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Restricting access to neonatal intensive care: effect on mortality and economic savings
1Joint Program in Neonatology, Harvard Medical School, Boston, Massachusetts 02215, USA.
Insights
Restricting neonatal intensive care (NICU) for very low birth weight (VLBW) infants based on weight would deny care to potential survivors. Such policies offer minimal cost savings while increasing racial disparities in NICU deaths.
Area of Science:
- Neonatal Medicine
- Healthcare Economics
- Public Health Policy
Background:
- Neonatal intensive care for very low birth weight (VLBW) infants is a significant financial burden.
- Cost-containment policies have been proposed, including restricting care based on birth weight.
- The ethical and practical implications of such rationing require careful examination.
Purpose of the Study:
- To evaluate the potential reduction in neonatal intensive care unit (NICU) charges for VLBW infants.
- To assess the impact on infant survivors if care is restricted based on extremely low birth weights or gestational ages.
- To analyze the national implications of birth weight-based rationing programs.
Main Methods:
- Retrospective cohort study of VLBW infants (1988-1992).
- Analysis of hospital charges and survival statistics.
- Application of local data to national VLBW birth statistics to model rationing effects.
Main Results:
- Mean charges per survivor varied significantly by birth weight, from $250,654 (<500g) to $74,101 (1000-1500g).
- Denying care to infants <500g, <600g, or <700g would yield NICU savings of 0.8%, 3.2%, and 10.3%, respectively.
- Nationally, these policies could deny care to 136, 575, or 2689 potential survivors annually and exacerbate racial disparities in NICU mortality.
Conclusions:
- Significant reductions in NICU charges through birth weight-based rationing would deny care to numerous infants who would otherwise survive.
- Policies prioritizing larger or more mature VLBW infants for NICU care have substantial ethical and survival-related drawbacks.
- The study highlights the trade-offs between cost containment and equitable access to life-saving neonatal care.
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.