Cost-effectiveness of care for very low birth weight infants

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

Newborns' clinical conditions are correlated with the neonatal assessment manual scorE (NAME)

OBJECTIVE

To investigate the relationship between the Neonatal Assessment Manual scorE (NAME) and newborns' clinical condition on a large number of infants. The NAME model was developed as an instrument to assess the infant's general conditions, especially in NICUs, by evaluating how the infant's body responds to an external stressor such as static touch. Previous studies, employing experienced assessors, showed good validity indices as well as high inter-rater reliability.

STUDY DESIGN

Newborns were recruited at the "Vittore Buzzi" Pediatric Hospital NICU ward in Milan and their clinical conditions were collected through a standardized form-the complexity index. Two manual practitioners assessed all eligible newborns using the NAME scores. Data was analyzed using Kendall's τ correlation and odds ratio (OR) to assess the relationship between the NAME scores and the complexity index.

RESULTS

Two hundred two newborns (46% female; 34.1 w ± 4.3; birth weight of 2,093.4 gr ± 879.8) entered the study. The Kendall's correlation between the clinical conditions (complexity index) and the NAME score was -0.206 [95% CI: (-0.292, -0.116), p-value < 0.001], corresponding to an OR of 0.838 [95% CI: (0.757, 0.924), p-value < 0.001]. Further exploratory analyses showed significant correlation between gestational age, birth weight and NAME scores.

CONCLUSION

The present paper adds evidence to the NAME model validity by demonstrating its applicability in the clinical neonatological context.

Cost determinants among adults hospitalized with respiratory syncytial virus in the United States, 2017-2019

BACKGROUND

Respiratory syncytial virus (RSV) infections are common in adults, but data describing the cost of RSV-associated hospitalization are lacking due to inconsistency in diagnostic coding and incomplete case ascertainment. We evaluated costs of RSV-associated hospitalization in adult patients with laboratory-confirmed, community-onset RSV.

METHODS

We included adults ≥ 18 years of age admitted to three hospital systems in New York during two RSV seasons who were RSV-positive by polymerase chain reaction (PCR) and had more than or equal to two acute respiratory infection symptoms or exacerbation of underlying cardiopulmonary disease. We abstracted costs from hospital finance systems or converted hospital charges to cost using cost-charge ratios. We converted cost into 2020 US dollars and extrapolated to the United States. We used a generalized linear model to determine predictors of hospitalization cost, stratified by admission to intensive care units (ICU).

RESULTS

Cost data were available for 79% (601/756) of eligible patients. The mean total cost of hospitalization was $8403 (CI₉₅ $7240-$9741). The highest costs were those attributed to ICU services $7885 (CI₉₅ $5877-$10,240), whereas the lowest were radiology $324 (CI₉₅ $275-$376). Other than longer length of stay, predictors of higher cost included having chronic liver disease (odds ratio [OR] 1.38 [CI₉₅ 1.05-1.80]) for patients without ICU admission and antibiotic use (OR 1.49 [CI₉₅ 1.10-2.03]) for patients with ICU admission. The annual US cost was estimated to be $1.2 (CI₉₅ 0.9-1.4) billion.

CONCLUSION

The economic burden of RSV hospitalization of adults ≥ 18 years of age in the United States is substantial. RSV vaccine programs may be useful in reducing this economic burden.

The Neonatal Assessment Manual scorE: A Reliability Study on Hospitalized Neonates

Despite clinical improvements in neonatal intensive care units (NICUs), prematurity keeps causing several comorbidities. To enhance the management of such conditions, in previous studies we devised the Neonatal Assessment Manual scorE (NAME) model, a structured touch-based assessment that aims to evaluate how newborns respond to gentle touch-based stimuli. The present study aimed to begin assessing the NAME interrater reliability and specific agreements. At the "Vittore Buzzi" Pediatric Hospital NICU ward in Milan, Italy, we enrolled 144 newborns, 85 male and 59 female, with a mean age of 35.9 weeks (±4.1) and a weight of 2,055.3 g (±750.6). Two experienced manual professionals performed the NAME procedure on all the infants. Regarding the total sample and the analysis by sex, we found moderate and statistically significant results for the interrater reliability (p < 0.001) and the specific agreements (p < 0.05), in particular for the "Marginal" score. Furthermore, interrater reliability significantly (p < 0.05) increased as age and weight increased, whereas there was an almost constant moderate and significant (p < 0.05) agreement especially for the "Marginal" score. Therefore, we found preliminary results showing that the NAME could be a reliable diagnostic tool for assessing the newborns' general condition.

The changing landscape of perinatal regionalization

Regionalization, which emphasizes matching patient needs with the capabilities of the hospital in which care is provided, has long been a recommended approach to reducing neonatal morbidity and mortality. Over the past decade, research methods surrounding the measurement and evaluation of such programs have improved, thus strengthening arguments for implementation of these strategies. However, regionalization policies vary widely across regions and between countries, with potential impacts on neonatal outcomes as well as costs of care. It is important to account for geographic and other regional differences when determining the feasibility of regionalization for a specific region, as certain areas and populations may need particular consideration in order for regionalization policies to be successful.

Cost Effectiveness of Neonatal Resuscitation at 22 Weeks of Gestation

OBJECTIVE

To evaluate the cost effectiveness of three different approaches to the care of neonates born at 22 weeks of gestation: universal resuscitation, selective resuscitation, or no resuscitation.

METHODS

We constructed a decision-analytic model using TreeAge to compare the outcomes of death and survival with and without neurodevelopmental impairment in a theoretical cohort of 5,176 neonates (an estimate of the annual number of deliveries that occur in the 22nd week of gestation in the United States). We took a societal perspective using a lifetime horizon, and all costs were expressed in 2017 U.S. dollars. Effectiveness was based on combined maternal and neonatal quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio was determined (cost/QALY) for each additional survivor. The willingness to pay threshold was set at $100,000/QALY. All model inputs were derived from the literature. Deterministic and probabilistic sensitivity analyses were performed to interrogate model assumptions.

RESULTS

Universal resuscitation would result in 373 survivors, 123 of whom would have severe disability. Selective resuscitation would produce 78 survivors with 26 affected by severe impairments. No resuscitation would result in only eight survivors and three neonates with severe sequelae. Selective resuscitation was eliminated by extended dominance because this strategy had a higher incremental cost-effectiveness ratio than universal resuscitation, which was a more effective intervention. The incremental cost-effectiveness ratio of universal resuscitation compared with no resuscitation was not cost effective at $106,691/QALY. Monte Carlo simulations demonstrated that universal resuscitation is more effective but also more expensive compared with no resuscitation, with only 35% of simulations below the willingness to pay threshold.

CONCLUSION

In our model, neither selective nor universal resuscitation of 22-week neonates is a cost-effective strategy compared with no resuscitation.

Association of Adverse Hearing, Growth, and Discharge Age Outcomes With Postnatal Cytomegalovirus Infection in Infants With Very Low Birth Weight

IMPORTANCE

Studies suggest that postnatal cytomegalovirus (CMV) infection can lead to long-term morbidity in infants with very low birth weight (VLBW; <1500 g), including bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and neurodevelopmental impairment. However, to date, the association of postnatal CMV with hearing, growth, and length of stay among VLBW infants is unknown.

OBJECTIVES

To determine the risk for failed hearing screen, increased postnatal age at discharge, or decreased growth at discharge in VLBW infants with postnatal CMV infection compared with CMV-uninfected infants and to compare the risk for other major outcomes of prematurity, including BPD and NEC, in infants with and without postnatal CMV infection.

PARTICIPANTS

This multicenter retrospective cohort study included VLBW infants from 302 neonatal intensive care units managed by the Pediatrix Medical Group from January 1, 2002, through December 31, 2016. Infants hospitalized on postnatal day 21 with a diagnosis of postnatal CMV and hearing screen results after a postmenstrual age of 34 weeks were included in the study population. Data were analyzed from December 11, 2017, to June 14, 2019.

MAIN OUTCOMES AND MEASURES

Infants with and without postnatal CMV infection were matched using propensity scores. Poisson and linear regression were used to examine the association between postnatal CMV and the risk of failed hearing screen, postnatal age at discharge, growth, BPD, and NEC.

RESULTS

A total of 304 infants with postnatal CMV were identified, and 273 of these infants (89.8%; 155 boys [56.8%]) were matched with 273 infants without postnatal CMV (148 boys [54.2%]). Hearing screen failure occurred in 45 of 273 infants (16.5%) with postnatal CMV compared with 25 of 273 infants (9.2%) without postnatal CMV (risk ratio [RR], 1.80; 95% CI, 1.14 to 2.85; P = .01). Postnatal CMV was also associated with an increased postnatal age at discharge of 11.89 days (95% CI, 6.72 to 17.06 days; P < .001) and lower weight-for-age z score (-0.23; 95% CI, -0.39 to -0.07; P = .005). Analysis confirmed an increased risk of BPD (RR, 1.30; 95% CI, 1.17 to 1.44; P < .001), previously reported on infants from this cohort from 1997 to 2012, but not an increased risk of NEC after postnatal day 21 (RR, 2.00; 95% CI, 0.18 to 22.06; P = .57).

CONCLUSIONS AND RELEVANCE

These data suggest that postnatal CMV infection is associated with lasting sequelae in the hearing and growth status of VLBW infants and with prolonged hospitalization. Prospective studies are needed to determine the full effects of postnatal CMV infection and whether antiviral treatment reduces the associated morbidity.

Trends in the incidence, mortality, and cost of neonatal herpes simplex virus hospitalizations in the United States from 2003 to 2014

OBJECTIVE

To examine the temporal trends in the incidence and outcomes of neonatal herpes simplex infections (NHSV) in the United States.

STUDY DESIGN

We conducted a retrospective study using the National Inpatient Sample (NIS). Neonates ≤28 days old with ICD-9 codes for NHSV (054.xx) from 2003 to 2014 were included. Trends in the incidence, mortality, length of stay (LOS), and hospital cost were analyzed using Jonckheere-Terpstra test.

RESULTS

NHSV increased from 7.9 to 10 per 100,000 live births from 2003-05 to 2012-14 (P = 0.04). Hospital costs increased from $21,650 to $27,843; P < 0.001). The overall mortality rate and median LOS were 7.9% and 20 days, respectively and there were no significant variations across years during the study period.

CONCLUSIONS

The incidence of NHSV in the United States increased between 2003 and 2014 without a significant change in mortality. NHSV remains a serious health threat and new and effective strategies to prevent NHSV are needed.

Charge Reductions Associated With Shorter Time to Recovery in Septic Shock

BACKGROUND

Septic shock therapies that shorten the time to physiologic and clinical recovery may result in financial savings. However, the financial implications of improving these nonmortal outcomes are not well characterized. Therefore, we quantified hospital charges associated with four outcomes: ICU length of stay, duration of invasive mechanical ventilation, duration of vasopressor use, and new renal replacement therapy.

METHODS

This was an observational study using administrative data from a large academic hospital in the United States. The analysis included adults treated with vasopressors for septic shock in a medical ICU. Linear regression modeling with ordinary least square was used to estimate the incremental hospital charges associated with 1 day of ICU length of stay, 1 day of mechanical ventilation, 1 day of vasopressor use, and new renal replacement therapy.

RESULTS

The study population included 587 adults with septic shock, including 180 (30.7%) who died in the hospital. The median charge for a septic shock hospitalization was $98,583 (interquartile range [IQR], $61,177-$136,672). Decreases in ICU length of stay, mechanical ventilation duration, and vasopressor duration of 1 day were associated with charge reductions of $15,670 (IQR, $15,023-$16,317), $15,284 (IQR, $13,566-$17,002), and $17,947 (IQR, $16,344-$19,549), respectively. Avoidance of new renal replacement therapy was associated with a charge reduction of $36,051 (IQR, $22,353-$49,750).

CONCLUSIONS

Septic shock therapies that reduce the duration of organ support and ICU care have the potential to lead to substantial financial savings.

Trends in incidence and outcomes of gastroschisis in the United States: analysis of the national inpatient sample 2010-2014

PURPOSE

Gastroschisis is a severe congenital anomaly associated with a significant morbidity and mortality. There are limited temporal trend data on incidence, mortality, length of stay, and hospital cost of gastroschisis. Our aim was to study these temporal trends using the National Inpatient Sample (NIS).

METHODS

We identified all neonatal admissions with a diagnosis of gastroschisis within the NIS from 2010 through 2014. We limited admission age to ≤ 28 days and excluded all those transferred to other hospitals. We estimated gastroschisis incidence, mortality, length of hospital stay, and cost of hospitalization. For continuous variables, trends were analyzed using survey regression. Cochrane-Armitage trend test was used to analyze trends for categorical variables. P < 0.05 was considered as significant.

RESULTS

The incidence of gastroschisis increased from 4.5 to 4.9/10,000 live births from 2010 through 2014 (P = 0.01). Overall mortality was 3.5%, median length of stay was 35 days (95% CI 26-55 days), and median cost of hospitalization was $75,859 (95% CI $50,231-$122,000). After adjusting for covariates, there was no statistically significant change in mortality (OR = 1.13; 95% CI 0.87-1.48), LOS (β = - 2.1 ± 3.5; 95% CI - 9.0 to 4.8) and hospital cost (β = - 2.137 ± 10.813; 95% CI - 23,331 to 19,056) with each calendar year increase on multivariate logistic regression analysis.

CONCLUSION

The incidence of neonates with gastroschisis increased between 2010 and 2014. Incidence was highest in the West. No difference in mortality and resource utilization was observed.

Neonatal Intensive Care Unit Length of Stay Reduction by Heart Rate Characteristics Monitoring

OBJECTIVE

To examine the effect of heart rate characteristics (HRC) monitoring on length of stay among very low birth weight (VLBW; <1500 g birth weight) neonates in the HeRO randomized controlled trial (RCT).

STUDY DESIGN

We performed a retrospective analysis of length of stay metrics among 3 subpopulations (all patients, all survivors, and survivors with positive blood or urine cultures) enrolled in a multicenter, RCT of HRC monitoring.

RESULTS

Among all patients in the RCT, infants randomized to receive HRC monitoring were more likely than controls to be discharged alive and prior to day 120 (83.6% vs 80.1%, P = .014). The postmenstrual age at discharge for survivors with positive blood or urine cultures was 3.2 days lower among infants randomized to receive HRC monitoring when compared with controls (P = .026). Although there were trends in other metrics toward reduced length of stay in HRC-monitored patients, none reached statistical significance.

CONCLUSIONS

HRC monitoring is associated with reduced mortality in VLBW patients and a reduction in length of stay among infected surviving VLBW infants.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00307333.

Mother's breast milk supplemented with donor milk reduces hospital and health service usage costs in low-birthweight infants

OBJECTIVE

to compare hospital and health service usage costs of feeding low-birthweight (LBW) infants predominantly with their mother's milk, supplemented with donor milk, with donor milk and preterm formula.

DESIGN

prospective matching study.

SETTING

tertiary public perinatal centre, neonatal intensive care unit (NICU) and donor human milk bank.

PARTICIPANTS

100LBW infants (Group I) fed predominantly with their mother's milk from the first hour of life, supplemented (mainly for the first week of life) with donor milk, were matched on a 1:1 basis with 100LBW infants (Group II) who were fed with donor milk for the first 3 weeks of life followed by preterm formula until hospital discharge. Individualised targeted fortification of human milk was implemented in both study groups.

FINDINGS

the costs of hospitalisation, doctor visits and prescription drugs for viral infections until 8 months of age were calculated for each infant. Infants fed predominantly with their mother's milk had significantly shorter hospital stays and lower hospitalisation costs. In Group I infants, the duration of enteral gavage feeding was shorter, resulting in significantly lower costs. Up to 8 months of age, Group I infants experienced fewer episodes of viral infections, and the cost of each doctor visit and drug prescription was lower for these infants.

CONCLUSIONS

feeding LBW infants predominantly with their mother's milk reduces hospital and health service usage costs.

IMPLICATIONS FOR PRACTICE

feeding LBW infants predominantly with their mother's milk, supplemented with donor milk, followed by exclusive breast feeding seems to result in potential savings in hospital and health service usage costs.

Professional Fee Ratios for US Hospital Discharge Data

BACKGROUND

US hospital discharge datasets typically report facility charges (ie, room and board), excluding professional fees (ie, attending physicians' charges).

OBJECTIVES

We aimed to estimate professional fee ratios (PFR) by year and clinical diagnosis for use in cost analyses based on hospital discharge data.

SUBJECTS

The subjects consisted of a retrospective cohort of Truven Health MarketScan 2004-2012 inpatient admissions (n=23,594,605) and treat-and-release emergency department (ED) visits (n=70,771,576).

MEASURES

PFR per visit was assessed as total payments divided by facility-only payments.

RESEARCH DESIGN

Using ordinary least squares regression models controlling for selected characteristics (ie, patient age, comorbidities, etc.), we calculated adjusted mean PFR for admissions by health insurance type (commercial or Medicaid) per year overall and by Major Diagnostic Category (MDC), Diagnostic Related Group, Healthcare Cost and Utilization Project Clinical Classification Software, and primary International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis, and for ED visits per year overall and by MDC and primary ICD-9-CM diagnosis.

RESULTS

Adjusted mean PFR for 2012 admissions, including preceding ED visits, was 1.264 (95% CI, 1.264, 1.265) for commercially insured admissions (n=2,614,326) and 1.177 (1.176, 1.177) for Medicaid admissions (n=816,503), indicating professional payments increased total per-admission payments by an average 26.4% and 17.7%, respectively, above facility-only payments. Adjusted mean PFR for 2012 ED visits was 1.286 (1.286, 1.286) for commercially insured visits (n=8,808,734) and 1.440 (1.439, 1.440) for Medicaid visits (n=2,994,696). Supplemental tables report 2004-2012 annual PFR estimates by clinical classifications.

CONCLUSIONS

Adjustments for professional fees are recommended when hospital facility-only financial data from US hospital discharge datasets are used to estimate health care costs.

Factors associated with high hospital resource use in a population-based study of children with orofacial clefts

BACKGROUND

Little is known about population-based maternal, child, and system characteristics associated with high hospital resource use for children with orofacial clefts (OFC) in the US.

METHODS

This was a statewide, population-based, retrospective observational study of children with OFC born between 1998 and 2006, identified by the Florida Birth Defects Registry whose records were linked with longitudinal hospital discharge records. We stratified the descriptive results by cleft type [cleft lip with cleft palate, cleft lip, and cleft palate] and by isolated versus nonisolated OFC (accompanied by other coded major birth defects). We used Poisson regression to analyze associations between selected characteristics and high hospital resource use (≥90th percentile of estimated hospitalized days and inpatient costs) for birth, postbirth, and total hospitalizations initiated before age 2 years.

RESULTS

Our analysis included 2,129 children with OFC. Infants who were born low birth weight (<2500 grams) were significantly more likely to have high birth hospitalization costs for CLP (adjusted prevalence ratio: 1.6 [95% confidence interval: 1.0-2.7]), CL (adjusted prevalence ratio: 3.0 [95% confidence interval: 1.1-8.1]), and CP (adjusted prevalence ratio: 2.3 [95% confidence interval: 1.3-4.0]). Presence of multiple birth defects was significantly associated with a three- to eleven-fold and a three- to nine-fold increase in the prevalence of high costs and number of hospitalized days, respectively; at birth, postbirth before age 2 years and overall hospitalizations.

CONCLUSION

Children with cleft palate had the greatest hospital resources use. Additionally, the presence of multiple birth defects contributed to greater inpatient days and costs for children with OFC.

Population-based study of hospital costs for hospitalizations of infants, children, and adults with a congenital heart defect, Arkansas 2006 to 2011

BACKGROUND

Congenital heart defects (CHDs) are common birth defects and are associated with high hospital costs. The objectives of this study were to assess hospitalization costs, across the lifespan, of patients with CHDs in Arkansas.

METHODS

Data from the 2006 to 2011 Healthcare Cost and Utilization Project Arkansas State Inpatient Databases were used. We included hospitalizations of patients whose admission occurred between January 1, 2006, and December 31, 2011, and included a principal or secondary CHD ICD-9-CM diagnosis code (745.0-747.49, except 747.0 and 745.5 for preterm infants). Hospitalizations were excluded if they involved out-of-state residents, normal newborn births, or if missing data included age at admission, state of residence, or hospital charges. Children were defined as those < 18 years-old at time of admission.

RESULTS

Between 2006 and 2011, there were 2,242,484 inpatient hospitalizations in Arkansas. There were 9071 (0.4%) hospitalizations with a CHD, including 5,158 hospitalizations of children (2.2% of hospitalizations among children) and 3,913 hospitalizations of adults (0.2% of hospitalizations of adults). Hospital costs for these CHD hospitalizations totaled $355,543,696. The average annual cost of CHD hospitalizations in Arkansas was $59,257,283 during this time period. Infants accounted for 72% of all CHD-related hospital costs; total costs of CHD hospitalizations for children were almost five times those of hospitalization costs for adults with CHD.

CONCLUSION

Hospitalizations with CHDs account for a disproportionate share of hospital costs in Arkansas. Hospitalizations of children with CHD accounted for a higher proportion of total hospitalizations than did hospitalizations of adults with CHD.

Cost of care and social consequences of very low birth weight infants without premature- related morbidities in Italy

Aim of this study was to estimate the cost that is borne by the Italian National Health Service, families, and social security due to very low birth weight infants (VLBWIs) without prematurity-related morbidities up to the age of 18 months. We followed up on 150 VLBWIs and 145 comparable full-term infants (FTIs) who were born in one of 25 different neonatal intensive care units upon discharge from the hospital and at six and 18 months of age. The average length of the primary hospitalisation of the VLBWIs was 59.7 days (SD 21.6 days), with a total cost of €20,502 (SD €8409), compared with three days (SD 0.4 days) with a total cost of €907 (SD €304) for the FTIs. The total societal cost of the VLBWIs for the first 18 months of life was €58,098 (SD €21,625), while the corresponding figure for FTIs was €24,209 (SD €15,557). Among VLBWIs, both low birth weight and gestational age were correlated with the length of hospitalisation after birth (r² = 0.61 and r² = 0.57, respectively; p values < 0.0005). Our findings highlight that the existing DRGs and tariffs inadequately reflect the actual costs for Italian National Health Service.

Improving health care usage in a very low birth weight population

BACKGROUND

Prematurity is the biggest contributor to admissions in the neonatal intensive care unit (NICU). The period following hospital discharge is a vital continuum for the very low birth weight (VLBW) infant. The objective of this study was to assess the impact of a unique discharge and follow-up process on the outcomes of VLBW infants leaving the NICU.

METHODS

All outpatient health care usage by VLBW infants born in the study year (cases) was retrospectively tracked through 12 months of age. A cohort of healthy newborn infants were matched by birthdate to each VLBW infant (controls) and similarly tracked.

RESULTS

In this study, there were 85 cases and 85 controls. The mean gestational age at birth for the cases was 29.1 ± 2.7 weeks with a mean birth weight of 1079 ± 263 g. That of the controls was 38.9 ± 1.3 weeks and 3202 ± 447 g. Over 90% of both populations had Medicaid coverage. All VLBW infants received care at the Special Care Developmental Follow-Up Clinic. When compared with the controls, VLBW infants discharged from the NICU made fewer acute, unscheduled visits to the Emergency Department or Urgent Care Clinic (2.3 ± 2.5 vs. 3.7 ± 3.5; P=0.007) despite their high-risk medical and social status. Their growth pattern showed significant "catch-up" and was similar to the matched controls at the last scheduled visit for each group.

CONCLUSIONS

Outcomes including health care utilization in high-risk infants can be improved through meticulous discharge planning and follow-up measures that utilize existing hospital infrastructure to provide affordable comprehensive care.

Factors associated with inpatient hospitalizations among patients aged 1 to 64 years with congenital heart defects, Arkansas 2006 to 2011

BACKGROUND

Individuals with congenital heart defects (CHDs) have high hospital resource use. We sought to identify factors associated with hospital costs and multiple hospitalizations among individuals with CHDs.

METHODS

Data from the 2006 to 2011 Healthcare Cost and Utilization Project Arkansas State Inpatient Databases were linked across encrypted patient identifiers to develop a cohort of Arkansas residents aged 1 to 64 years who were hospitalized at least once with a CHD during this time period. Infants were excluded because patient identifiers were missing for 18 to 52% each year. CHDs were identified using principal and secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses codes. All hospitalizations of individuals ever admitted with a CHD were included. Mean and median patient-level costs were estimated; the association of hospital costs and patient readmissions were examined with linear and logistic regression.

RESULTS

There were 1,185,868 inpatient hospitalizations of Arkansas residents aged 1 to 64 years between 2006 and 2011; these were accrued by 603,925 patients. Of those, 2542 patients (0.42%) had at least one hospitalization with a CHD diagnosis. Total costs for these 2542 patients were $126,999,837 and they accumulated 7898 hospitalizations. Factors associated with increased costs included patient age, CHD type, cardiac procedures, and comorbidities. Factors associated with hospital readmission within 1 year included age, CHD type, expected payer, and comorbidities.

CONCLUSION

Individuals with CHDs in Arkansas experience variation in hospital use and costs by patient characteristics. Future research should investigate factors associated with readmissions, cardiac procedures, and comorbidities, as these are strongly associated with hospital costs. Birth Defects Research (Part A) 103:589-596, 2015. © 2015 Wiley Periodicals, Inc.

The impact of changes in preterm birth among twins on stillbirth and infant mortality in the United States

OBJECTIVE

To examine trends for preterm births, stillbirths, neonatal and infant deaths in twin births by gestational age and birth weight categories, as well as trends in induction of labor and cesarean delivery during 1995-2006.

STUDY DESIGN

A trend analysis was performed on data derived from the National Centers for Health Statistics' Vital Statistics Data files (1995-2006). The primary outcomes examined were preterm birth, stillbirth, neonatal and infant mortality.

RESULT

During the study period, rates of labor induction among twins decreased by 8% and rates of cesarean delivery increased by 35%. Concurrently, the preterm birth rate increased by 13% from 54% in 1995-96 to 61% in 2005-06. The overall stillbirth rate, and neonatal and infant death rates decreased during the same period by 21% (95% confidence interval (CI): 18-25%), 13% (95% CI: 9-16%) and 12% (95% CI: 8-15%), respectively. There were significant reductions in neonatal death rates related to respiratory distress syndrome (RDS; 48%, 95% CI: 41-54%) and congenital anomalies (25%, 95% CI: 16-33%) during the study period. Reductions in post-neonatal infant mortality were mainly in RDS (88%) and sudden infant death syndrome (26%). Mortality rates among infants born by either induction of labor or cesarean delivery fell during the study period and remained much lower than the overall infant mortality rate.

CONCLUSION

The findings of this study suggest that during 1995-2006 there was an increase in preterm birth rates and a decrease in labor inductions with a sharp decline in stillbirth, neonatal and infant mortality rates.

Hospitalizations and associated costs in a population-based study of children with Down syndrome born in Florida

BACKGROUND

Our objective was to examine differences in hospital resource usage for children with Down syndrome by age and the presence of other birth defects, particularly severe and nonsevere congenital heart defects (CHDs).

METHODS

This was a retrospective, population-based, statewide study of children with Down syndrome born 1998 to 2007, identified by the Florida Birth Defects Registry (FBDR) and linked to hospital discharge records for 1 to 10 years after birth. To evaluate hospital resource usage, descriptive statistics on number of hospitalized days and hospital costs were calculated. Results were stratified by isolated Down syndrome (no other coded major birth defect); presence of severe and nonsevere CHDs; and presence of major FBDR-eligible birth defects without CHDs.

RESULTS

For 2552 children with Down syndrome, there were 6856 inpatient admissions, of which 68.9% occurred during the first year of life (infancy). Of the 2552 children, 31.7% (n = 808) had isolated Down syndrome, 24.0% (n = 612) had severe CHDs, 36.3% (n = 927) had nonsevere CHDs, and 8.0% (n = 205) had a major FBDR-eligible birth defect in the absence of CHD. Infants in all three nonisolated DS groups had significantly higher hospital costs compared with those with isolated Down syndrome. From infancy through age 4, children with severe CHDs had the highest inpatient costs compared with children in the other sub-groups.

CONCLUSION

Results support findings that for children with Down syndrome the presence of other anomalies influences hospital use and costs, and children with severe CHDs have greater hospital resource usage than children with other CHDs or major birth defects without CHDs.

Resuscitation of neonates at 23 weeks' gestational age: a cost-effectiveness analysis

OBJECTIVE

Resuscitation of infants at 23 weeks' gestation remains controversial; clinical practices vary. We sought to investigate the cost effectiveness of resuscitation of infants born 23 0/7-23 6/7 weeks' gestation.

DESIGN

Decision-analytic modeling comparing universal and selective resuscitation to non-resuscitation for 5176 live births at 23 weeks in a theoretic U.S. cohort. Estimates of death (77%) and disability (64-86%) were taken from the literature. Maternal and combined maternal-neonatal utilities were applied to discounted life expectancy to generate QALYs. Incremental cost-effectiveness ratios were calculated, discounting costs and QALYs. Main outcomes included number of survivors, their outcome status and incremental cost-effectiveness ratios for the three strategies. A cost-effectiveness threshold of $100 000/QALY was utilized.

RESULTS

Universal resuscitation would save 1059 infants: 138 severely disabled, 413 moderately impaired and 508 without significant sequelae. Selective resuscitation would save 717 infants: 93 severely disabled, 279 moderately impaired and 343 without significant sequelae. For mothers, non-resuscitation is less expensive ($19.9 million) and more effective (127 844 mQALYs) than universal resuscitation ($1.2 billion; 126 574 mQALYs) or selective resuscitation ($845 million; 125 966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22 256 and 15 134 nQALYS, respectively, versus 247 nQALYs for non-resuscitation. In sensitivity analyses, universal resuscitation was cost-effective from a maternal perspective only at utilities for neonatal death <0.42. When analyzed from a maternal-neonatal perspective, universal resuscitation was cost-effective when the probability of neonatal death was <0.95.

CONCLUSIONS

Over wide ranges of probabilities for survival and disability, universal and selective resuscitation strategies were not cost-effective from a maternal perspective. Both strategies were cost-effective from a maternal-neonatal perspective. This study offers a metric for counseling and decision-making for extreme prematurity. Our results could support a more permissive response to parental requests for aggressive intervention at 23 weeks' gestation.

Economical Analysis of Different Clinical Approaches in Pre-Viability Amniorrhexis-A Case Series

Prolonged oligohydramnios following extreme preterm prelabour rupture of membranes (EPPROM) is traditionally associated with a high morbidity and mortality to both the mother and the baby. The clinical maternal evaluation and fetal ultrasound assessment may provide important prognostic information for the clinicians and should be taken into account when counselling the patients so as to provide them with enough information to make decision of continuing or interrupting the pregnancy. Current financial constraints on the National Healthcare Service (NHS) resources make it imperative for clinical decision-makers and budgetary planners to make the right decision of continuing or terminating a second trimester pre-viability amniorrhexis for desperate parents. To assess the economic consequences following EPPROM, the risk of infection to both baby and mother, psychological impact on the parents and associated complications and further disability after delivery on this fragile group of patients to the NHS resources. We review the clinical course, outcome, and the challenges to parents and health care professionals on three pregnancies complicated by EPPROM, occurring before 24 weeks’ gestation with a membrane rupture to delivery interval (latent period) of 14 days or more. The anticipated birth of an extremely premature infant poses many challenges for parents and health care professionals. As parents are faced with difficult decisions that can have a long-term impact on the infant, family and country’s resources, it is critical to provide the type of information and support that is needed by them. Taking all these into consideration with the period of ventilation and respiratory assistance in Neonatal Intensive Care Unit (NICU) is essential to provide maximum chances for survival, minimizing the risk for long term sequelae of the neonate and provides the parents enough time to decide on making the right decision with the associated guidance of the healthcare provider.

Existing data analysis in pediatric critical care research

Our objectives were to review and categorize the existing data sources that are important to pediatric critical care medicine (PCCM) investigators and the types of questions that have been or could be studied with each data source. We conducted a narrative review of the medical literature, categorized the data sources available to PCCM investigators, and created an online data source registry. We found that many data sources are available for research in PCCM. To date, PCCM investigators have most often relied on pediatric critical care registries and treatment- or disease-specific registries. The available data sources vary widely in the level of clinical detail and the types of questions they can reliably answer. Linkage of data sources can expand the types of questions that a data source can be used to study. Careful matching of the scientific question to the best available data source or linked data sources is necessary. In addition, rigorous application of the best available analysis techniques and reporting consistent with observational research standards will maximize the quality of research using existing data in PCCM.

Cost of morbidities in very low birth weight infants

OBJECTIVE

To determine the association between direct costs for the initial neonatal intensive care unit hospitalization and 4 potentially preventable morbidities in a retrospective cohort of very low birth weight (VLBW) infants (birth weight <1500 g).

STUDY DESIGN

The sample included 425 VLBW infants born alive between July 2005 and June 2009 at Rush University Medical Center. Morbidities included brain injury, necrotizing enterocolitis, bronchopulmonary dysplasia, and late-onset sepsis. Clinical and economic data were retrieved from the institution's system-wide data and cost accounting system. A general linear regression model was fit to determine incremental direct costs associated with each morbidity.

RESULTS

After controlling for birth weight, gestational age, and sociodemographic characteristics, the presence of brain injury was associated with a $12048 (P = .005) increase in direct costs; necrotizing enterocolitis, with a $15 440 (P = .005) increase; bronchopulmonary dysplasia, with a $31565 (P < .001) increase; and late-onset sepsis, with a $10055 (P < .001) increase. The absolute number of morbidities was also associated with significantly higher costs.

CONCLUSION

This study provides collective estimates of the direct costs incurred during neonatal intensive care unit hospitalization for these 4 morbidities in VLBW infants. The incremental costs associated with these morbidities are high, and these data can inform future studies evaluating interventions aimed at preventing or reducing these costly morbidities.

Costs associated with low birth weight in a rural area of Southern Mozambique

BACKGROUND

Low Birth Weight (LBW) is prevalent in low-income countries. Even though the economic evaluation of interventions to reduce this burden is essential to guide health policies, data on costs associated with LBW are scarce. This study aims to estimate the costs to the health system and to the household and the Disability Adjusted Life Years (DALYs) arising from infant deaths associated with LBW in Southern Mozambique.

METHODS AND FINDINGS

Costs incurred by the households were collected through exit surveys. Health system costs were gathered from data obtained onsite and from published information. DALYs due to death of LBW babies were based on local estimates of prevalence of LBW (12%), very low birth weight (VLBW) (1%) and of case fatality rates compared to non-LBW weight babies [for LBW (12%) and VLBW (80%)]. Costs associated with LBW excess morbidity were calculated on the incremental number of hospital admissions in LBW babies compared to non-LBW weight babies. Direct and indirect household costs for routine health care were 24.12 US$ (CI 95% 21.51; 26.26). An increase in birth weight of 100 grams would lead to a 53% decrease in these costs. Direct and indirect household costs for hospital admissions were 8.50 US$ (CI 95% 6.33; 10.72). Of the 3,322 live births that occurred in one year in the study area, health system costs associated to LBW (routine health care and excess morbidity) and DALYs were 169,957.61 US$ (CI 95% 144,900.00; 195,500.00) and 2,746.06, respectively.

CONCLUSIONS

This first cost evaluation of LBW in a low-income country shows that reducing the prevalence of LBW would translate into important cost savings to the health system and the household. These results are of relevance for similar settings and should serve to promote interventions aimed at improving maternal care.

Clinical benefits, costs, and cost-effectiveness of neonatal intensive care in Mexico

BACKGROUND

Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico.

METHODS AND FINDINGS

A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24-26, 27-29, and 30-33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24-26, 27-29, and 30-33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses.

CONCLUSIONS

Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis. Please see later in the article for the Editors' Summary.

[Costs for treatment of very-low-birth-weight infants]

BACKGROUND

The cost of treating premature infants is increasing due to use of advanced medical technology and rising labour costs. Few Norwegian studies have been published in the field. This study has assessed treatment costs for very-low-birth-weight infants in St. Olavs University Hospital.

MATERIAL AND METHODS

Children born in 1997 or 2007 were studied retrospectively. Individual costs (diagnostics and treatment) were estimated from detailed analysis of each patient's daily medical record. General daily costs (salary, equipment etc.) for treatment levels 1 (growth and development), 2 (observation) and 3 (intensive treatment) were estimated from department and hospital budgets.

RESULTS

The total mean treatment cost from admission to discharge was 603,238 NOK per patient in 2007, an increase from 475,131 NOK in 1997. As more infants survived without serious complications in 2007, the cost of a surviving healthy infant was actually lower in 2007 (922,599 NOK) than in 1997 (1,135,035 NOK). DRG reimbursements cover the cost for treating children with a birth weight in the range 1000 - 1499 g, but not for those weighing < 1000 g.

INTERPRETATION

Very-low-birth-weight infants are probably the most expensive patient group treated in hospitals; the total cost in 2007 was (mean) 900,000 NOK.

Impaired sleep and well-being in mothers with low-birth-weight infants

OBJECTIVE

To explore relationships between impaired sleep and well-being in mothers with low-birth-weight infants in the neonatal intensive care unit.

DESIGN

Cross-sectional descriptive exploratory design.

SETTING

Neonatal intensive care unit in metropolitan Atlanta, GA.

PARTICIPANTS

Twenty second-week postpartum, first-time mothers who had a low-birth-weight infant hospitalized in the neonatal intensive care unit.

METHODS

Self-report data were collected for sleep, fatigue, depression, and well-being. Total sleep time, wake after sleep onset, circadian activity rhythms, and light exposure were measured using a wrist actigraph.

RESULTS

Mothers reported clinically significant sleep disturbance and fatigue severity. Actigraphy showed the average nighttime total sleep time was less than 7 hours with 19%+/-2.2% wake after sleep onset, and the total daytime sleep was more than an hour. Mothers also experienced moderate depressive symptoms. Maternal well-being as measured by the Medical Outcomes Short Form-36, version 2 was approximately 1 SD below the mean scores of age-matched women in the general U.S. population.

CONCLUSION

Mothers of hospitalized low-birth-weight infants are vulnerable. The presence of sleep disturbances and negative physical and mental health indicators warrants further study. Intervention is needed to promote sleep for new mothers during postpartum recovery, especially mothers who are dealing with a medically ill infant.

The economic burden of preterm/very low birth weight care in Nigeria

The care of very low birth weight (VLBW) neonates may impose an enormous burden on professional resources and finances of caregivers. This study seeks to evaluate the immediate cost of care of VLBW babies in a developing economy. Twenty-four hospital case records VLBW babies who survived till discharge over a 1 year period at the University College Hospital, Ibadan, Nigeria were reviewed. Estimates of the out of pocket costs of managing these babies were calculated. The overall cost of hospital care ranged from US$211.1 to US$1573.9. The direct (median) and indirect (median) cost of care ranged from US$80 to US$1055 (US$247.3) and US$101.0 to US$1128.1 (US$257.2), respectively. These constituted 22.8% and 3966.3% (median 133.4%) of the combined family income. In conclusion, the cost of care of the VLBW deliveries in Nigeria is very high for the level of the economy and constitutes a major financial burden on the family.

Economic evaluation of recombinant human copper zinc superoxide dismutase administered at birth to premature infants

OBJECTIVE

To determine the cost-effectiveness of recombinant human superoxide dismutase (rhSOD) in the prevention of chronic respiratory morbidity, defined as use of respiratory medications, in preterm infants.

STUDY DESIGN

This retrospective economic evaluation was undertaken using data from a previously published randomized controlled trial of the use of rhSOD in neonates of birthweight 600 to 1200 g. This ancillary study measured all relevant direct medical costs from birth to 1 year corrected age using resource data collected for infants from the clinical trial. Unit costs were derived from secondary datasets in similar populations, stratified by level of care or diagnosis. All costs were expressed in 2003 US dollars.

RESULT

rhSOD was associated with a highly favorable incremental cost of only $378 per chronic respiratory morbidity averted at 1 year corrected age. There was a 95% probability that the therapy would be considered cost-effective if a decision maker was willing to pay $7000 to avert one infant with long-term significant respiratory illness, and a 52% probability that it would actually reduce costs while improving outcomes. These results were more pronounced among infants <27 weeks gestational age at birth.

CONCLUSION

Based on resource data from a single randomized trial, this retrospective analysis supports the potential economic desirability of rhSOD treatment in this population.

Issues and biases in matching medicaid pregnancy episodes to vital records data: the Arkansas experience

OBJECTIVES

This study examines the extent of selection biases identified in the process of linking Medicaid claims with evidence of pregnancy to vital records.

METHODS

Two years of Medicaid claims were scanned to identify pregnancy-related diagnoses and procedures. Information on 55,764 Medicaid recipients was provided to the Division of Health Statistics, which linked the information to vital records data on a range of identifying characteristics. Claims were then clustered by date and then into episodes of care surrounding the birth date of the infant. We identified 38,222 pregnancy episodes matched to vital records; 8,474 episodes unmatched to vital records that appeared to terminate before a delivery; and 5,278 episodes that appeared to include a delivery but did not match to vital records. The characteristics of matched episodes and unmatched episodes and the characteristics of matched episodes with and without delivery claims are compared.

RESULTS

Unmatched episodes spanned fewer weeks than matched episodes, included more diagnostic indicators of elevated risk, and occurred more frequently in more impoverished populations. Among the matched records, 13% did not include claims for delivery services. These episodes occurred more frequently among Hispanic women, women delivering out of hospitals and women with preterm births and infant deaths.

CONCLUSIONS

The results provide evidence, as other studies have demonstrated, that matching Medicaid claims and vital records data is feasible. However, the matched analytic data set does tend to under-represent the outcomes of high-risk pregnancies. An additional source of selection bias can be avoided by using evidence of pregnancy as the Medicaid index for matching against vital records, rather than using only index cases with evidence of delivery.

Cost of hospitalization for preterm and low birth weight infants in the United States

OBJECTIVE

The objective of this study was to estimate national hospital costs for infant admissions that are associated with preterm birth/low birth weight.

METHODS

Infant (<1 year) hospital discharge data, including delivery, transfers, and readmissions, were analyzed by using the 2001 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project. The Nationwide Inpatient Sample is a 20% sample of US hospitals weighted to approximately >35 million hospital discharges nationwide. Hospital costs, based on weighted cost-to-charge ratios, and lengths of stay were calculated for preterm/low birth weight infants, uncomplicated newborns, and all other infant hospitalizations and assessed by degree of prematurity, major complications, and expected payer.

RESULTS

In 2001, 8% (384,200) of all 4.6 million infant stays nationwide included a diagnosis of preterm birth/low birth weight. Costs for these preterm/low birth weight admissions totaled $5.8 billion, representing 47% of the costs for all infant hospitalizations and 27% for all pediatric stays. Preterm/low birth weight infant stays averaged $15,100, with a mean length of stay of 12.9 days versus $600 and 1.9 days for uncomplicated newborns. Costs were highest for extremely preterm infants (<28 weeks' gestation/birth weight <1000 g), averaging $65,600, and for specific respiratory-related complications. However, two thirds of total hospitalization costs for preterm birth/low birth weight were for the substantial number of infants who were not extremely preterm. Of all preterm/low birth weight infant stays, 50% identified private/commercial insurance as the expected payer, and 42% designated Medicaid.

CONCLUSIONS

Costs per infant hospitalization were highest for extremely preterm infants, although the larger number of moderately preterm/low birth weight infants contributed more to the overall costs. Preterm/low birth weight infants in the United States account for half of infant hospitalization costs and one quarter of pediatric costs, suggesting that major infant and pediatric cost savings could be realized by preventing preterm birth.

Preterm birth-associated cost of early intervention services: an analysis by gestational age

OBJECTIVES

Characterizing the cost of preterm birth is important in assessing the impact of increasing prematurity rates and evaluating the cost-effectiveness of therapies to prevent preterm delivery. To assess early intervention costs that are associated with preterm births, we estimated the program cost of early intervention services for children who were born in Massachusetts, by gestational age at birth.

METHODS

Using the Pregnancy to Early Life Longitudinal Data Set, birth certificates for infants who were born in Massachusetts between July 1999 and June 2000 were linked to early intervention claims through 2003. We determined total program costs, in 2003 dollars, of early intervention and mean cost per surviving infant by gestational age. Costs by plurality, eligibility criteria, provider discipline, and annual costs for children's first 3 years also were examined.

RESULTS

Overall, 14,033 of 76,901 surviving infants received early intervention services. Program costs totaled almost $66 million, with mean cost per surviving infant of $857. Mean cost per infant was highest for children who were 24 to 31 weeks' gestational age ($5393) and higher for infants who were 32 to 36 weeks' gestational age ($1578) compared with those who were born at term ($725). Cost per surviving infant generally decreased with increasing gestational age. Among children in early intervention, mean cost per child was higher for preterm infants than for term infants. At each gestational age, mean cost per surviving infant was higher for multiples than for singletons, and annual early intervention costs were higher for toddlers than for infants.

CONCLUSIONS

Compared with their term counterparts, preterm infants incurred higher early intervention costs. This information along with data on birth trends will inform budget forecasting for early intervention programs. Costs that are associated with early childhood developmental services must be included when considering the long-term costs of prematurity.

Preterm birth in Sweden: what are the average lengths of hospital stay and the associated inpatient costs?

AIM

To provide estimates of the first-year length of stay and inpatient costs of Swedish infants admitted for neonatal care by week of gestation and by birthweight; and to provide estimates of the length of stay and inpatient costs of delivering mothers during the ante- and postpartum period by week of gestation and birthweight of the infant.

METHODS

Population-based registry study covering all live singleton deliveries in Sweden between 1998 and 2001 (n=336 136). First-year hospitalizations of infants admitted for neonatal care 0-6 d after birth (n=24 583) were tracked, as were hospitalizations of mothers for whom the date of admission lay+/-1 mo from the date of delivery. Monetary values were assigned to each hospitalization using the Nord-DRG classification system.

RESULTS

On average, preterm infants (GA < 37 wk) had first-year lengths of stay roughly four times as long as full-term infants admitted for neonatal care (30 d vs 8 d, p<0.0001). The average first-year length of stay of the extremely immature infants (GA 22-25 wk) was more than six times as long that of infants born at 34-36 wk (108 d vs 17 d, p<0.0001). Mothers delivering preterm had an average length of stay slightly more than twice as long (p<0.0001) as that of mothers of full-term infants during the ante- and postpartum period.

CONCLUSION

The estimated lengths of stay and costs may serve as reference values for a Swedish setting.

17α-hydroxyprogesterone Caproate for the Prevention of Preterm Delivery

OBJECTIVE

To evaluate whether the use of 17alpha-hydroxyprogesterone caproate for the prevention of recurrent preterm deliveries is cost-effective.

METHODS

Using decision-analysis modeling, we compared the cost-effectiveness of using 17alpha-hydroxyprogesterone caproate in four subgroups: 1) Prior preterm deliveries less than 32 weeks; 2) prior preterm deliveries 32-37 weeks; 3) prior term delivery; and 4) no prior delivery. Each subgroup was compared with a "no treatment" group. Costs included those for 17alpha-hydroxyprogesterone caproate, hospital admissions, and complications from preterm deliveries. The main outcome measures include cost per quality-adjusted life-year gained and the number of preterm deliveries prevented. Secondary outcomes include neonatal complications prevented. One-way and multiway sensitivity analyses were performed.

RESULTS

The use of 17alpha-hydroxyprogesterone caproate for the prevention of preterm deliveries result in cost-savings in women with prior preterm deliveries less than 32 weeks and 32-37 weeks. The sensitivity analyses revealed the model to be robust over a wide range of values for evaluated variables.

CONCLUSION

Within our baseline assumptions, 17alpha-hydroxyprogesterone caproate was associated with cost-savings when used for the prevention of preterm deliveries in women with prior preterm deliveries.

Quality-of-care indicators for the neurodevelopmental follow-up of very low birth weight children: results of an expert panel process

OBJECTIVE

To develop a set of quality indicators for the neurodevelopmental follow-up care of very low birth weight (VLBW; <1500 g) children.

METHODS

We reviewed the scientific literature on predictors of neurodevelopmental outcomes for VLBW children and the clinical practice guidelines relevant to their care after hospital discharge. An expert panel with members nominated by the American Academy of Pediatrics, the National Institute of Child Health and Human Development, the Vermont Oxford Network, and the California Children's Service was convened. We used a modified Delphi method to evaluate and select the quality-of-care indicators.

RESULTS

The panel recommended a total of 70 indicators in 5 postdischarge follow-up areas: general care; physical health; vision, hearing, speech, and language; developmental and behavioral assessment; and psychosocial issues. Of these, 58 (83%) indicators were in preventive care, 5 (7%) were in acute care, and 7 (10%) were in chronic care.

CONCLUSION

The quality indicators cover follow-up care for VLBW infants with various medical conditions. Given the elevated rates of long-term neurodevelopmental disabilities and the potential impact of poor health care, this new set of indicators provides an opportunity to assess and monitor the quality of follow-up care with the ultimate aim of improving the quality of care for this high-risk population.

Pushing the boundaries of viability: the economic impact of extreme preterm birth

BACKGROUND

Previous assessments of the economic impact of preterm birth focussed on short term health service costs across the broad spectrum of prematurity.

OBJECTIVE

To estimate the societal costs of extreme preterm birth during the sixth year after birth.

METHODS

Unit costs were applied to estimates of health, social and broader resource use made by 241 children born at 20 through 25 completed weeks of gestation in the United Kingdom and Republic of Ireland and a comparison group of 160 children born at full term. Societal costs per child during the sixth year after birth were estimated and subjected to a rigorous sensitivity analysis. The effects of gestational age at birth on annual societal costs were analysed, first in a simple linear regression and then in a multiple linear regression.

RESULTS

Mean societal costs over the 12 month period were 9541 pounds sterling (standard deviation 11,678 pounds sterling) for the extreme preterm group and 3883 pounds sterling (1098 pounds sterling) for the term group, generating a mean cost difference of 5658 pounds sterling (bootstrap 95% confidence interval: 4203 pounds sterling, 7256 pounds sterling) that was statistically significant (P<0.001). After adjustment for clinical and sociodemographic covariates, sex-specific extreme preterm birth was a strong predictor of high societal costs.

CONCLUSION

The results of this study should facilitate the effective planning of services and may be used to inform the development of future economic evaluations of interventions aimed at preventing extreme preterm birth or alleviating its effects.

Costs of newborn care in California: a population-based study

OBJECTIVE

We sought to describe the current costs of newborn care by using population-based data, which includes linked vital statistics and hospital records for both mothers and infants. These data allow costs to be reported by episode of care (birth), instead of by hospitalization.

METHODS

Data for this study were obtained from the linked 2000 California birth cohort data. These data (n = 518,704), provided by the California Office of Statewide Health Planning and Development (OSHPD), contain infant vital statistics data (birth and death certificate data) linked to infant and maternal hospital discharge summaries. In addition to the infant and maternal hospital discharge summaries associated with delivery, these data include discharge summaries for all infant hospital-to-hospital transfers and maternal prenatal hospitalizations. The linkage algorithm that is used by OSHPD in creating the linked cohort data file is highly accurate. More than 99% of the maternal and infant discharge abstracts were linked successfully with the birth certificates. These data were also linked successfully with the infant discharge abstracts from the receiving hospital for 99% of the infants who were transferred to another hospital. The hospital discharge records were the source of the hospital charges and length-of-stay information summarized in this study. Hospital costs were estimated by adjusting charges by hospital-specific ratios of costs to charges obtained from the OSHPD Hospital Financial Reporting data. Costs, lengths of stay, and mortality were summarized by birth weight groups, gestational age, cost categories, and types of admissions.

RESULTS

Low birth weight (LBW) and very low birth weight (VLBW) infants had significantly longer hospital stays and accounted for a significantly higher proportion of total hospital costs. The average hospital stay for LBW infants ranged from 6.2 to 68.1 days, whereas the average hospital stay for infants who weighed >2500 g at birth was 2.3 days. Overall, VLBW infants accounted for 0.9% of cases but 35.7% of costs, whereas LBW infants accounted for 5.9% of cases but 56.6% of total hospital costs. Although total maternal and infant costs were similar (approximately 1.6 billion dollars), the distribution of maternal costs was much less skewed. For infants, 5% of infants accounted for 76% of total infant hospital costs. Conversely, the most expensive 3% of deliveries accounted for only 17% of total maternal costs.

CONCLUSIONS

The very smallest infants make up a hugely disproportionate share of costs; more than half of all neonatal costs are incurred by LBW or premature infants. Maternal costs are similar in magnitude to newborn costs, but they are much less skewed than for infants. Preventing premature deliveries could yield very large cost savings, in addition to saving lives.

Maternal Demographic and Psychosocial Factors Associated with Low Birth Weight in Eastern Taiwan

The relationship between birth weight and maternal sociodemographic characteristics was examined in a sample from two teaching hospitals in eastern Taiwan. Using a structured questionnaire, we conducted face-to-face interviews with women at antenatal clinics between 1998 and 1999 in Hualien City. One year later, we took the outcome of pregnancy from medical records and birth certificates from the Public Health Bureau of Hualien County. Of the 1,128 single live births, 6.8% had low birth weight (LBW) using the World Health Organization cut-off of 2,500 g. LBW was more common in teenage (< 20 years), older (> 30 years), first-time, and unmarried mothers; those with basic/intermediate educational attainment; and residents of aboriginal districts. Teenage pregnancies were more likely than those in adults to be unplanned, and such mothers had smoking or alcohol-drinking behavior. Prevention of teenage pregnancy is crucial to lower LBW rates in eastern Taiwan. For adult mothers, basic or intermediate educational attainment, residence in an aboriginal district, and first-term pregnancy were significant factors associated with LBW, after adjustment for other psychosocial attributes, such as psychologic distress and poor family support. Thus, we should pay more attention when caring for pregnant women with such sociodemographic characteristics, and ensure that they have adequate prenatal care and can adopt a healthy lifestyle.

International comparison of care for very low birth weight infants: parents' perceptions of counseling and decision-making

OBJECTIVE

To characterize parent perceptions and satisfaction with physician counseling and delivery-room resuscitation of very low birth weight infants in countries with neonatal intensive care capacity.

STUDY DESIGN

Convenience sample of 327 parents of 379 inborn very low birth weight infants (<1501 g) who had received resuscitation and neonatal intensive care in 9 neonatal intensive care units (NICUs) in 6 Pacific Rim countries and in 2 California hospitals. The sample comprised mostly parents whose infants survived, because in some centers interviews of parents of nonsurviving infants were culturally inappropriate. Of 359 survivors for whom outcome data were asked of parents, 29% were reported to have long-term sequelae. Half-hour structured interviews were performed, using trained interpreters as necessary, at an interval of 13.7 months after the infant's birth. We compared responses to interview questions that detailed counseling patterns, factors taken into consideration in decisions, and acceptance of parental decision-making.

RESULTS

Parents' recall of perinatal counseling differed among centers. The majority of parents assessed physician counseling on morbidity and mortality as adequate in most, but not all, centers. They less commonly perceived discussions of other issues as adequate to their needs. The majority (>65%) of parents in all centers felt that they understood their infant's prognosis after physician counseling. The proportion of parents who expected long-term sequelae in their infant varied from 15% (in Kuala Lumpur, Malaysia) to 64% (in Singapore). The majority (>70%) of parents in all centers, however, perceived their infant's outcome to be better than they expected from physician counseling. A majority of parents across all centers feared that their infant would die in the NICU, and approximately one third continued to fear that their infant might die at home after nursery discharge. The parents' regard for physicians' and, to a lesser extent, partners' opinions was important in decision-making. Less than one quarter of parents perceived that physicians had made actual life-support decisions on their own except in Melbourne, Australia, and Tokyo, Japan (where 74% and 45% of parents, respectively, reported sole physician decision-making). Parents would have preferred to play a more active, but not autonomous, role in decisions made for their infants. Counseling may heighten parents' anxiety during and after their infant's hospitalization, but that does not diminish their recalled satisfaction with counseling and the decision-making process.

CONCLUSIONS

Counseling differs by center among these centers in Australasia and California. Given that parents desire to play an active role in decision-making for their premature infant, physicians should strive to provide parents the medical information critical for informed decision-making. Given that parents do not seek sole decision-making capacity, physicians should foster parental involvement in life-support decisions to the extent appropriate for local cultural norms.

The cost of prematurity: hospital charges at birth and frequency of rehospitalizations and acute care visits over the first year of life: a comparison by gestational age and birth weight

The proportion of preterm and low-birth-weight infants has been growing steadily for two decades. Most of the more than US 10 billion dollars spent on neonatal care in the United States in 2003 was spent on the 12.3% of infants who were born preterm. Research has shown higher initial hospital costs and a higher rate of acute care visits and rehospitalization for preterm and low-birth-weight infants, but only a limited number of studies of the cost of prematurity that follow infants through the first year of life have been conducted. This study is a secondary analysis of data on a subset of infants drawn from a randomized clinical trial that examined health outcomes and health care costs in women with high-risk pregnancies and their infants. For the current study, a sample of 84 singleton infants was chosen. Forty-three infants (51%) were full term (37 weeks' gestation or more) and 41 (49%) were born preterm (less than 37 weeks' gestation). Fifty-five infants (65.5%) were born at normal birth weights (2,500 g or greater), 24 (28.5%) were born at low birth weights (1,501 to 2,499 g), and five (6%) were born at very low birth weights (less than 1,500 g). Data on the initial hospital charges and the rates of rehospitalization and acute care visits in the first year of life in relation to gestational age and birth weight were collected. The results clearly demonstrated that the charges for initial hospitalizations increased as birth weights and gestational ages decreased. Low-birth-weight infants were less likely to have unscheduled acute care visits than normal-birth-weight infants. Interventions to improve prenatal care targeted to women at high risk for delivering preterm or low-birth-weight infants would reduce health care costs and improve health outcomes of infants as well.

The economic consequences of preterm birth during the first 10 years of life

OBJECTIVE

To examine the association between gestational age at the time of birth and long-term use and cost of hospital inpatient services.

DESIGN

Multi-level modelling of the hospital service utilisation and cost profile of each child born in hospital during 1978-1988 in two areas covered by the Oxford Record Linkage Study.

SETTING

Oxfordshire and West Berkshire.

POPULATION

117,212 children divided into four subgroups by gestational age at birth: <28 weeks, 28-31 weeks, 32-36 weeks, 37 weeks or greater.

MAIN OUTCOME MEASURES

Number and duration of hospital admissions during the first 10 years of life. Costs, expressed in pound sterling and valued at 1998-1999 prices, of hospital inpatient services.

RESULTS

The cumulative cost of hospital inpatient admissions incurred during the first 10 years of life, including the initial birth admission, averaged 17,819.94 [22,322.87 UK pounds] for children born at <28 weeks gestation, 17,751.00 [19,055.53 UK pounds] for children born at 28-31 weeks gestation, 5,376.39 [7,393.78 UK pounds] for children born at 32-36 weeks gestation, and 1,658.63 [3,409.14 UK pounds] for children born at 37 weeks gestation or greater. The adjusted number of hospital inpatient admissions, inpatient days and costs, respectively, over the first 10 years of life was 130%, 77% and 443% higher for children born at <28 weeks gestation than for children born at term.

CONCLUSION

The adverse sequelae of preterm birth are likely to have considerable long-term economic consequences for the health services and for society as a whole.

APN-physician collaboration in caring for women with high-risk pregnancies

PURPOSE

To examine: (a) frequency and focus of APN-physician collaborations in a clinical trial in which half of physician prenatal care for women with high-risk pregnancies was substituted with APN prenatal care delivered in women's homes; and (b) characteristics of women requiring greater numbers of collaborations.

DESIGN AND METHODS

Descriptive study with secondary analysis of data from 83 of the original trial's 85 intervention participants followed by APNs prenatally through 8 weeks postpartum. APN practices, recorded in logs, included APN interactions with the women and the physician, and type of APN contact (e.g., home visit, telephone call). Each APN-physician collaboration was coded for type, timing, and focus.

FINDINGS

Total number of APN-physician collaboration contacts was 351, with a mean of 4.5 and a range of 1 to 16 per woman. Focus of collaborations was: status updates (59%), new physical findings (21%), change in treatment (8%), patient concerns (7%) and medication adjustment (5%). No significant differences in numbers of collaborations were found according to age, primary diagnosis, marital status, type of health insurance, race, or income. Women with high school education received more collaborations than did those not completing high school or those with some postsecondary education. Prenatally, women with a first pregnancy required more collaborations than did multipara participants.

CONCLUSIONS

Most APN-physician collaborative contacts were focused on monitoring women's physical and emotional status and discussing new physical findings. These collaborations were important in the original trial's successful pregnancy and infant outcomes and savings in health care dollars.

Cost-effectiveness analysis of Malaysian neonatal intensive care units

OBJECTIVE

To perform a cost-effective analysis on the care of infants between 1000 and 1500 g birthweight (the study group), where outcomes are measured as survival to 1 year of age.

METHODOLOGY

This was a multicenter observational study to determine the outcome, cost and cost-effectiveness of neonatal intensive care provided by Ministry of Health (MOH) Pediatric services. A total of 333 patients enrolled were eligible for analysis according to the inclusion and exclusion criteria of this study.

RESULTS

Overall survival probability of the study group infants at 1 year of age was 78%. Survival at 1-year of age was 77% for infants with birth weight 1000 to 1249 g, 79% for 1250 to 1499 g. Survival at 1 year of age for the sample group was 53% for 22 to 27 weeks gestation, 80% for 28 to 36 weeks. The average cost-effectiveness ratio (CER) of neonatal intensive care for the study group infants was US$3979 [corrected] per survivor at 1 year of age (95% confidence interval US$3411, 5160).

CONCLUSION

There was variability in the outcome and cost-effectiveness between the neonatal units, which need to be further assessed. However, neonatal intensive care services provided for the study group infants were cost-effective compared to that in developed countries.