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Increasing the survival of extremely-immature (24- to 28-weeks' gestation) infants--at what cost?
L W Doyle1, L J Murton, W H Kitchen
1Department of Obstetrics and Gynaecology, University of Melbourne, Parkville.
Insights
Positive-pressure assisted ventilation improved neonatal survival, but costs increased disproportionately for extremely premature infants. Further resource increases yielded diminishing returns, making intensive care less cost-effective for very low birth weight neonates.
Area of Science:
- Neonatal intensive care
- Perinatal medicine
- Health economics
Background:
- Positive-pressure assisted ventilation (PPV) use increased survival for neonates born between 24-28 weeks gestation starting in the 1970s.
- Improvements in survival and resource consumption were not linear, necessitating cost-effectiveness analysis.
Purpose of the Study:
- To evaluate the cost-effectiveness of neonatal intensive care (NIC) for extremely premature infants (24-28 weeks gestation) over different eras of assisted ventilation resource utilization.
Main Methods:
- Comparative analysis of patient-days and total nursery resources consumed per survivor.
- Calculation of cost-effectiveness (cost per additional survivor) during two distinct periods: 1977-1983 and 1984-1986, compared to 1971-1974.
Main Results:
- During 1977-1983, NIC cost $62,268 per additional survivor. Infants at 24 weeks gestation required 14.4 times more ventilation and 4.9 times more resources than those at 28 weeks.
- Post-1983, resource consumption doubled, but survival gains diminished. The cost per additional survivor rose to $99,574 (60% increase).
Conclusions:
- Increasing resources for assisted ventilation alone may become less cost-effective for improving survival in the most immature neonates.
- Further improvements in survival for extremely premature infants may require strategies beyond solely increasing assisted ventilation resources.
Abstract:
In one tertiary perinatal centre, the advent of positive-pressure assisted ventilation in the 1970s improved the survival of neonates of 24 to 28 completed weeks of gestation. However, the rate of increase in the resources for assisted ventilation and the improvements in survival rates were stepwise and not smooth. Consequently, it has been possible to calculate the cost-effectiveness of neonatal intensive care up to the time of hospital discharge over two separate eras of stable consumption of resources for assisted ventilation. During 1977-1983, to produce one survivor at 24-weeks' gestation compared with one at 28-weeks' gestation consumed 14.4-times the number of patient-days of assisted ventilation, and 4.9-times more of the total nursery resources; the cost-effectiveness of intensive care during this period decreased with decreasing maturity. The over-all cost-effectiveness up to the time of hospital discharge for infants of 24- to 28-weeks' gestation during 1977-1983, compared with 1971-1974, when assisted ventilation was rare, was $62,268 per additional survivor. After 1983, the consumption of resources for assisted ventilation more than doubled in infants of 24- to 28-weeks' gestation. However, there was a diminishing return with respect to the gains in survival during 1984-1986 and the costs per additional survivor averaged $99,574, which was 60% more than were those for 1977-1983. We speculate that to improve survival further in the most-immature infants by increasing resources for assisted ventilation only can be more difficult and more expensive, and even less cost-effective.
