Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants

Economic Analysis of Induction versus Elective Cesarean in Term Nulliparas with Supermorbid Obesity

OBJECTIVE

 We sought to evaluate the economic benefit of the induction of labor compared with elective cesarean delivery in individuals with supermorbid obesity (body mass index 60 kg/m2 or greater) at term.

STUDY DESIGN

 We developed an economic analysis model to compare induction of labor with elective cesarean delivery in nulliparous individuals with supermorbid obesity at term. The primary outcome was the total cost per strategy from a health system perspective with elective cesarean delivery as a reference group. Pregnancy outcomes for the index and subsequent pregnancies were considered. When available, probabilities of pregnancy outcomes were extracted from our institutions. Rare pregnancy outcomes, relative risks, and costs were derived from the literature. All costs in this analysis were inflated to 2022 USD (U.S. dollar). To determine the robustness of the decision model, we conducted one-way sensitivity analyses by changing point estimates of variables. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation repeating 1,000 times to test the robustness of the results in the setting of simultaneous changes in probabilities, relative risks, and costs.

RESULTS

 In the base-case analysis, assuming that 72.7% of nulliparous individuals undergoing induction of labor would have a cesarean delivery, induction of labor would cost $41,084 compared with $40,742 for elective cesarean delivery, resulting in a higher cost of $342 per nulliparous individuals with supermorbid obesity. In a sensitivity analysis, we found that induction of labor compared with elective cesarean is less economical if the probability of cesarean delivery after induction of labor exceeds 71%. Monte Carlo simulation suggests that elective cesarean delivery was the preferred cost-beneficial strategy with a frequency of 53.5%.

CONCLUSION

Among our patient population, induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals with supermorbid obesity.

KEY POINTS

· The prevalence of obesity in the United States continues to rise.. · Morbid obesity compared with normal weight is associated with increased risks of adverse pregnancy outcomes.. · Induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals..

Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis

BACKGROUND

Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants.

OBJECTIVE

This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery.

STUDY DESIGN

A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies.

RESULTS

Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy.

CONCLUSION

The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.

Fetoscopic Laser Ablation of Type II Vasa Previa: A Cost Benefit Analysis

OBJECTIVE

We aimed to compare costs of two strategies for third-trimester type II vasa previa management: (1) fetoscopic laser ablation surgery (FLS) referral and (2) standard management (SM).

STUDY DESIGN

A decision analytic model and cost-benefit analysis from a health care perspective were performed. The population included patients with type II vasa previa at approximately 32 weeks. SM entailed 32-week antepartum admission and cesarean at approximately 35 weeks. FLS referral included consultation and possible laser surgery at 32 weeks for willing/eligible candidates. Successful laser surgery allowed the possibility of term vaginal delivery. Outcomes included antepartum admission, preterm birth, cesarean, neonatal transfusion, and death. Sensitivity analyses were performed.

RESULTS

In base case analysis, FLS referral was cost saving compared with SM (total cost per patient $65,717.10 vs. 71,628.16). FLS referrals yielded fewer antepartum admissions, cesareans, premature births, neonatal transfusions, and deaths. Eligible referred patients choosing FLS incurred a total cost of $41,702.46, a >40% decrease compared with SM. FLS referral was cost saving in all one-way sensitivity analyses except when antepartum admission costs were low. In threshold analyses, FLS referral was cost saving unless laser surgery cost was >$39,892 (2.75x expected cost), antepartum admission cost for monitoring of vasa previa or ruptured membranes was <$7,455, <11% patients were eligible for laser surgery, and when <12% of eligible patients chose laser surgery. In two-way sensitivity analysis, FLS referral was cost saving except at very high laser surgery costs and extremely low antepartum admission costs.

CONCLUSION

Referral for FLS for type II vasa previa was cost saving and improved outcomes compared with SM, despite upfront costs, fetoscopy-related risks, and many patients being ineligible or not opting for surgery after referral.

KEY POINTS

· Vasa previa rupture may lead to fetal exsanguination and death.. · Late preterm cesarean is common practice for prenatally diagnosed vasa previa.. · Successful fetoscopic laser ablation for type II vasa previa has been described.. · Laser ablation of vasa previa allows for a safe-term vaginal delivery.. · Referral for laser surgery is cost saving and is associated with improved outcomes..

Treating Mild Chronic Hypertension During Pregnancy: A Cost-Effectiveness Analysis

OBJECTIVE

To assess the cost effectiveness of targeting a blood pressure of less than 140/90 mm Hg compared with 160/105 mm Hg.

METHODS

A decision-analytic model was constructed to compare the treatment of chronic hypertension in pregnancy at mild-range blood pressures (140/90 mm Hg) with the treatment of chronic hypertension before 20 weeks of gestation at severe-range blood pressures (160/105 mm Hg) in a theoretical cohort of 180,000 patients with mild chronic hypertension. Probabilities, costs, and utilities were derived from literature and varied in sensitivity analyses. Primary outcomes included incremental cost per quality-adjusted life-year (QALY), cases of preeclampsia, preeclampsia with severe features, severe maternal morbidity (SMM), preterm birth, maternal death, neonatal death, and neurodevelopmental delay. The cost-effectiveness threshold was $100,000 per QALY.

RESULTS

Treating chronic hypertension in a population of 180,000 pregnant persons at mild-range blood pressures, compared with severe-range blood pressures, resulted in 14,177 fewer cases of preeclampsia (43,953 vs 58,130), 11,835 of which were cases of preeclampsia with severe features (40,530 vs 52,365). This led to 817 fewer cases of SMM (4,375 vs 5,192), and 18 fewer cases of maternal death (102 vs 120). Treating at a lower threshold also resulted in 8,078 fewer cases of preterm birth (22,000 vs 30,078), which led to 26 fewer neonatal deaths (276 vs 302) and 157 fewer cases of neurodevelopmental delay (661 vs 818). Overall, treating chronic hypertension at a lower threshold was a dominant strategy that resulted in decreased costs of $600 million and increased effectiveness of 12,852 QALYs.

CONCLUSION

Treating chronic hypertension at a threshold of mild-range blood pressures is a dominant (lower costs, better outcomes) and cost-effective strategy that results in fewer neonatal and maternal deaths compared with the standard treatment of treating at severe range blood pressures.

Universal Fetal Echocardiography for Pregestational Diabetes Mellitus: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost effectiveness of universal fetal echocardiogram for patients with pregestational diabetes mellitus by first-trimester hemoglobin A1c (Hb A1c) level.

METHODS

We developed a cost-effectiveness model comparing two strategies of screening for critical fetal congenital heart disease among patients with diabetes: universal fetal echocardiogram and fetal echocardiogram only after abnormal findings on detailed anatomy ultrasonogram. We excluded ventricular septal defect, atrial septal defects, and bicuspid aortic valve from the definition of critical fetal congenital heart disease. Probabilities and costs were derived from the literature. We used individual models to evaluate different scenarios: first-trimester Hb A1c lower than 6.5%, Hb A1c 6.5-9.0%, and Hb A1c higher than 9.0%. Primary outcomes included fetal death, neonatal death, and false-positive and false-negative results. A cost-effectiveness threshold was set at $100,000 per quality-adjusted life-year. Univariable sensitivity analyses were performed to investigate the drivers of the model.

RESULTS

Universal fetal echocardiogram is not cost effective except for when first-trimester Hb A1c level is higher than 9.0% (incremental cost-effectiveness ratio $638,100, $223,693, and $67,697 for Hb A1c lower than 6.5%, 6.5-9.0%, and higher than 9.0%, respectively). The models are sensitive to changes in the probability of congenital heart disease at a given Hb A1c level, as well as the cost of neonatal transfer to a higher level of care. Universal fetal echocardiogram became both cost saving and more effective when the probability of congenital heart disease reached 14.48% (15.4 times the baseline risk). In the Monte Carlo simulation, universal fetal echocardiogram is cost effective in 22.7%, 48.6%, and 62.3% of scenarios for each of the three models, respectively.

CONCLUSION

For pregnant patients with first-trimester Hb A1c levels lower than 6.5%, universal fetal echocardiogram was not cost effective, whereas, for those with first-trimester Hb A1c levels higher than 9.0%, universal fetal echocardiogram was cost effective. For those with intermediate Hb A1c levels, universal fetal echocardiogram was cost effective in about 50% of cases; therefore, clinical judgment based on individual patient values, willingness to pay to detect congenital heart disease, and resource availability needs to be considered.

Quality, outcome, and cost of care provided to very low birth weight infants in California

OBJECTIVE

To examine association of costs with quality of care and patient outcome across hospitals in California.

METHODS

Retrospective study of very low birth weight (VLBW) births from 2014-2018 linking birth certificate, hospital discharge records and clinical data. Quality was measured using the Baby-MONITOR score. Clinical outcome was measured using survival without major morbidity (SWMM). Hierarchical generalized linear models, adjusting for clinical factors, were used to estimate risk-adjusted measures of costs, quality, and outcome for each hospital. Association between these measures was evaluated using Pearson correlation coefficient.

RESULTS

In total, 15,415 infants from 104 NICUs were included. Risk-adjusted Baby-MONITOR score, SWMM rate, and costs varied substantially. There was no correlation between risk-adjusted cost and Baby-MONITOR score (r = 0, p = 0.998). Correlation between risk-adjusted cost and SWMM rate was inverse and not significant (r = -0.07, p = 0.48).

CONCLUSIONS

With the metrics used, we found no correlation between cost, quality, and outcomes in the care of VLBW infants.

The Hassan Neonatal Morbidity Composite Scale and Neonatal Length of Stay-A Validation Study

OBJECTIVE

Obstetric studies often report neonatal morbidity as a composite score. Composite scores can simplify data analysis when multiple outcomes of interest are present and allows researchers to conduct smaller, more manageable trials. The Hassan scale is a neonatal morbidity composite scale that assigns high scores to infants with multiple morbidities and low scores to infants without or with single morbidities. The objective of this study was to validate the association between scores on the Hassan scale and neonatal intensive care unit (NICU) length of stay STUDY DESIGN:  We conducted a cohort study of all infants born between 22 and 366/7 weeks' gestation and cared for within 419 neonatal units in the Pediatrix Medical Group between 1997 and 2018. Each infant was assigned a Hassan's score based on the number of neonatal morbidity events that occurred during the delivery hospitalization. The association between Hassan's scores and neonatal length of stay was evaluated using linear regression. Multivariable models were constructed to determine if the Hassan score was independently associated with neonatal length of stay.

RESULTS

There were 760,037 infants included. The median (interquartile range [IQR]) gestational age of delivery was 34 (31, 35) weeks and the median (IQR) birth weight at delivery was 2,000 (1,503, 2,430) g. The median length of stay for infants discharged home was 17 (10-33) days. A Hassan's score was able to be assigned to 699,206 (92%) patients. Neonatal morbidities included in the Hassan scale were more common among infants born earlier in gestation. On adjusted analysis, the Hassan scale was found to be independently associated with neonatal length of stay (p < 0.001, coefficient = 10.4 days [95% confidence interval (CI): 10.3, 10.4 days]) with higher scores associated with longer lengths of stay.

CONCLUSION

The Hassan scale, more than a binary composite score, is able to differentiate preterm infants with prolonged hospitalizations from those with short hospitalizations.

KEY POINTS

· The Hassan scale is an independent predictor of neonatal length of stay.. · Classification of infants based on number of morbidities correlates with neonatal length of stay.. · The Hassan scale provided better discrimination than binary composite morbidity scores.. · The Hassan scale may be an economic predictor of health-related costs..

Optimal timing of delivery for growth restricted fetuses with gastroschisis: A decision analysis

OBJECTIVE

Our objective was to determine the optimal timing of delivery of growth restricted fetuses with gastroschisis in the setting of normal umbilical artery (UA) Dopplers.

METHODS

We designed a decision analytic model using TreeAge software for a hypothetical cohort of 2000 fetuses with isolated gastroschisis, fetal growth restriction (FGR), and normal UA Dopplers across 34-39 weeks of gestation. This model accounted for costs and quality adjusted life years (QALYs) for the pregnant individual and the neonate. Model outcomes included stillbirth, respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), short gut syndrome (SGS), neonatal sepsis, neonatal death, and neurodevelopmental disability (NDD).

RESULTS

We found 38 weeks to be the optimal timing of delivery for minimizing overall perinatal mortality and leading to the highest total QALYs. Compared to 37 weeks, delivery at 38 weeks resulted in 367.98 more QALYs, 2.22 more cases of stillbirth, 2.41 fewer cases of RDS, 0.02 fewer cases of NEC, 1.65 fewer cases of IVH, 0.5 fewer cases of SGS, 2.04 fewer cases of sepsis, 11.8 fewer neonatal deaths and 3.37 fewer cases of NDD. However, 39 weeks were the most cost-effective strategy with a savings of $1,053,471 compared to 38 weeks. Monte Carlo analysis demonstrated that 38 weeks was the optimal gestational age for delivery 51.70% of the time, 39 weeks were optimal 47.40% of the time, and 37 weeks was optimal 0.90% of the time.

CONCLUSION

Taking into consideration a range of adverse perinatal outcomes and cost effectiveness, 38-39 weeks gestation is ideal for the delivery of fetuses with gastroschisis, FGR, and normal UA Dopplers. However, there are unique details to consider for each case, and the timing of delivery should be individualized using shared multidisciplinary decision making.

Newborn Outcomes Among Veterans Utilizing VHA Maternity Benefits, 2016-2020

INTRODUCTION

Public Law 111-163 Section 206 of the Caregivers and Veteran Omnibus Health Services Act amended the Veterans Health Administration's (VHA) medical benefits package to include 7 days of medical care for newborns delivered by Veterans. We examined the newborn outcomes among a cohort of women Veterans receiving VHA maternity benefits and care coordination.

MATERIALS AND METHODS

We conducted a secondary analysis of phone interview data from Veterans enrolled in the COMFORT (Center for Maternal and Infant Outcomes Research in Translation) study 2016-2020. Multivariable regression estimated associations with newborn outcomes (preterm birth; low birthweight).

RESULTS

During the study period, 829 infants were born to 811 Veterans. Mothers reported "excellent health" for 94% of infants. The prevalence of preterm birth was slightly higher in our cohort (11% vs. 10%), as were low birthweight (9%) deliveries, compared to the general population (8.28%). Additionally, 42% of infants in our cohort required follow-up care for non-routine health conditions; 11% were uninsured at 2 months of age. Adverse newborn outcomes were more common for mothers who were older in age, self-identified as non-white in race and/or of Hispanic ethnicity, had a diagnosis of posttraumatic stress disorder, or had gestational comorbidities.

CONCLUSIONS

The current VHA maternity coverage appears to be an effective policy for ensuring the well-being and health care coverage for the majority of Veterans and their newborns in the first days of life, thereby reducing the risk of inadequate prenatal and neonatal care. Future research should examine costs associated with extending coverage to 14 days or longer, comparing those to the projected excess costs of neonatal health problems. VHA policy should continue to support expanding care and resources through the Maternity Care Coordinator model.

Universal Tetanus-Diphtheria-Pertussis Vaccination During Pregnancy: A Cost-Effectiveness Analysis

OBJECTIVE

To assess the cost effectiveness of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination in pregnant patients in the United States.

METHODS

A decision-analytic model in TreeAge was developed to compare universal Tdap vaccination in pregnancy with no Tdap vaccination in pregnancy using a theoretical cohort of 3.66 million pregnant individuals, the approximate number of deliveries per year in the United States. Outcomes included infant pertussis infections, infant hospitalizations, infant encephalopathy cases, infant deaths, and maternal pertussis infections. All probabilities and costs were derived from the literature. Utilities were applied to discounted life expectancies at a rate of 3% to generate quality-adjusted life-years (QALYs). A strategy was considered cost effective if it had an incremental cost-effectiveness ratio of less than $100,000 per QALY. Univariable and multivariable sensitivity analyses were performed to assess the robustness of the model to changes in the baseline assumptions.

RESULTS

With a baseline assumption of vaccine cost at $47.75, Tdap vaccination was cost effective at $7,601 per QALY. The vaccination strategy was associated with a decrease of 22 infant deaths, 11 infant encephalopathy cases, 2,018 infant hospitalizations, 6,164 infant pertussis infections, and 8,585 maternal pertussis infections, with an increase of 19,489 QALYs. In sensitivity analyses, the strategy was cost effective until the incidence of maternal pertussis became lower than 1.6 cases per 10,000 individuals, the cost of the Tdap vaccine was greater than $540, or previous pertussis immunity was present in more than 92.1% of pregnant individuals.

CONCLUSION

In a theoretical U.S. cohort of 3.66 million pregnant individuals, Tdap vaccination during pregnancy is cost effective and reduces infant morbidity and mortality compared with no vaccination during pregnancy. These findings are especially relevant given that approximately half of individuals are not vaccinated during pregnancy and recent data have shown that postpartum maternal vaccination and cocooning strategies are ineffective. Public health strategies to encourage greater uptake of Tdap vaccination should be used to reduce the morbidity and mortality of pertussis infection.

Universal First-Trimester Cytomegalovirus Screening and Valaciclovir Prophylaxis in Pregnant Persons: A Cost-Effectiveness Analysis

BACKGROUND

Recent studies suggest a possible benefit of valaciclovir prophylaxis to prevent vertical transmission after a positive serologic screen for primary maternal cytomegalovirus infection during pregnancy, although its cost-effectiveness remains uncertain.

OBJECTIVE

We sought to determine the circumstances under which universal first-trimester maternal serologic screening for maternal cytomegalovirus infection, with valaciclovir prophylaxis to prevent congenital cytomegalovirus, is cost-effective.

STUDY DESIGN

We performed a decision analysis from the perspective of the pregnant person to assess whether universal maternal screening in the first trimester, with subsequent valaciclovir prophylaxis (8g/day from time of positive serologic screen for primary maternal cytomegalovirus infection through 21 weeks' gestation) for those who are acutely infected, is cost-effective compared to usual care (i.e., no routine serologic screening, but amniocentesis if mid-trimester sonographic findings suggest cytomegalovirus). For baseline estimates, we assumed a 35% risk of congenital cytomegalovirus after primary maternal infection and a 71% risk reduction with valaciclovir. We varied valaciclovir's efficacy to identify whether and at what threshold universal screening would be estimated to be cost-effective, compared to usual care. Monte Carlo analyses were performed. A willingness-to-pay threshold of $100,000/quality-adjusted life year was used to define cost-effectiveness.

RESULTS

Under base-case estimates, first-trimester universal screening and valaciclovir prophylaxis for seropositive pregnant persons with acute cytomegalovirus infection is not cost-effective, with a cost of $137,854 per maternal QALY, but results in 14 fewer cytomegalovirus-affected children per 100,000 pregnancies compared to usual care. In one-way sensitivity analysis, universal screening and treatment is estimated to be the cost-effective strategy if the incidence of primary maternal cytomegalovirus infection exceeds 2.6%, baseline risk of vertical transmission of cytomegalovirus without prophylaxis is greater than 36.8%, and the risk reduction of vertical transmission of cytomegalovirus with valaciclovir prophylaxis exceeds 75.9%. In Monte Carlo analyses, first-trimester universal serologic screening with valaciclovir prophylaxis is estimated to be the cost-effective strategy in 46.8% of runs.

CONCLUSION

Universal first-trimester serologic screening with valaciclovir prophylaxis is not the cost-effective strategy for antenatal management of cytomegalovirus under the base-case estimates. Although universal screening is cost-effective in certain circumstances when the efficacy of valaciclovir exceeds the base case, that result is not robust to variation of estimates across their reasonable ranges. These data can inform future studies to evaluate screening and treatment to prevent congenital CMV.

Postpartum Health Experiences of Women with Newborns in Intensive Care: The Desire to Be by the Infant Bedside as a Driver of Postpartum Health

INTRODUCTION

Women with infants in a neonatal intensive care unit (NICU) encounter multiple challenges following childbirth, including greater burden of chronic disease and increased risk for depression, compared with women with well infants. At the same time, they are confronted with the trauma of a hospitalized infant while also managing their postpartum recovery. Limited research exists describing the health needs of these women, despite the many numbers living this experience daily. This study aimed to better understand postpartum health needs of women with infants in the NICU in the 90 days following birth and to propose actionable system improvements to address identified needs.

METHODS

The authors conducted in-depth individual interviews with 50 postpartum women of infants admitted to the NICU at a quaternary care hospital. Eligible women were aged at least 18 years, spoke English or Spanish, and had infants in the NICU longer than 3 days. Interview topics included NICU experience, recommended and desired health care, and suggestions for improvement. Interviews were audiotaped and transcribed verbatim. The authors used qualitative description techniques including memo-writing, coding, matrices, diagramming, and team discussion to analyze the data.

RESULTS

Women reported significant intrapartum health conditions and concerns (eg, preeclampsia, emergency cesarean birth, anxiety) and described unmet social, emotional, mental, and physical health needs. Unmet practical needs while in the NICU (eg, a place to rest, affordable parking, access to food, childcare) caused considerable burden. Despite disease burden and emergent health needs, few women reported regular monitoring of their postpartum health by maternal health care providers. Women frequently minimized and delayed care for their health needs so as to remain by the infant bedside.

DISCUSSION

Women with infants in the NICU would benefit from patient-centered care that provides greater attention to their postpartum health and recovery while also supporting their drive to remain close to their hospitalized infant.

Safety and efficacy of a home nasogastric monitoring program for premature infants

BACKGROUND

A novel home monitoring program, in which premature infants are cared for at home with a nasogastric tube in place prior to achievement of full oral feeding, was evaluated. The program combines a digital, fully EMR-integrated, virtual daily rounding platform with direct provider video and telephone contact.

METHODS

A case-control study was performed evaluating infants <  34 weeks' gestation who were followed in our program. A historical control group, was created by matching 2 : 1 based on gestational age±6 days, retroactively.

RESULT

15 patients discharged in the program were compared with 30 controls. The home cohort gained an average of 30 g/day compared with the in-hospital group at 27g/day (p = 0.325). The home group required a mean of 5.9±2.9 days to full oral feeding once discharged, not different from the control group at 5.4±3.7 days (p = 0.606). The percentage of oral feeds for the home cohort, however, increased at a rate of 12.2%before discharge compared to rising 57%at home (p <  0.001). The control group spent an additional 8.1±3.9 days in the hospital after reaching criteria. There were no reported adverse events or readmissions.

CONCLUSION

Premature infants can safely advance oral feeds using a home monitoring program. While at home, infants gained weight similarly to their inpatient controls inpatient, yet gained full oral skills at a significantly faster rate compared to when they were in the hospital.

Fetoscopic compared with open repair of myelomeningocele: a 2-delivery cost-effectiveness analysis

BACKGROUND

Recent studies have compared maternal and neonatal outcomes associated with fetoscopic surgical approach for repair of myelomeningocele compared with an open approach.

OBJECTIVE

In this study, we compared the cost-effectiveness of these techniques in the setting of a woman seeking future pregnancies.

STUDY DESIGN

A decision-analytical model using TreeAge software was designed to compare the costs and outcomes of fetoscopic vs open repair in patients with prenatally diagnosed myelomeningocele. We assumed a theoretical cohort of 500 women with a pregnancy affected by myelomeningocele planning to have a future pregnancy. Our model accounted for costs and quality-adjusted life years of the woman, the neonate with myelomeningocele, and the neonate in a subsequent pregnancy. Neonatal outcomes from the incident pregnancy included motor function >2 levels better than the anatomic level, motor function <2 levels better than the anatomic level, and same motor function as the anatomic level, preterm birth in the index pregnancy, neonatal death in the index pregnancy, and major neurodevelopmental disability as a result of preterm birth in the index pregnancy. Neonatal outcomes in the subsequent pregnancy included stillbirth, preterm birth, and neonatal and major neurodevelopmental disability as a result of preterm birth. Probabilities were derived from the literature, and we used a willingness-to-pay threshold of $100,000 per quality-adjusted life year.

RESULTS

In the index pregnancy, fetoscopic surgical technique resulted in 140 fewer cases of preterm birth and fewer cases of neurodevelopmental disability and neonatal death. Fetoscopic technique resulted in 130 more cases of functional level >2 levels better than the anatomic level, 35 fewer cases of functional level >2 levels worse than the anatomic level, and 107 fewer cases of function same as the anatomic level. In the subsequent pregnancy, fetoscopic surgery led to 22 fewer cases of delivery complications (uterine dehiscence, uterine rupture, and excessive bleeding), 24 fewer cases of stillbirth, and 22 fewer cases of preterm birth. Although the fetoscopic approach was more costly, it was cost-effective with an incremental cost-effectiveness ratio of $1029 per quality-adjusted life year in our theoretical cohort of 500 patients. Monte Carlo probabilistic sensitivity analysis showed that fetoscopic technique is cost-effective 100% of the time.

CONCLUSION

In our theoretical cohort, the fetoscopic approach was more costly, but resulted in improved outcomes when a subsequent pregnancy was considered.

When is My Baby Going Home? Moderate to Late Preterm Infants are Discharged at 36 Weeks Based on Admission Data

OBJECTIVE

This study evaluates the effect of admission characteristics of uncomplicated moderate to late preterm infants on timing of discharge. One of the first questions that families of infants admitted to the Neonatal Intensive Care Unit (NICU) ask is, "When is my baby going home?" Moderate to late preterm infants are the largest cohort of NICU patients but little data exist about their length of stay (LOS).

STUDY DESIGN

A retrospective electronic chart review was completed on 12,498 infants admitted to our NICU between January 1, 2009 and December 31, 2015. All inborn infants with a gestational age between 32^0/7 and 36^6/7 weeks were studied.

RESULTS

A total of 3,240 infants met our inclusion criteria. The mean postmenstrual age at discharge was 36^3/7 weeks. Infants who were small for gestational age were significantly more likely to have an increased LOS. Infants born between 34 and 36^6/7 weeks had a significantly increased LOS if they had respiratory distress syndrome. Admission diagnoses of neonatal abstinence syndrome, meconium aspiration syndrome, hydrops, hypoxic ischemic encephalopathy, biliary emesis, ABO incompatibly, and a genetic diagnosis all had increased LOS for all late preterm infants.

CONCLUSION

For uncomplicated moderate to late preterm infants, clinicians can counsel families that their infants will likely be discharged at 36 weeks of postmenstrual age. Small for gestational age infants and those with specific diagnoses may stay longer.

Duration of and trends in respiratory support among extremely preterm infants

OBJECTIVE

To evaluate annual trends in the administration and duration of respiratory support among preterm infants.

DESIGN

Retrospective cohort study.

SETTING

Tertiary neonatal intensive care units in the Canadian Neonatal Network.

PATIENTS

8881 extremely preterm infants born from 2010 to 2017 treated with endotracheal and/or non-invasive positive pressure support (PPS).

MAIN OUTCOME MEASURES

Competing risks methods were used to investigate the outcomes of mortality and time to first successful extubation, definitive extubation, weaning off PPS, and weaning PPS and/or low-flow oxygen, according to gestational age (GA). Cox proportional hazards and regression models were fitted to evaluate the trend in duration of respiratory support, survival and surfactant treatment over the study period.

RESULTS

The percentages of infants who died or were weaned from respiratory support were presented graphically over time by GA. Advancing GA was associated with ordinally earlier weaning from respiratory support. Year over year, infants born at 23 weeks were initially and definitively weaned from endotracheal and all PPS earlier (HR 1.06, 95% CI 1.01 to 1.11, for all outcomes), while survival simultaneously increased (OR 1.11, 95% CI 1.03 to 1.18). Infants born at 26 and 27 weeks remained on non-invasive PPS longer (HR 0.97, 95% CI 0.95 to 0.98 and HR 0.97, 95% CI 0.95 to 0.99, respectively). Early surfactant treatment declined among infants born at 24-27 weeks GA.

CONCLUSIONS

Infants at the borderline of viability have experienced improved survival and earlier weaning from all forms of PPS, while those born at 26 and 27 weeks are spending more time on PPS in recent years. GA-based estimates of the duration of respiratory support and survival may assist in counselling, benchmarking, quality improvement and resource planning.

The financial burden on families of infants requiring neonatal intensive care

While the high costs of neonatal intensive care have been a topic of increasing study, the financial impact on families have been less frequently reported or summarized. We conducted a systematic review of the literature using Pubmed/Medline and EMBASE (1990-2020) for studies reporting estimates of out-of-pocket costs or qualitative estimates of financial burden on families during a neonatal intensive care unit stay or after discharge. 44 studies met inclusion criteria, with 25 studies providing cost estimates. Cost estimates primarily focused on direct non-medical out-of-pocket costs or loss of productivity, and there was a paucity of cost estimates for insurance cost-sharing. Available estimates suggest these costs are significant to families, cause significant stress, and may impact care received by patients. More high-quality studies estimating the entirety of out-of-pocket costs are needed, and particular attention should be paid to how these costs directly impact the care of our high-risk population.

Trends in Costs of Birth Hospitalization and Readmissions for Late Preterm Infants

Background: The objective is to study previously unexplored trends of birth hospitalization and readmission costs for late preterm infants (LPIs) in the United States between 2005 and 2016. Methods: We conducted a retrospective analysis of claims data to study healthcare costs of birth hospitalization and readmissions for LPIs compared to term infants (TIs) using a large private insurance database. We used a generalized linear regression model to study birth hospitalization and readmission costs. Results: A total of 2,123,143 infants were examined (93.2% TIs; 6.8% LPIs). The proportion of LPIs requiring readmission was 4.2% compared to 2.1% of TIs, (p < 0.001). The readmission rate for TIs decreased during the study period. LPIs had a higher mean cost of birth hospitalization (25,700 vs. 3300 USD; p < 0.001) and readmissions (25,800 vs. 14,300 USD; p < 0.001). For LPIs, birth hospitalization costs increased from 2007 to 2013, and decreased since 2014. Conversely, birth hospitalization costs of TIs steadily increased since 2005. The West region showed higher birth hospitalization costs for LPIs. Conclusions: LPIs continue to have a higher cost of birth hospitalization and readmission compared to TIs, but these costs have decreased since 2014. Standardization of birth hospitalization care for LPIs may reduce costs and improve quality of care and outcomes.

Cost-effectiveness of influenza vaccination during pregnancy

OBJECTIVE

To assess the cost-effectiveness of influenza vaccination for all pregnant patients in the United States.

METHODS

We designed a cost-effectiveness model to compare outcomes and costs in pregnant patients who received the inactivated, trivalent influenza vaccine to those who did not. We used a theoretical cohort of 4 million patients, the number of individuals giving birth in the United States per year. We assumed that H1N1 and A or B type influenza were of equal incidence based on seasonal variation from the past ten years. Our outcomes include acquiring H1N1, acquiring A or B type influenza, maternal death, stillbirth, infant death, preterm birth, and cerebral palsy in addition to cost and quality-adjusted life years (QALYs). Probabilities were derived from the literature and QALYs generated at a discount rate of 3%. Sensitivity analyses were performed to assess the robustness of our model.

RESULTS

In our theoretical cohort of 4 million pregnant patients, the influenza vaccination strategy was associated with 1632 fewer stillbirths (24,332 in the vaccine strategy vs. 25,964 in the no vaccine strategy), 120 fewer maternal deaths (284 vs. 404), 340 fewer infant deaths (5608 vs. 5948), 32,856 fewer preterm births (403,896 vs. 436,752), and 641 fewer cases of moderate cerebral palsy (12,388 vs. 13,029). Additionally, the vaccination strategy corresponded to savings of $3.7 billion ($63.3 billion vs. $67.0 billion) and increased QALYs of 81,696 (226,852,076 vs 226,770,380). Therefore, it was considered a dominant strategy. Univariate sensitivity analysis demonstrated that the vaccine is cost saving until vaccine cost passes $900, far above the current cost of $12.16. In addition, we used sensitivity analysis to vary seasonal proportions of H1N1 to A or B type influenza. The vaccine was cost saving and increased QALYs for any proportion of H1N1 to A or B type influenza including when H1N1 was absent.

CONCLUSION

We demonstrate that in a cohort of 4 million patients, the influenza vaccine may save $3.7 billion per year, improve maternal and infant outcomes, and reduce morbidity and mortality. Our study provides further evidence that providers should strongly recommend that pregnant patients receive their annual influenza vaccine.

Cost effectiveness of buprenorphine vs. methadone for pregnant people with opioid use disorder

OBJECTIVE

To assess the cost effectiveness of buprenorphine versus methadone in the management of opioid use disorder (OUD) during pregnancy.

METHODS

We designed a decision-analytic model to evaluate the costs and outcomes associated with buprenorphine compared to methadone for pregnant people with OUD. We used a theoretical cohort of 22,400 pregnant people, which is an estimation of pregnancies affected by OUD per year in the United States. Outcomes included maternal retention in maintenance treatment, neonatal opioid withdrawal syndrome, preterm birth, fetal growth restriction, cerebral palsy, and maternal overdose in addition to cost and quality-adjusted life-years (QALYs). We used a willingness-to-pay threshold of $100,000/QALY. All model inputs were derived from the literature and varied in sensitivity analyses to assess the robustness of our baseline inputs.

RESULTS

In our theoretical cohort, treatment of OUD with buprenorphine during pregnancy resulted in 2413 fewer cases of neonatal opioid withdrawal syndrome, 1089 fewer preterm births, 299 fewer cases of fetal growth restriction, 32 fewer stillbirths, and 13 fewer cases of cerebral palsy compared to methadone treatment. Despite lower rates of retention, buprenorphine treatment saved nearly 123 million healthcare dollars and resulted in 558 additional QALYs, making it the dominant strategy compared to methadone treatment. Our findings were robust over a wide range of assumptions.

CONCLUSION

Our data suggest that buprenorphine should be considered a cost effective treatment option for OUD in pregnancy, as it is associated with improved neonatal outcomes compared to methadone despite the risk of treatment discontinuation.

Does late second-trimester cervical length predict unscheduled preterm birth in asymptomatic triplet pregnancies?

OBJECTIVE

Multiple gestation increases the risk of unscheduled preterm birth (PTB), both spontaneous and indicated, leading to increased neonatal morbidity and additional healthcare costs. The purpose of this study was to determine whether cervical length (CL) assessment by 28 weeks could predict unscheduled PTB <34 weeks in triplet pregnancies. Secondary outcomes included prediction of PTB <30 weeks, prediction of PTB based on degree of cervical change and effect of ART-use on PTB.

METHODS

This was a retrospective cohort of women with triplet pregnancies. The exposure variable of interest was short cervix < 25 and <20 millimeters (mm) by 28 weeks. Maternal characteristics were described. The distribution of CLs was analyzed by the primary outcome of unscheduled PTB < 34 weeks, and by PTB <30 weeks (secondary outcome). Gestational age at delivery was compared between women with and without a short cervix. Changes in CL were compared between the groups with unscheduled PTB and those delivering ≥34 and ≥30 weeks. Statistical analyses were performed using appropriate tests.

RESULTS

Of 92 triplet pregnancies, 51 met the criteria, with 1233 total (411 shortest) CL measurements from 16 to 34 weeks' gestation. The overall rate of PTB <34 weeks was 31.4% and <30 weeks was 9.8%. The median gestational age at delivery was 32.7 (IQR 2.3) weeks. There were no statistically significant differences in rates of unscheduled PTB in women who had a short cervix and those that did not: PTB <34 weeks with CL <25 mm (p = .53) and CL <20 mm (p = .70); PTB <30 weeks with CL <25 mm (p = .38) and CL <20 mm (p = .26). The degree of cervical change from 18 to 28 weeks was not statistically significant for predicting unscheduled PTB <34 and <30 weeks. Of 70.6% of triplet pregnancies conceived by ARTs, 13.9% had unscheduled PTB <30 weeks, whereas no spontaneously-conceived pregnancies delivered <30 weeks (p = .14).

CONCLUSION

Short cervix did not predict unscheduled spontaneous PTB <34 weeks nor <30 weeks in our triplet cohort, nor did the degree of cervical change by 28 weeks predict PTB. Triplets conceived by ARTs may have an increased risk of unscheduled PTB.

Hospitalization charges for extremely preterm infants: a ten-year analysis in Shanghai, China

OBJECTIVES

Extreme prematurity exerts a substantial economic burden on families and societies worldwide, especially in developing countries with limited healthcare resources. This study aimed to estimate initial hospitalization charges after extremely preterm birth in China over the previous decade.

METHODS

A retrospective study was conducted in the largest tertiary neonatal intensive care unit in Shanghai, China, including 441 extremely preterm infants (gestational age <28 weeks) discharged between 2010 and 2019. Hospitalization data and medical charges were obtained from electronic inpatient medical records. Subgroup analysis was conducted to examine how the charges and length of stay varied by gestational age, discharge year, survival status, and major morbidities.

RESULTS

The median total hospitalization charge was $20,770.70 with a median length of stay of 70.0 days. Total and daily charges declined as gestational age increased. A rising trend was found over time for overall and daily medical charges. Compared with decedents, survivors had a longer length of stay and higher total hospitalization charges, but their charge per day was lower. Total hospitalization charges were significantly higher in infants with necrotizing enterocolitis (Stage II-III), bronchopulmonary dysplasia, and sepsis when compared with neonates of the same gestational age without these co-morbidities. Charges for treatments accounted for the highest proportion (31.3%).

LIMITATIONS

Local statistics collected retrospectively might limit generalizability to other regions. Long-term medical charges were not reported.

CONCLUSION

Economic burden of the initial hospitalization for extremely preterm infants was substantial in China. Such economic factors should be fully taken into account for perinatal consultations, medical insurance policy-making, and clinical decisions.

First trimester fasting plasma glucose screen in advanced maternal age women: a cost-effectiveness analysis

BACKGROUND

The prevalence of preexisting type 2 diabetes mellitus (T2DM) in the United States is on the rise. Women of advanced maternal age (AMA, ≥35 years) are more likely to have preexisting T2DM in pregnancy because glucose intolerance increases with age. Diabetes in pregnancy is associated with significant maternal and neonatal morbidity and mortality, and earlier treatment initiation improves pregnancy outcomes. However, maternal age is not currently recognized as an independent risk factor that warrants diabetes screening prior to the traditional screen at 24-28 weeks gestation.

OBJECTIVE

To evaluate the cost-effectiveness of screening all AMA women with a first trimester fasting plasma glucose (FPG) test for earlier diagnosis and management of preexisting T2DM.

STUDY DESIGN

A decision-analytic model was created to compare pregnancy outcomes in AMA women who undergo a first trimester FPG test vs third trimester oral glucose tolerance test alone. Probabilities were obtained from the literature. Outcomes examined included preeclampsia, preterm delivery, macrosomia, shoulder dystocia, brachial plexus injury (BPI), intrauterine fetal demise (IUFD), cerebral palsy, and neonatal death. The cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio of the first trimester screening strategy were examined as well. Sensitivity analyses and a Monte Carlo simulation were performed to test the model's robustness.

RESULTS

In AMA women, screening for preexisting T2DM in the first trimester with an FPG test resulted in fewer cases of preeclampsia, preterm delivery, BPI, IUFD, cerebral palsy, and neonatal death compared to performing a third trimester oral glucose tolerance test alone, and is cost-effective. Monte Carlo analysis incorporating the distribution of all probabilities showed that first trimester FPG screening remained cost-effective as long as the incremental cost of initiating diabetes treatment in the first trimester was less than $150,000 and the cost of the FPG screen was less than $2700.

CONCLUSION

Compared to third trimester oral glucose tolerance test alone, performing a first trimester FPG screen in AMA women is cost-saving and more effective.

Determinants of length of stay after cesarean sections in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Since Italy has the highest cesarean section (CS) rate (38.1%) among all European countries, the containment of health care costs associated with CS is needed, along with control of length of hospital stay (LOS) following CS. This population based cross-sectional study aims to investigate LoS post CS (overall CS, OCS; planned CS, PCS; urgent/emergency CS, UCS), in Friuli Venezia Giulia (a region of North-Eastern Italy) during 2005-2015, adjusting for a considerable number factors, including various obstetric conditions/complications. Maternal and newborn characteristics (health care setting and timeframe; maternal health factors; child's size factors; child's fragility factors; socio-demographic background; obstetric history; obstetric conditions) were used as independent variables. LoS (post OCS, PCS, UCS) was the outcome measure. The statistical analysis was conducted with multivariable linear (LoS expressed as adjusted mean, in days) as well as logistic (adjusted proportion of LoS > 4 days vs. LoS ≤ 4 days, using a 4 day cutoff for early discharge, ED) regression. An important decreasing trend over time in mean LoS and LoS > ED was observed for both PCS and UCS. LoS post CS was shorter with parity and history of CS, whereas it was longer among non-EU mothers. Several obstetric conditions/complications were associated with extended LoS. Whilst eclampsia/pre-eclampsia and preterm gestations (33-36 weeks) were predominantly associated with longer LoS post UCS, for PCS LoS was significantly longer with birthweight 2.0-2.5 kg, multiple birth and increasing maternal age. Strong significant inter-hospital variation remained after adjustment for the major clinical conditions. This study shows that routinely collected administrative data provide useful information for health planning and monitoring, identifying inter-hospital differences that could be targeted by policy interventions aimed at improving the efficiency of obstetric care. The important decreasing trend over time of LoS post CS, coupled with the impact of some socio-demographic and obstetric history factors on LoS, seemingly suggests a positive approach of health care providers of FVG in decision making on hospitalization length post CS. However, the significant role of several obstetric conditions did not influence hospital variation. Inter-hospital variations of LoS could depend on a number of factors, including the capacity to discharge patients into the surrounding non-acute facilities. Further studies are warranted to ascertain whether LoS can be attributed to hospital efficiency rather than the characteristics of the hospital catchment area.

Impact of maternal obesity on fetal cardiac screening: which follow-up strategy is cost-effective?

OBJECTIVE

To perform a cost-effectiveness analysis of different follow-up strategies for non-obese and obese women who had incomplete fetal cardiac screening for major congenital heart disease (CHD).

METHODS

Three decision-analytic models, one each for non-obese, obese and Class-III-obese women, were developed to compare five follow-up strategies for initial suboptimal fetal cardiac screening. The five strategies were: (1) no follow-up ultrasound (US) examination but direct referral to fetal echocardiography (FE); (2) one follow-up US, then FE if fetal cardiac views were still suboptimal; (3) up to two follow-up US, then FE if fetal cardiac views were still suboptimal; (4) one follow-up US and no FE; and (5) up to two follow-up US and no FE. The models were designed to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. A cost-effectiveness willingness-to-pay threshold was set at US$100 000 per quality-adjusted life year (QALY). Base-case and sensitivity analysis and Monte-Carlo simulation were performed.

RESULTS

In our base-case models for all body mass index (BMI) groups, no follow-up US, but direct referral to FE led to the best outcomes, detecting 7%, 25% and 82% more fetuses with CHD in non-obese, obese and Class-III-obese women, respectively, compared with the baseline strategy of one follow-up US and no FE. However, no follow-up US, but direct referral to FE was above the US$100 000/QALY threshold and therefore not cost-effective. The cost-effective strategy for all BMI groups was one follow-up US and no FE. Both up to two follow-up US with no FE and up to two follow-up US with FE were dominated (being more costly and less effective), while one follow-up US with FE was over the cost-effectiveness threshold. One follow-up US and no FE was the optimal strategy in 97%, 93% and 86% of trials in Monte-Carlo simulation for non-obese, obese and Class-III-obese models, respectively.

CONCLUSION

For both non-obese and obese women with incomplete fetal cardiac screening, the optimal CHD follow-up screening strategy is no further US and immediate referral to FE; however, this strategy is not cost-effective. Considering costs, one follow-up US and no FE is the preferred strategy. For both obese and non-obese women, Monte-Carlo simulations showed clearly that one follow-up US and no FE was the optimal strategy. Both non-obese and obese women with initial incomplete cardiac screening examination should therefore be offered one follow-up US. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Antenatal Corticosteroids for Pregnant Women at High Risk of Preterm Delivery with COVID-19 Infection: A Decision Analysis

OBJECTIVE

Antenatal corticosteroids given prior to preterm deliveries reduce the risk of adverse neonatal outcomes. However, steroid administration in the setting of a viral respiratory infection can worsen maternal outcomes. Therefore, the decision to administer corticosteroids must balance the neonatal benefits with the potential harm to the mother if she is infected with the novel coronavirus disease 2019 (COVID-19). This study aimed to determine the gestational ages for which administering antenatal corticosteroids to women at high risk of preterm labor with concurrent COVID-19 infection results in improved combined maternal and infant outcomes.

STUDY DESIGN

A decision-analytic model using TreeAge (2020) software was constructed for a theoretical cohort of hospitalized women with COVID-19 in the United States. All model inputs were derived from the literature. Outcomes included maternal intensive care unit (ICU) admission and death, along with infant outcomes of death, respiratory distress syndrome, intraventricular hemorrhage, and neurodevelopmental delay. Quality-adjusted life years (QALYs) were assessed from the maternal and infant perspectives. Sensitivity analyses were performed to determine if the results were robust over a range of assumptions.

RESULTS

In our theoretical cohort of 10,000 women delivering between 24 and 33 weeks of gestation with COVID-19, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths. Overall, we found that corticosteroid administration resulted in higher combined QALYs up to 31 weeks of gestation in all hospitalized patients, and up to 29 weeks of gestation in ICU patients.

CONCLUSION

Administration of antenatal corticosteroids at less than 32 weeks of gestation for hospitalized patients and less than 30 weeks of gestation for patients admitted to the ICU resulted in higher combined maternal and infant outcomes compared with expectant management for women at high risk of preterm birth with COVID-19 infection. These results can guide clinicians in their counseling and management of these pregnant women.

KEY POINTS

· Antenatal steroids reduce adverse neonatal outcomes.. · Steroids worsen maternal outcomes in COVID-19.. · Steroids given < 32 weeks result in improved outcomes..

Estimates of healthcare spending for preterm and low-birthweight infants in a commercially insured population: 2008-2016

The growth in healthcare spending is an important topic in the United States, and preterm and low-birthweight infants have some of the highest healthcare expenditures of any patient population. We performed a retrospective cohort study of spending in this population using a large, national claims database of commercially insured individuals. A total of 763,566 infants with insurance coverage through Aetna, Inc. for the first 6 months of post-natal life were included, and received approximately $8.4 billion (2016 USD) in healthcare services. Infants with billing codes indicating preterm status (<37 weeks, n = 50,511) incurred medical expenditures of $76,153 on average, while low-birthweight status (<2500 g) was associated with average spending of $114,437. Infants born at 24 weeks gestation (n = 418) had the highest per infant average expenditures of $603,778. Understanding the drivers of variation in costs within gestational age and birthweight bands is an important target for future studies.

Detection of fetal cardiac anomalies: cost-effectiveness of increased number of cardiac views

OBJECTIVE

To compare the recommended three-view fetal heart screening method to detect major congenital heart disease (CHD) with more elaborate screening strategies to determine the cost-effective strategy in unselected (low-risk) pregnancies.

METHODS

A decision-analytic model was designed to compare four screening strategies to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. The four strategies were: (1) three views: four-chamber view (4CV) and views of the left (LVOT) and right (RVOT) ventricular outflow tracts; (2) five views: 4CV, LVOT, RVOT and longitudinal views of the ductal arch and aortic arch; (3) five axial views: 4CV, LVOT, RVOT, three-vessel (3V) view and three-vessels-and-trachea view; and (4) six views: 4CV, LVOT, RVOT and 3V views and longitudinal views of the ductal arch and aortic arch. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. The analysis was performed from a healthcare-system perspective, with a cost-effectiveness willingness-to-pay threshold set at $100 000 per quality-adjusted life year (QALY). Baseline analysis, one-way sensitivity analysis and Monte-Carlo simulation were performed.

RESULTS

In our baseline model, screening with five axial views was the optimal strategy, detecting 3520 more CHDs, and resulting in 259 fewer children with neurodevelopmental disability, 40 fewer neonatal deaths and only slightly higher costs, compared with screening with the currently recommended three views. Screening with six views was more effective, but also cost considerably more, compared with screening with five axial views, and had an incremental cost of $490 023/QALY, which was over the willingness-to-pay threshold. The five-view strategy was dominated by the other three strategies, i.e. it was more costly and less effective in comparison. The data were robust when tested with Monte-Carlo and one-way sensitivity analysis.

CONCLUSION

Although current guidelines recommend a minimum of three views for detecting CHD during the mid-trimester anatomy scan, screening with five axial views is a cost-effective strategy that may lead to improved outcome compared with three-view screening. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

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.

Antenatal corticosteroids for pregnant women with COVID-19 infection and preterm prelabor rupture of membranes: a decision analysis

Background: While antenatal corticosteroids are routinely used to decrease adverse neonatal outcomes following preterm delivery, corticosteroids are also associated with worse outcomes in patients with viral respiratory infections. Currently in the setting of the COVID-19 pandemic, it is unclear whether antenatal corticosteroids for infant benefit outweigh the potential harm to a pregnant woman with a COVID-19 infection.Objective: To determine at which gestational ages administering antenatal corticosteroids is the optimal management strategy for hospitalized women with preterm prelabor rupture of membranes (PPROM) who have a COVID-19 infection.Methods: We designed a decision-analytic model to assess the maternal and infant outcomes associated with antenatal corticosteroid administration for risk of preterm delivery following rupture of membranes in the setting of a COVID-19 infection. We used a theoretical cohort of 10,000 women at each gestational age between 24 and 32 weeks who were hospitalized with PPROM and found to be COVID-19 positive. Maternal outcomes included intensive care unit admission and death related to COVID-19 infection. The infant outcomes of interest included respiratory distress syndrome, intraventricular hemorrhage, neurodevelopmental delay, and death, and were assessed along with maternal and infant quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were used to evaluate model assumptions.Results: In our theoretical cohort of 10,000 women with COVID-19 infection and preterm prelabor rupture of membrane between 24 and 32 weeks, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths at each gestational age. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths at each gestational age. Antenatal corticosteroid administration also resulted in fewer cases of respiratory distress syndrome, intraventricular hemorrhage, and infant death. Overall, we found that between 24 and 30 weeks of gestation, administering antenatal corticosteroids was the optimal management strategy as it resulted in higher combined QALYs than no corticosteroid use. For 31 and 32 weeks of gestation, antenatal corticosteroid administration resulted in lower combined QALYs. On sensitivity analyses, we found that with increasing gestational age, the probability which antenatal corticosteroids was the optimal management strategy decreased.Conclusion: Administration of antenatal corticosteroids was an effective management strategy compared to no corticosteroid administration at gestational ages less than 31 weeks. These results provide data for clinicians to utilize when counseling pregnant patients hospitalized with PPROM and have a COVID-19 infection.

Do most premature babies get discharged by the expected date of delivery?

OBJECTIVE

To compare the length of stay (LOS) against the expected date of delivery (EDD) and to describe mortality and LOS outcomes by gestational age (GA) categories over the years.

STUDY DESIGN

Healthcare Cost and Utilization Project Kids' Inpatient database discharge records for years 2003, 2006, 2009, 2012, and 2016 were analyzed. For premature infants after inclusion-exclusion, actual, and calculated LOS were compared. Mortality and LOS outcomes were analyzed by GA and years.

RESULTS

The majority (99%) of infants >28 weeks were discharged by EDD while, for neonate ≤28 weeks, about three-quarters (75%) of infants were discharged by calculated EDD. LOS is increasing while mortality is decreasing by GA categories in recent years.

CONCLUSIONS

This is the largest study of mortality and LOS in the United States. Our study provides evidence-based numbers comparing actual LOS against EDD, which can be used in perinatal settings to counsel parents.

Late preterm infants - Changing trends and continuing challenges

Late preterm infants, defined as newborns born between 340/7-366/7 weeks of gestational age, constitute a unique group among all premature neonates. Often overlooked because of their size when compared to very premature infants, this population is still vulnerable because of physiological and structural immaturity. Comprising nearly 75% of babies born less than 37 weeks of gestation, late preterm infants are at increased risk for morbidities involving nearly every organ system as well as higher risk of mortality when compared to term neonates. Neurodevelopmental impairment has especially been a concern for these infants. Due to various reasons, the rate of late preterm births continue to rise worldwide. Caring for this high risk population contributes a significant financial burden to health systems. This article reviews recent trends in regarding rate of late preterm births, common morbidities and long term outcomes with special attention to neurodevelopmental outcomes.

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.

The value of routine laboratory screening in the neonatal intensive care unit

BACKGROUND

Healthcare spending is expected to grow faster than the economy over the next decade, and the cost of prematurity increases annually. The aim of this study was to investigate the frequency of intervention after routine laboratory testing in preterm infants.

METHODS

This was a retrospective study of preterm infants (≤34 weeks) admitted to the NYU Langone Health NICU from June 2013 to December 2014. Data collected included demographics, results of laboratory tests, and resulting interventions. Intervention after a hemogram was defined as a blood transfusion. Intervention after a hepatic panel was defined as initiation or termination of ursodiol or change in dose of vitamin D. Subjects were stratified into 3 groups based on gestation (<28 weeks, 28-31 6/7 weeks, 32-34 weeks). Chi-square analysis was used to compare the frequency of intervention between the groups.

RESULTS

A total of 135 subjects were included in the study. The frequency of intervention after a hemogram was 8.4% in infants <28 weeks, 4.6% in infants 28-31 6/7 weeks, and 0% in infants 32-34 weeks; this difference was found to be statistically significant (p = 0.02). The frequency of intervention after a hepatic panel was 4.2% in infants <28 weeks, 5.7% in infants 28-31 6/7 weeks, and 0% in infants 32-34 weeks, which was not found to be a statistically significant different.

CONCLUSION

No interventions were undertaken post-routine laboratory testing in any infant 32-34 weeks and routine testing in this population may be unnecessary. Further studies are needed to elucidate if routine testing affects neonatal outcomes.

Maternal and Infant Health Care Costs Related to Preeclampsia

OBJECTIVE

To provide U.S. case-based preeclampsia health care cost estimates for mothers and infants from a U.S. payer perspective, with comparisons with both uncomplicated and hypertensive pregnancies.

METHODS

Electronic health record and billing data from a large regional integrated health care system in Pennsylvania were used to identify mother-singleton infant pairs with deliveries between 2010 and 2015. Data on clinical care and costs using actual payment amounts were compiled from 20 weeks of gestation to 6 weeks postdelivery for mothers and birth to 12 months for infants. Three defined pregnancy study cohorts, uncomplicated, hypertension and preeclampsia, were matched using a 1:1:1 ratio on the basis of maternal age, parity, body mass index, and comorbidities. Costs per pregnancy were calculated in 2015 dollars and preeclampsia incremental costs estimated by subtracting the average cost of the matched cohorts.

RESULTS

The final study population included 712 matched mother-infant pairs in each cohort. The mean combined maternal and infant medical care costs in the preeclampsia cohort of $41,790 were significantly higher than those for the uncomplicated cohort of $13,187 (P<.001) and hypertension cohort of $24,182 (P<.001), and were largely driven by differences in the infant costs. The mean infant cost in the preeclampsia cohort were $28,898, in the uncomplicated cohort $3,669 and $12,648 in the hypertension cohort (P<.001). Mothers with preeclampsia delivered 3 weeks earlier (median 36.5 weeks of gestation) than women in the uncomplicated cohort and more than 2 weeks earlier than women in the hypertension cohort. A significantly larger percentage of women with preeclampsia and their infants experienced adverse events (13.9% for mothers and 14.6% for infants) compared with unaffected women (4.1% and 0.7%) and those with hypertension (9.4% and 4.8%), respectively (P<.001).

CONCLUSION

The economic burden of preeclampsia health care is significant with the main cost drivers being infant health care costs associated with lower gestational age at birth and greater adverse outcomes.

FUNDING SOURCE

This study is funded by Progenity, Inc.

Early life antecedents of positive child health among 10-year-old children born extremely preterm

BACKGROUND

To identify modifiable antecedents during pre-pregnancy and pregnancy windows associated with a positive child health at 10 years of age.

METHODS

Data on 889 children enrolled in the Extremely Low Gestational Age Newborn (ELGAN) study in 2002-2004 were analyzed for associations between potentially modifiable maternal antecedents during pre-pregnancy and pregnancy time windows and a previously described positive child health index (PCHI) score at 10 years of age. Stratification by race was also investigated for associations with investigated antecedents.

RESULTS

Factors associated with higher PCHI (more positive health) included greater gestational age, birth weight, multiple gestation, and medical interventions, including assisted reproduction and cervical cerclage. Factors associated with lower PCHI included correlates of lower socioeconomic status, pre-pregnancy chronic medical disorders in the mother such as pre-pregnancy body mass index (BMI), and maternal asthma. When stratified by race, variation in significant results was observed.

CONCLUSIONS

Among children born extremely preterm, medical interventions and higher socioeconomic status were associated with improved PCHI, while chronic illness and high BMI in the mother is associated with lower PCHI at 10 years of age. Knowledge of such antecedent factors could inform efforts to develop interventions that promote positive child health outcomes in future pregnancies.

Repeat Screening for Syphilis in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis

OBJECTIVE

To estimate the cost-effectiveness of screening all women during the first and third trimesters compared with screening just once during pregnancy.

METHODS

We used a theoretical cohort of 3.9 million women in the United States to model syphilis screening approaches in pregnancy, particularly comparing one-time screening with repeat third-trimester screening. Outcomes of syphilis infection included in the model were congenital syphilis, intrauterine fetal demise, neonatal death, and total quality-adjusted life-years (QALYs). Probabilities, utilities, and costs were obtained from the literature, and a cost-effectiveness threshold was set at $100,000 per QALY. A societal perspective was assumed.

RESULTS

Our model demonstrated that repeat screening in the third trimester for syphilis in pregnancy will result in fewer maternal and neonatal adverse outcomes and higher QALYs when compared with screening once in the first trimester. Specifically, we demonstrated that repeat screening results in 41 fewer neonates with evidence of congenital syphilis, 73 fewer cases of intrauterine fetal demise, 27 fewer neonatal and infant deaths, in addition to a cost savings of $52 million and 4,000 additional QALYs.

CONCLUSION

Using our baseline assumptions, our data support that in pregnancy, repeat screening for syphilis is superior to single screening during the first trimester and is both cost-effective and results in improvement in maternal and neonatal outcomes. When screening policies are being created for pregnant women, the cost-effectiveness of repeat screening for syphilis should be considered.

Cell-free fetal DNA screening for detection of microdeletion syndromes: a cost-effectiveness analysis

OBJECTIVE

Fetuses with genetic copy number variants are poorly detected through traditional prenatal screening. Microdeletions and duplications are clearly identified with diagnostic testing through chromosomal microarray, and screening of a select number of microdeletions has become available with cell-free DNA (cfDNA). Our study compares the costs and outcomes of cfDNA for five pathogenic microdeletions and aneuploidy to cfDNA for aneuploidy alone in conjunction with ultrasound.

METHODS

A decision-analytic model was constructed using TreeAge software to compare cfDNA with microdeletions versus traditional cfDNA in a theoretical cohort of 4,000,000 pregnancies that would also be screened with ultrasound. Probabilities, costs, and utilities were derived from literature. The primary outcomes were the incremental cost per quality-adjusted life-year (QALY), terminations, and procedure-related losses. Because the microdeletion results are available, but not reported, on all cfDNA testing we set the incremental cost of the cfDNA microdeletion screening test to zero at baseline and varied the cost in sensitivity analysis.

RESULTS

Screening with cfDNA for microdeletions among all pregnant women would result in 83 fewer anomalous neonates compared to traditional cfDNA with ultrasound. This reduction is due to increased diagnosis and termination of fetuses with microdeletions in this group. Routine use of cfDNA with microdeletions resulted in more procedure-related losses. cfDNA with microdeletions would improve effectiveness by 977 QALYs and decrease costs by $90,991,784. When we varied the specificity of the screening test, we found that it remained cost-effective down to a specificity of 91%. With a threshold of $100,000/QALY, microdeletion screening is cost-effective to an incremental increase in cost over cfDNA for aneuploidy alone of $47.10.

CONCLUSION

For detection of fetal subchromosomal abnormalities, use of cfDNA with microdeletions is a cost-effective strategy compared to cfDNA for aneuploidy alone in conjunction with ultrasound. Cell-free DNA for microdeletions is not currently recommended as routine screening for low-risk obstetric populations by the American College of Obstetrics and Gynecologists or the Society for Maternal-Fetal Medicine. The test characteristics of cfDNA with microdeletions require greater examination before being routinely recommended.

Economic assessment of neonatal intensive care

Most of the studies on the costing of neonatal intensive care has concentrated on the costs associated with preterm infants which takes up more than half of neonatal intensive care unit (NICU) costs. The focus has been on determining the cost-effectiveness of extreme preterm infants and those at threshold of viability. While the costs of care have an inverse relationship with gestational age (GA) and the lifetime medical costs of the extreme preterm can be as high as $450,000, the total NICU expenditure are skewed towards the care of moderate and late preterm infants who form the main bulk of patients. Neonatal intensive care, has been found to be very cost-effective at $1,000 per term infant per QALY and $9,100 for extreme preterm survivor per QALY. For low and LMIC, where NICU resources are limited, the costs of NICU care is lower largely due to a patient profile of more term and preterm of greater GAs and correspondingly less intensity of care. Public health measures, neonatal resuscitation training, empowerment of nurses to do resuscitation, increasing the accessibility to essential newborn care are recommended cheaper cost-effective measures to reduce neonatal mortality in countries with high neonatal mortality rate, whilst upgraded neonatal intensive care services are needed to further reduce neonatal mortality rate once below 15 per 1,000 livebirths. Economic evaluation of neonatal intensive care should also include post discharge costs which mainly fall on the health, social and educational sectors. Strategies to reduce neonatal intensive care costs could include more widespread implementation of cost-effective methods of improving neonatal outcome and reducing neonatal morbidities, including access to antenatal care, perinatal interventions to delay preterm delivery wherever feasible, improving maternal health status and practising cost saving and effective neonatal intensive care treatment.

Induction of labor at 39 weeks of gestation versus expectant management for low-risk nulliparous women: a cost-effectiveness analysis

BACKGROUND

A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes.

OBJECTIVE

We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States.

STUDY DESIGN

A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years.

RESULTS

In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time.

CONCLUSION

In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences. KEY WORDS: cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes.

Use of gestational surrogates for women with Eisenmenger syndrome: a cost-effectiveness analysis

Objective: Eisenmenger syndrome (ES) is regarded as a contraindication to pregnancy, with therapeutic abortion recommended in the event of unintended pregnancy. However, women with ES continue to desire and attempt pregnancy despite grave risks to their own health. This study compares the costs and outcomes of pregnancy in women with ES to the use of gestational surrogates in their pregnancies.Study design: A decision-analytic model was built using TreeAge software that compared use of gestational surrogates and pregnancy in women with ES. Maternal death and neonatal outcomes including intrauterine fetal demise, preterm birth, cerebral palsy, and death were assessed. All probabilities and costs were derived from the literature. Utilities were discounted at a rate of 3% across the expected lifespan to generate quality-adjusted life years (QALYs). Univariate and multivariate sensitivity analyses were performed to evaluate the robustness of the model given changes in baseline assumptions.Results: In a theoretical cohort of 1000 women with ES, pregnancy would result in 360 maternal deaths, 100 stillbirths, 477 preterm births, and 157 neonatal deaths . In these highly desired pregnancies, use of gestational surrogates would prevent 99 and 98% of maternal and neonatal death, respectively. Cases and costs of preterm birth and associated cerebral palsy are also significantly reduced. Use of a gestational surrogate would save $518,255 per woman with a gain of 6.77 QALYs, a dominant strategy. The approach is cost-effective up to a cost of surrogacy of $1.2 million and even if the surrogate achieves pregnancy only 30% of the time.Conclusions: The use of surrogate mothers for those with ES is cost-effective and results in significantly improved maternal and neonatal outcomes. These benefits are robust in the face of high surrogacy costs largely due to the marked reduction in maternal mortality and preterm birth. These findings should be used to underscore the importance of broadening health care financing for medically-indicated assisted reproduction.

Timing of delivery in women with prior uterine rupture: a decision analysis

Background: Uterine rupture is an obstetric complication with high rates of associated maternal and neonatal morbidity and mortality. However, limited guidance for the timing of delivery in women with a history of prior uterine rupture exists.Objective: To determine the optimal gestational age of delivery in women with prior uterine rupture.Study design: A decision-analytic model was built using TreeAge software to compare the outcomes of repeat cesarean delivery when performed at 32, 33, 34, 35, or 36 weeks gestation in a theoretical cohort of 1000 women with prior uterine rupture. Strategies involved expectant management until a later gestational age accounting for the risks of spontaneous uterine rupture, spontaneous labor, uterine rupture following spontaneous labor, and stillbirth during each successive week that a woman was still pregnant. Maternal outcomes included uterine rupture, hysterectomy, and death. Neonatal outcomes included hypoxic-ischemic encephalopathy, cerebral palsy, and death. Probabilities were derived from the literature and total quality-adjusted life years (QALYs) were calculated. Sensitivity analyses were used to vary model inputs to investigate the robustness of our baseline assumptions.Results: In our theoretical cohort of 1000 pregnant women with a history of prior uterine rupture, cesarean delivery at 34 weeks maximized maternal and neonatal QALYs. Compared to delivery at 36 weeks, delivery at 34 weeks would prevent 38.6 uterine ruptures, 0.079 maternal deaths, 6.10 hysterectomies, and 12.1 neonatal deaths but results in 4.70 more cases of cerebral palsy. Univariate sensitivity analysis found that repeat cesarean at 34 weeks remained the optimal strategy until the probability of spontaneous repeat uterine rupture (baseline estimate: 0.68%) fell below 0.2% or rose above 0.9%, at which point, a strategy of delivery at 35 or 32 weeks became optimal, respectively. However, Monte Carlo simulation demonstrated that delivery at 35 weeks was the optimal strategy 37% of the time, whereas 34 weeks was the optimal strategy 17% of the time.Conclusion: The optimal time for repeat cesarean delivery in women with prior uterine rupture appears to be between 34-0/7 and 35-6/7 weeks gestation.

Characteristics and health care utilization of otherwise healthy commercially and Medicaid-insured preterm and full-term infants in the US

Purpose

This study examined health care utilization and costs during the first year of life for preterm and full-term infants in the US.

Subjects and methods

Preterm (<37 weeks gestational age [GA]) and full-term infants born 2003 to 2012 without complex medical conditions were identified in the MarketScan^® Commercial and Multi-State Medicaid claims databases using ICD-9-CM diagnosis and diagnosis-related grouping codes. Inpatient and outpatient claims from birth through the first year were analyzed for preterm and full-term subgroups. Results were stratified by payer.

Results

There were 1,692,935 commercially insured infants (12.5% preterm) and 1,873,324 Medicaid-insured infants (13.9% preterm). The majority (>75%) of preterm infants were admitted to the neonatal intensive care unit during their birth hospitalization. Generally, mean length of stay and costs for birth hospitalizations increased with decreasing GA. The average cost of a birth hospitalization was US $62,931 (SD $134,347) for commercially insured preterm infants and $43,858 (SD $115,412) for Medicaid-insured preterm infants compared to $2,401 (SD $7,399) and $1,894 (SD $5,444) for commercially insured and Medicaid-insured full-term infants, respectively. Post-neonatal hospitalization rates increased as GA decreased (in full-term to <29 weeks GA: commercial =3.3%–19.5%; Medicaid =6.1%–26.2%). Preterm infants had greater average numbers of outpatient office visits and pharmacy claims than full-term infants. Following birth discharge, mean monthly health care costs per infant increased as GA decreased (commercial = $334 to $3,126; Medicaid = $205 to $2,473).

Conclusion

During the first year of life, post-neonatal hospitalization rates, outpatient office visits, pharmacy claims, and monthly costs increased as GA decreased.

Universal cervical length screening with a cervicometer to prevent preterm birth <34 weeks: a decision and economic analysis

Background: Preterm birth is a leading cause of neonatal morbidity and mortality worldwide; evidence-based strategies to decrease preterm birth are desperately needed.Objective: The purpose of this study was to estimate which of three strategies for screening for shortened cervix in asymptomatic low-risk women is the most cost-effective in terms of prevention of preterm birth and associated morbidity.Study design: A decision analysis model was developed from available published evidence comparing three strategies in screening asymptomatic low-risk women for shortened cervix: (1) cervicometer with subsequent referral for transvaginal ultrasound, (2) transvaginal ultrasound screening, and (3) no screening. The cost and effectiveness of each strategy was assessed in terms of quality-adjusted life-years (QALYs), and cost in US dollars.Results: Screening with a cervicometer with referral was the most cost-effective strategy and represented a savings of $999.65 ($11,617.28 versus $12,616.93) over screening with ultrasound, and a savings of $15,601.62 ($11,617.28 versus $27,218.90) over no screening. Costs for outcomes ranged from $3528 for a healthy neonate ≥34 weeks to $717,467.5 for a neonate <34 weeks with severe morbidity. The cervicometer strategy avoided 11.68 neonatal deaths per 1000 deliveries (3.59 deaths versus 15.27 deaths) compared with no screening, and avoided 0.73 neonatal deaths per 1000 deliveries (3.59 deaths versus 4.32 deaths) compared with ultrasound strategy. The cervicometer strategy prevented 82.44 preterm births per 1000 deliveries (22.56 versus 105.00) compared with no screening, and 5.10 preterm births per 1000 deliveries (22.56 versus 27.66) compared with ultrasound strategy. Per QALY, cervicometer screening cost $386.57, transvaginal ultrasound cost $420.31, and no screening cost $922.73. Sensitivity analyses confirmed the robustness of these findings, including evaluation across the range of quoted transvaginal ultrasound costs ($43-$300).Conclusion: A simulation of universal screening of asymptomatic low-risk women with a cervicometer with subsequent referral for ultrasound for those with a cervix <25 mm is cost-effective and yields the greatest reduction in preterm births at <34 weeks. A risk simulation trial noted that a cervicometer strategy may be more expensive than a universal transvaginal ultrasound strategy, but both are less expensive than a no screening strategy.

Estimating neonatal length of stay for babies born very preterm

OBJECTIVE

To predict length of stay in neonatal care for all admissions of very preterm singleton babies.

SETTING

All neonatal units in England.

PATIENTS

Singleton babies born at 24-31 weeks gestational age from 2011 to 2014. Data were extracted from the National Neonatal Research Database.

METHODS

Competing risks methods were used to investigate the competing outcomes of death in neonatal care or discharge from the neonatal unit. The occurrence of one event prevents the other from occurring. This approach can be used to estimate the percentage of babies alive, or who have been discharged, over time.

RESULTS

A total of 20 571 very preterm babies were included. In the competing risks model, gestational age was adjusted for as a time-varying covariate, allowing the difference between weeks of gestational age to vary over time. The predicted percentage of death or discharge from the neonatal unit were estimated and presented graphically by week of gestational age. From these percentages, estimates of length of stay are provided as the number of days following birth and corrected gestational age at discharge.

CONCLUSIONS

These results can be used in the counselling of parents about length of stay and the risk of mortality.

Health economic aspects of late preterm and early term birth

Despite an increasing body of knowledge on the adverse clinical sequelae associated with late preterm birth and early term birth, little is known about their economic consequences or the cost-effectiveness of interventions aimed at their prevention or alleviation of their effects. This review assesses the health economic evidence surrounding late preterm and early term birth. Evidence is gathered on hospital resource use associated with late preterm and early term birth, economic costs associated with late preterm and early term birth, and economic evaluations of prevention and treatment strategies. The article highlights the limited perspective and time horizon of most studies of economic costs in this area; the limited evidence surrounding health economic aspects of early term birth; the gaps in current knowledge; and it discusses directions for future research in this area, including the need for validated tools for measuring preference-based health-related quality-of-life outcomes in infants that will aid cost-effectiveness-based decision-making.

Incremental Cost of Prematurity by Week of Gestational Age

Objective  This study was aimed to compare health care costs and utilization at birth through 1 year, between preterm and term infants, by week of gestation. Methods  A cross-sectional study of infants born at ≥ 23 weeks of gestational age (GA) at Kaiser Permanente Northern California facilities between 2000 and 2011, using outcomes data from an internal neonatal registry and cost estimates from an internal cost management database. Adjusted models yielded estimates for cost differences for each GA group. Results  Infants born at 25 to 37 weeks incur significantly higher birth hospitalization costs and experience significantly more health care utilization during the initial year of life, increasing progressively for each decreasing week of gestation, when compared with term infants. Among all very preterm infants (≤ 32 weeks), each 1-week decrease in GA is associated with incrementally higher rates of mortality and major morbidities. Conclusion  We provide estimates of potential cost savings that could be attributable to interventions that delay or prevent preterm delivery. Cost differences were most extreme at the lower range of gestation (≤ 30 weeks); however, infants born moderately preterm (31-36 weeks) also contribute substantially to the burden, as they represent a higher proportion of total births.

Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011

OBJECTIVE

To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.

STUDY DESIGN

We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212.

RESULTS

The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.

CONCLUSIONS

Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.

Length of stay and cost of birth hospitalization: effects of subfertility and ART

OBJECTIVE

The objective of this study is to measure delivery length of stay (LOS) and cost as proxies for infant morbidity in assisted reproductive technology (ART) and subfertile deliveries.

STUDY DESIGN

Massachusetts singleton births, ≥  23 weeks gestational age (GA) between 2004 and 2010, were linked with ART data, vital records, and hospital discharges. LOS and costs (2010 US dollars) of infants born to fertile (no ART or indicators of infertility), subfertile (indicators of infertility but no ART), and ART-treated (linked to ART data) deliveries were compared. Least-square means and SE were calculated.

RESULTS

Of 345,756 singletons (fertile n = 332,481, subfertile n = 4987, and ART-treated n = 8288), overall LOS was 3.79 ± 0.01, 4.32 ± 0.15, and 4.90 ± 0.04 days, and costs were $2980 ± 6, $3217 ± 58, and $4483 ± 62, respectively. GA and birthweight predicted much of the intergroup difference.

CONCLUSION

Maternal fertility group was not an independent predictor of infant LOS and costs. Prematurity and birthweight were driving factors in resource utilization.