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

Vitamin A supplementation for the prevention of chronic lung disease in premature infants: A cost-utility analysis

INTRODUCTION

Despite the growing evidence on efficacy, little is known regarding the efficiency of Vitamin A supplementation to decrease the probability of chronic lung disease (CLD) in preterm infants. This study aims to determine the cost-utility of Vitamin A to prevent CLD in preterm infants in Colombia.

METHODS

A decision tree model was used to estimate the cost and quality-adjusted life-years (QALYs) of Vitamin A supplementation in preterm infants. Multiple sensitivity analyses were conducted to evaluate the robustness of the model. Cost-effectiveness was evaluated at a willingness-to-pay value of US$5180.

RESULTS

Vitamin A was associated with lower costs and higher QALYs. The expected annual cost per patient with Vitamin A was US$1579 (95% CI US$1555-US$1585) and without Vitamin A was US$1913 (95% CI US$1891-US$1934). The QALYs per person estimated with Vitamin A was 0.66 (95% CI 0.66-0.67) and without Vitamin A was 0.61 (95% CI 0.60-0.61). This position of absolute dominance (Vitamin A has lower costs and higher QALYs than without Vitamin A) is unnecessary to estimate the incremental cost-effectiveness ratio.

CONCLUSION

Our economic evaluation shows that Vitamin A is cost-effective to reduce the incidence rate of CLD in premature infants in Colombia. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines.

Unbiasing costs? An appraisal of economic assessment alongside randomized trials in neonatology

Economic evaluations performed alongside randomized controlled trials benefit from the protections against bias inherent in randomization. In this systematic review, we assessed the frequency and quality of economic assessments alongside randomized controlled trials of interventions in neonates published between 1990 and 2016. Over that period, 58 economic assessments were published, corresponding to approximately 2% of RCTs. We noted significant methodological limitations of these studies, including limitation of included costs to the health sector or payer rather than broader categories such as family or community expenditures (81%), short time horizon for cost measurement (less than one year in 60%), lack of reporting of uncertainty (26%), and infrequent analysis of costs and effects in a single metric (combined in 45%). Strategies for improving the quality and frequency of economic evaluations in neonatology are discussed, including selection of appropriate trials, funding, and peer review.

Oxidative stress biomarkers in the preterm infant

Oxidative stress (OS) plays a key role in the pathophysiology of preterm infants. Accurate assessment of OS remains an analytical challenge that has been partially addressed during the last few decades. A plethora of approaches have been developed to assess preterm biofluids to demonstrate a link postnatally with preterm OS, giving rise to a set of widely employed biomarkers. However, the vast number of different analytic methods and lack of standardization hampers reliable comparison of OS-related biomarkers. In this chapter, we discuss approaches for the study of OS in prematurity with respect to methodologic considerations, the metabolic source of different biomarkers and their role in clinical studies.

Have Changing Palivizumab Administration Policies Led to More Respiratory Morbidity in Infants Born at 32-35 Weeks?

OBJECTIVES

To determine differences in the incidence of respiratory morbidity during the first year of life among infants born 32(0/7)-34(6/7) weeks' gestational age (GA) before and after the administration policy for palivizumab, as written by the American Academy of Pediatrics, was updated in 2009.

STUDY DESIGN

Secondary analysis of the dataset collected for the Gastrointestinal Risk Factors for Wheezing in Premature Infants study, which enrolled preterm infants without bronchopulmonary dysplasia and followed them by parental questionnaires at 3, 6, 9, and 12 months adjusted age for prematurity. Participants were included if they were enrolled in Gastrointestinal Risk Factors for Wheezing in Premature Infants, born 32(0/7)-34(6/7) weeks' GA, and completed the 12-month questionnaire. We compared rates of recurrent wheezing, respiratory medication use, and health care use before (Epoch 1) and after (Epoch 2) the 2009 administration policy change.

RESULTS

A total of 165 infants met inclusion criteria. There was a significant increase in recurrent wheezing in Epoch 2 (46.2%) vs Epoch 1 (28.8%) (OR 2.22 [95% CI 1.08-4.53], P = .03). There was a nonsignificant increase in visits to the emergency department in Epoch 2 (27.4%) vs Epoch 1 (15.3%) (OR 2.12 [95% CI 0.91-4.96], P = .08). There were no differences in hospital admissions or respiratory medication use.

CONCLUSIONS

Infants born 32(0/7)-34(6/7) weeks' GA treated after the American Academy of Pediatrics administration policy change in 2009 had a greater incidence of recurrent wheezing than those treated according to the previous policy. It will be important to track rates of recurrent wheezing after the 2014 administration policy, because it may be an important factor in future cost-effectiveness analyses.

Evidence, Quality, and Waste: Solving the Value Equation in Neonatology

Rising health care costs challenge governments, payers, and providers in delivering health care services. Tremendous pressures result to deliver better quality care while simultaneously reducing costs. This has led to a wholesale re-examination of current practice methods, including explicit consideration of efficiency and waste. Traditionally, reductions in the costs of care have been considered as independent, and sometimes even antithetical, to the practice of high-quality, intensive medicine. However, it is evident that provision of evidence-based, locally relevant care can result in improved outcomes, lower resource utilization, and opportunities to reallocate resources. This is particularly relevant to the practice of neonatology. In the United States, 12% of the annual birth cohort is affected by preterm birth, and 3% is affected by congenital anomalies. Both of these conditions are associated with costly health care during, and often long after, the NICU admission. We will discuss how 3 drivers of clinical practice in neonatal care (evidence-based medicine, evidence-based economics, and quality improvement) can together optimize clinical and fiscal outcomes.

Mouse lung development and NOX1 induction during hyperoxia are developmentally regulated and mitochondrial ROS dependent

Animal models demonstrate that exposure to supraphysiological oxygen during the neonatal period compromises both lung and pulmonary vascular development, resulting in a phenotype comparable to bronchopulmonary dysplasia (BPD). Our prior work in murine models identified postnatal maturation of antioxidant enzyme capacities as well as developmental regulation of mitochondrial oxidative stress in hyperoxia. We hypothesize that consequences of hyperoxia may also be developmentally regulated and mitochondrial reactive oxygen species (ROS) dependent. To determine whether age of exposure impacts the effect of hyperoxia, neonatal mice were placed in 75% oxygen for 72 h at either postnatal day 0 (early postnatal) or day 4 (late postnatal). Mice exposed to early, but not late, postnatal hyperoxia demonstrated decreased alveolarization and septation, increased muscularization of resistance pulmonary arteries, and right ventricular hypertrophy (RVH) compared with normoxic controls. Treatment with a mitochondria-specific antioxidant, (2-(2,2,6,6-tetramethylpiperidin-1-oxyl-4-ylamino)-2-oxoethyl)triphenylphosphonium chloride (mitoTEMPO), during early postnatal hyperoxia protected against compromised alveolarization and RVH. In addition, early, but not late, postnatal hyperoxia resulted in induction of NOX1 expression that was mitochondrial ROS dependent. Because early, but not late, exposure resulted in compromised lung and cardiovascular development, we conclude that the consequences of hyperoxia are developmentally regulated and decrease with age. Attenuated disease in mitoTEMPO-treated mice implicates mitochondrial ROS in the pathophysiology of neonatal hyperoxic lung injury, with potential for amplification of ROS signaling through NOX1 induction. Furthermore, it suggests a potential role for targeted antioxidant therapy in the prevention or treatment of BPD.

Cost-effectiveness of transdermal nitroglycerin use for preterm labor

OBJECTIVE

The objective of this study was to determine the cost-effectiveness of using transdermal nitroglycerin (GTN) for cases of preterm labor.

METHODS

The study included 153 women with clinical preterm labor, who were randomly allocated to either a GTN or placebo arm. All randomized cases were included in the final economic analysis. Differences between the two arms in gestational age at delivery, neonatal intensive care unit (NICU) admission, length of NICU stay, and NICU cost were assessed. Costs for non-NICU cases were calculated using Ottawa Hospital data through the Ontario Case Costing Initiative (OCCI). Cost-effectiveness and sensitivity analyses using a hospital perspective were both conducted.

RESULTS

In the 153 randomized cases, 55 babies were admitted to NICU (GTN = 24; placebo = 31). We found no significant differences between the two arms in gestational age at delivery, NICU admission rate (32.4% vs. 39.2%), NICU length of stay (42.7 days vs. 52.8 days), or NICU cost (CAN $34,306 vs. CAN $44,326). Overall, (based on all randomized cases) the cost-effectiveness analyses showed that the GTN arm was the dominant strategy, with both lower cost (CAN $13,397 vs. CAN $18,427) and higher NICU admission avoided rate (67.6% vs. 60.8%) compared to the placebo arm. This dominance persisted in all sensitivity analyses.

CONCLUSION

The use of GTN patch for preterm labor could reduce NICU costs, while improving important neonatal outcomes.

Economic evaluation of inhaled nitric oxide in preterm infants undergoing mechanical ventilation

OBJECTIVE

In the previously reported Nitric Oxide for Chronic Lung Disease (NO CLD) trial, ventilated preterm infants who received a course of inhaled nitric oxide (iNO) between 7 and 21 days of life had a significant improvement in survival without bronchopulmonary dysplasia (BPD), as well as a shorter duration of admission and ventilation. However, the price for the drug may be a barrier to widespread use. We sought to estimate the incremental cost-effectiveness of iNO therapy to prevent BPD in infants of <1250 g birth weight.

METHODS

We used patient-level data from the NO CLD randomized trial. The study took a third-party payer perspective and measured costs and effects through hospital discharge. We applied previously reported hospital per-diem costs stratified according to intensity of ventilatory support, nitric oxide costs from standard market prices, and professional (physician) fees from the Medicare fee schedule. We compared log transformed costs by using multivariable modeling and performed incremental cost-effectiveness analysis with estimation of uncertainty through nonparametric bootstrapping.

RESULTS

The mean cost per infant was $193125 in the placebo group and $194702 in the iNO group (adjusted P = .17). The point estimate for the incremental cost per additional survivor without BPD was $21297. For infants in whom iNO was initiated between 7 and 14 days of life, the mean cost per infant was $187407 in the placebo group and $181525 in the iNO group (adjusted P = .46). In this group of early treated infants, there was a 71% probability that iNO actually decreased costs while improving outcomes.

CONCLUSIONS

Despite its higher price relative to many other neonatal therapies, iNO in this trial was not associated with higher costs of care, an effect that is likely due to its impact on length of stay and ventilation. Indeed, for infants who receive nitric oxide between 7 and 14 days of life, the therapy seemed to lower costs while improving outcomes.