1
|
Gyamfi-Bannerman C. Antenatal Late Preterm Steroids: The Evolution of the ALPS Trial. Clin Obstet Gynecol 2024; 67:399-410. [PMID: 38688083 PMCID: PMC11068095 DOI: 10.1097/grf.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
The Antenatal Late Preterm Steroids (ALPS) trial was designed to address respiratory morbidity common in infants born late preterm. The study was published in April, 2016 and, shortly thereafter, changed clinical practice in obstetrics in the United States. The following chapter describes the ALPS trial study design in detail, including the background leading to the trial, the study outcomes, and the initial findings of the long-term follow-up study. The ALPS story would not be complete without Elizabeth Thom, PhD, who died before her time. Her brilliance largely contributed to the design of the ALPS trial.
Collapse
Affiliation(s)
- Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, La Jolla, California
| |
Collapse
|
2
|
Yieh L, King BC, Hay S, Dukhovny D, Zupancic JAF. Economic considerations at the threshold of viability. Semin Perinatol 2022; 46:151547. [PMID: 34887108 DOI: 10.1016/j.semperi.2021.151547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neonatal intensive care for infants born at 22-24 weeks has become more prevalent in the past three decades, but outcomes remain highly variable between centers, in part due to different approaches in management. With this increased frequency of intervention, there has been concern for a concurrent increase in costs of care for survivors. This article reviews the direct medical, direct non-medical, and indirect costs of care for periviable infants and their families, as well as the current limitations of published data. In addition, we highlight the cost-effectiveness of neonatal intensive care and various therapies offered to extremely preterm infants, while also considering the ethical dilemmas inherently tied to periviable decision-making. Strategies to improve the gaps in knowledge on the economic impact of the smallest infants are discussed.
Collapse
Affiliation(s)
- Leah Yieh
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, MS #31, Los Angeles, CA 90027, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Brian C King
- Department of Pediatrics, University of Pittsburgh, Pittsburgh PA, USA
| | - Susanne Hay
- Division of Newborn Medicine, Harvard Medical School, Boston, MA, USA; Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dmitry Dukhovny
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, USA
| | - John A F Zupancic
- Division of Newborn Medicine, Harvard Medical School, Boston, MA, USA; Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
3
|
Kanthimathinathan HK, Plunkett A, Scholefield BR, Pearson GA, Morris KP. Trends in long-stay admissions to a UK paediatric intensive care unit. Arch Dis Child 2020; 105:558-562. [PMID: 31848145 DOI: 10.1136/archdischild-2019-317797] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/22/2019] [Accepted: 12/04/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Prolonged admission to a paediatric intensive care unit (PICU) consumes significant healthcare resource. An increase in the number of long-stay admissions and bed utilisation has been reported elsewhere in the world but not in the UK. If an increasing trend of long-stay admissions is evident, this may have significant implications for provision of paediatric intensive care in the future. DESIGN/SETTING/PATIENTS We retrospectively analysed prospectively collected data from Birmingham Children's Hospital, UK, over a 20-year period from 1998 to 2017. PICU admissions, bed-days, length of stay and mortality trends were analysed and reported over four different epochs (1998-2002, 2003-2007, 2008-2012 and 2013-2017) for long-stay admissions (PICU length of stay ≥28 days) and others. Differences in patient demographics, diagnostic categorisation and hospital utilisation were also analysed. RESULTS In total, 24 203 admissions accounted for 131 553 bed-days over the 20-year period. 705 (2.9%) long-stay admissions accounted for 42 312 (32%) bed-days. Proportion of long-stay admissions and corresponding bed-days increased from 1.6% and 20.5% in 1998-2002 to 4.5% and 42.6%, respectively, in 2013-2017 (p<0.001). Long-stay patients had a significantly higher number of hospital admissions (median: 4 vs 2, p<0.001) per patient and overall hospital length of stay (median: 98 vs 15, p<0.001) bed-days compared with other patients. Long-stay admissions were associated with significantly higher crude mortality (23% vs 6%, p<0.001) compared with other admissions. CONCLUSIONS A significant increase in the proportion of prolonged PICU admissions with disproportionately high resource utilisation and mortality is evident over two decades.
Collapse
Affiliation(s)
- Hari Krishnan Kanthimathinathan
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK .,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Adrian Plunkett
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Gale A Pearson
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| |
Collapse
|
4
|
A trial comparing continuous positive airway pressure (CPAP) devices in preterm infants. J Perinatol 2020; 40:1193-1201. [PMID: 32433510 PMCID: PMC7375950 DOI: 10.1038/s41372-020-0690-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/06/2020] [Accepted: 05/07/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To test the hypothesis that infants born <30 weeks' gestation supported by Seattle-PAP will have lower rates of continuous positive airway pressure (CPAP) failure than infants supported with conventional, Fisher&Paykel-CPAP (FP-CPAP). STUDY DESIGN Randomized trial (3/2017-01/2019) at 5 NICUs. The primary outcome was CPAP failure; subgroup analyses (gestational age, receipt antenatal corticosteroids) were performed. RESULTS A total of 232 infants were randomized. Infants in the Seattle-PAP and FP-CPAP groups had mean gestational ages of 27.0 and 27.2 weeks, respectively. We observed no differences in rates of treatment failure between Seattle-PAP (40/112, 35.7%) and FP-CPAP (38/120, 31.7%; risk difference, 4.1%; 95% CI, -8.1-16.2; P = 0.51). Subgroup analysis indicated no differences in rates of CPAP failure. We observed no differences between the two groups in frequencies of adverse events or duration of respiratory support. CONCLUSIONS Among infants born <30 weeks' gestation, rates of CPAP failure did not differ between Seattle-PAP and FP-CPAP.
Collapse
|
5
|
Gyamfi-Bannerman C, Zupancic JAF, Sandoval G, Grobman WA, Blackwell SC, Tita ATN, Reddy UM, Jain L, Saade GR, Rouse DJ, Iams JD, Clark EAS, Thorp JM, Chien EK, Peaceman AM, Gibbs RS, Swamy GK, Norton ME, Casey BM, Caritis SN, Tolosa JE, Sorokin Y, VanDorsten JP. Cost-effectiveness of Antenatal Corticosteroid Therapy vs No Therapy in Women at Risk of Late Preterm Delivery: A Secondary Analysis of a Randomized Clinical Trial. JAMA Pediatr 2019; 173:462-468. [PMID: 30855640 PMCID: PMC6503503 DOI: 10.1001/jamapediatrics.2019.0032] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/01/2019] [Indexed: 01/12/2023]
Abstract
Importance Administration of corticosteroids to women at high risk for delivery in the late preterm period (34-36 weeks' gestation) improves short-term neonatal outcomes. The cost implications of this intervention are not known. Objective To compare the cost-effectiveness of treatment with antenatal corticosteroids with no treatment for women at risk for late preterm delivery. Design, Setting, and Participants This secondary analysis of the Antenatal Late Preterm Steroids trial, a multicenter randomized clinical trial of antenatal corticosteroids vs placebo in women at risk for late preterm delivery conducted from October 30, 2010, to February 27, 2015. took a third-party payer perspective. Maternal costs were based on Medicaid rates and included those of betamethasone, as well as the outpatient visits or inpatient stay required to administer betamethasone. All direct medical costs for newborn care were included. For infants admitted to the neonatal intensive care unit, comprehensive daily costs were stratified by the acuity of respiratory illness. For infants admitted to the regular newborn nursery, nationally representative cost estimates from the literature were used. Effectiveness was measured as the proportion of infants without the primary outcome of the study: a composite of treatment in the first 72 hours of continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, supplemental oxygen with a fraction of inspired oxygen of 30% or more for 4 hours or more, and extracorporeal membrane oxygenation or mechanical ventilation. This secondary analysis was initially started in June 2016 and revision of the analysis began in May 2017. Exposures Betamethasone treatment. Main Outcomes and Measures Incremental cost-effectiveness ratio. Results Costs were determined for 1426 mother-infant pairs in the betamethasone group (mean [SD] maternal age, 28.6 [6.3] years; 827 [58.0%] white) and 1395 mother-infant pairs in the placebo group (mean [SD] maternal age, 27.9 [6.2] years; 794 [56.9%] white). Treatment with betamethasone was associated with a total mean (SD) woman-infant-pair cost of $4681 ($5798), which was significantly less than the mean (SD) amount of $5379 ($8422) for women and infants in the placebo group (difference, $698; 95% CI, $186-$1257; P = .02). The Antenatal Late Preterm Steroids trial determined that betamethasone use is effective: respiratory morbidity decreased by 2.9% (95% CI, -0.5% to -5.4%). Thus, the cost-effectiveness ratio was -$23 986 per case of respiratory morbidity averted. Inspection of the bootstrap replications confirmed that treatment was the dominant strategy in 5000 samples (98.8%). Sensitivity analyses showed that these results held under most assumptions. Conclusions and Relevance The findings suggest that antenatal betamethasone treatment is associated with a statistically significant decrease in health care costs and with improved outcomes; thus, this treatment may be an economically desirable strategy.
Collapse
Affiliation(s)
- Cynthia Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - John A. F. Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Grecio Sandoval
- George Washington University Biostatistics Center, Washington, DC
| | - William A. Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Sean C. Blackwell
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Children’s Memorial Hermann Hospital, Houston
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham
| | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Lucky Jain
- Department of Obstetrics and Gynecology, Emory University, Atlanta, Georgia
| | - George R. Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Jay D. Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus
| | - Erin A. S. Clark
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Edward K. Chien
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alan M. Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Ronald S. Gibbs
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Geeta K. Swamy
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Mary E. Norton
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California
| | - Brian M. Casey
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Steve N. Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jorge E. Tolosa
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - J. Peter VanDorsten
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston
| |
Collapse
|
6
|
Kaempf JW, Suresh G. Antenatal corticosteroids for the late preterm infant and agnotology. J Perinatol 2017; 37:1265-1267. [PMID: 29192694 DOI: 10.1038/jp.2017.76] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/19/2017] [Accepted: 04/27/2017] [Indexed: 01/21/2023]
Affiliation(s)
- J W Kaempf
- Department of Neonatology, Women and Children's Program, Providence St. Vincent Medical Center, Portland, OR, USA
| | - G Suresh
- Department of Pediatrics, Baylor College of Medicine, Section Head and Service Chief of Neonatology, Texas Children's Hospital, Houston, TX, USA
| |
Collapse
|