that I have worked in a smaller NICU? Of course!
But here's the thing: The studies looking at outcomes of large versus small NICU's were using size of the NICU as a proxy, a substitute for the actual quality of outcomes at a given place, because the outcomes were not easily available. That is no longer necessary, because nearly every NICU now belongs to some collaboration of NICU's that keeps track of outcomes and lets you know how your unit is doing in comparison to others. (One of the largest of these is the Vermont Oxford Network, in which our NICU participates.) So it is no longer necessary to assume that a unit has better or worse outcomes because of its size. Instead, you can fairly easily compare the actual outcomes.
Although large NICU's might in general do better than smaller ones, there will be some large NICU's that do worse than smaller ones. It would be a shame to close those smaller ones and send the babies to larger units with worse outcomes, so let's stop this nonsense about assigning babies only to large NICU's and instead send babies to NICU's with the best outcomes, regardless of size. (You could make a case that small, good NICU's should combine and possibly become even better, but a discussion of regionalization of NICU's - or rather the lack of it - would give me a headache.)
Pay for performance. Supposedly it's coming. Let's do it right.
P.S. Due to some Blogger malfunction, you and I have not been able to get into my comments section for about the last day. I was able to see my comments, though, by going through my "edit posts" page. Thanks to all for the kind comments, well wishes, and suggestions.