Roundtable: survival and outcome of the extremely low-birthweight infant

The prediction and cost of futility in the NICU

AIM

To quantify the cost and prediction of futile care in the Neonatal Intensive Care Unit (NICU).

METHODS

We observed 1813 infants on 100,000 NICU bed days between 1999 and 2008 at the University of Chicago. We determined costs and assessed predictions of futility for each day the infant required mechanical ventilation.

RESULTS

Only 6% of NICU expenses were spent on nonsurvivors, and in this sense, they were futile. If only money spent after predictions of death is considered, futile expenses fell to 4.5%. NICU care was preferentially directed to survivors for even the smallest infants, at the highest risk to die. Over 75% of ventilated NICU infants were correctly predicted to survive on every day of ventilation by every caretaker. However, predictions of 'die before discharge' were wrong more than one time in three. Attendings and neonatology fellows tended to be optimistic, while nurses and neonatal nurse practitioners tended to be pessimistic.

CONCLUSIONS

Criticisms of the expense of NICU care find little support in these data. Rather, NICU care is remarkably well targeted to patients who will survive, particularly when contrasted with care in adult ICUs. We continue to search for better prognostic tools for individual infants.

Economics of prematurity in the era of managed care

Both the acute intensive care of premature infants and the management of their long-term medical and educational sequelae are costly. Because neonatal intensive care is very effective in reducing mortality, however, its cost effectiveness as described previously is actually quite favorable when compared with other well-accepted medical interventions, such as coronary artery bypass grafting and renal dialysis. This article has highlighted the relatively scant literature on which those estimates of costs and cost effectiveness of both neonatal intensive care and its component interventions rest. This is particularly true with respect to long-term resource use by graduates of NICUs. Without such information, we cannot hope to allocate resources in a way that ensures optimal care of this vulnerable population.

The impact of fetal compromise on outcome at the border of viability

OBJECTIVE

Our goal was to evaluate the impact of fetal compromise on the outcome of borderline viable babies.

STUDY DESIGN

All 142 babies born in our hospital from 1990 to 1995 with a gestational age of 23 to 25 weeks were included. Fetal compromise was considered present if one of the following was documented: a major anomaly, congenital sepsis, chronic intrauterine infection, intrauterine drug exposure, congenital anemia, severe growth restriction, fetal acidosis, or cardiorespiratory and neurologic depression in the delivery room.

RESULTS

The 43 babies who had at least one cause of fetal compromise had a lower birth weight (p < 0.001), but there were no other differences in demographics or complications of prematurity. The survival rate was significantly better for babies free of fetal compromise (75% vs 33%, p < 0.001), particularly for babies born at 23 weeks of gestation (75% vs 6%, p < 0.001). For surviving babies free of fetal compromise, the outcome at 23 weeks was comparable to that at 24 to 25 weeks for major causes of long-term neurologic morbidity.

CONCLUSIONS

Like advancing gestational age and increasing birth weight, the absence of fetal compromise has a major beneficial impact on the outcome of borderline viable babies that might be important when decisions are made about the appropriate level of support.

Restricting access to neonatal intensive care: effect on mortality and economic savings

OBJECTIVE

Neonatal intensive care for very low birth weight (VLBW) infants is expensive, and cost-containment policies have been proposed that would restrict care according to birth weight. We examined the potential reduction in neonatal intensive care unit (NICU) VLBW charges and the impact on survivors if care were not offered to infants of extremely low birth weights or gestational ages.

DESIGN

We reviewed hospital charges for a retrospective cohort of VLBW infants born during the 5-year period from 1988 to 1992. Local charges and survival statistics were applied to national VLBW birth statistics to estimate the national effects of a birth weight-based rationing program.

SETTING

A high-risk perinatal referral center.

PATIENTS

A consecutive sample of 1361 VLBW infants was tracked from birth to discharge home, transfer to a level II nursery, or death.

MAIN OUTCOME MEASURES

Hospital charges and survival.

RESULTS

Mean charges per survivor ranged from $250 654 for infants weighing <500 g to $74 101 for those weighing 1000 to 1500 g. Policies denying care to infants born at <500, 600, or 700 g would lead to total NICU care savings of 0.8%, 3.2%, and 10.3%, respectively. Applying the local birth weight-specific survival rates, such policies applied nationally would not have offered care to 136, 575, and 2689 potential survivors annually. Birth weight-based rationing schemes also are shown to increase further the racial disparity of NICU deaths.

CONCLUSIONS

To attain significant reduction in NICU charges, policies offering care to the larger or more mature VLBW infants only will result in denying care to many infants who would otherwise survive.

Parents' experience surrounding the death of a newborn whose birth is at the margin of viability

OBJECTIVE

To describe the experience of parents surrounding the death of a newborn weighing less than 500 g at birth.

DESIGN

Descriptive, using an eidetic phenomenologic approach.

SETTING

Interviews were conducted in the parents' homes or by telephone between 4 and 15 weeks after the loss.

PARTICIPANTS

Eight parents (five mothers and three of their husbands) who had experienced the death of a newborn weighing less than 500 g at birth.

MAIN OUTCOME MEASURES

The lived parental experience of the death of a newborn consists of a number of parental processes, responses, and activities that occur over time.

RESULTS

Five themes were generated from the data: (a) realization that the loss is occurring; (b) initial response to the loss; (c) decision making at the time of the loss; (d) components of supportive relationships with others; and (e) the adjustment at home.

CONCLUSIONS

The findings demonstrate the unique experience of having a newborn who is born at the margin of viability and support the need for individualized, caring-based interventions for parents.

Mixed blessings: an essay

It has been 12 years since Robert and Peggy Stinson chronicled the brief life of their prematurely born son in The Long Dying of Baby Andrew. Their story examined the ethical dilemmas involved in providing neonatal intensive care to marginally viable infants. Although much has changed in neonatal intensive care in 12 years time, issues regarding treatment of marginal infants remain unresolved. Further, neonatal intensive care has provided society a window through which to observe the growing fetus, with potentially profound implication for women's reproductive decision-making. The unintended and unanticipated consequences of neonatal intensive care are examined according to Roger's change model, as described in his book Diffusion of Innovations.