Health care utilization by preterm infants with respiratory complications in Quebec

Cost-saving effect of early less invasive surfactant administration versus continuous positive airway pressure therapy alone for preterm infants with respiratory distress syndrome

OBJECTIVES

Early rescue surfactant therapy using less invasive surfactant administration (LISA) can reduce the need for mechanical ventilation and avoid complications in preterm infants with respiratory distress syndrome. The purpose of this study was to estimate the budget impact of LISA compared with management based on continuous positive airway pressure (CPAP) alone and rescue surfactant therapy in case of CPAP failure.

METHODS

A budget impact model was built comparing LISA with CPAP alone in order to estimate the potential resource consumption and budget impact from the perspective of the National Health Service in England. A literature review was conducted to populate the model. Deterministic and probabilistic sensitivity analyses were conducted to characterise the existing uncertainty and to explore the contribution of individual model parameters to the overall budget impact.

RESULTS

Early rescue with LISA is expected to reduce resource consumption and costs compared with conservative therapy based on CPAP alone for preterm infants born at 25-32 weeks gestation. Savings are higher for preterm infants of 25-28 weeks (expected budget impact -£5146 per case, 95% credible interval (CrI) -£22 403 to £13, probability of being cost saving 97.4%) than for preterm infants of 29-32 weeks (-£176, 95% CrI -£4279 to £339, probability of being cost saving 85%). The impact of bronchopulmonary dysplasia (BPD) and intraventricular haemorrhage on resource consumption and the expected reduction in the incidence of BPD with LISA are the most influential parameters on the budget.

CONCLUSIONS

Early rescue with LISA used in preterm infants with respiratory distress syndrome and fraction of inspired oxygen ≥0.3 is expected to be cost saving compared with management based on CPAP alone, particularly in those born at 25-28 weeks gestation.

Cost-effectiveness analysis of extended extracorporeal membrane oxygenation duration in newborns with congenital diaphragmatic hernia in the United States

BACKGROUND

The duration of extracorporeal membrane oxygenation (ECMO) has been historically confined in many centers to two weeks. We evaluated the cost-effectiveness of additional weeks on ECMO beyond two weeks for newborns with congenital diaphragmatic hernia (CDH) who may require longer stays to maximize survival potential.

METHODS

We modeled lifetime outcomes using a decision tree from the US societal perspective. Survival at discharge, probability of long-term sequelae, direct medical costs, indirect costs, and quality-adjusted life years (QALY) for long-term disability were considered. Considering the nature of severity of CDH, we used $200,000 per QALY as the willingness-to-pay threshold in the base case.

RESULTS

The lifetime costs per CDH infant generated from staying on ECMO for ≤2 weeks, 2-3 weeks, and >3 weeks are $473,334, $654,771, $1,007,476, respectively (2018 USD), and the total QALYs gained from each treatment arm are 1.83, 3.6, and 5.05. In the base case, the net monetary benefits are -$108,034 for ECMO ≤2 weeks, $64,258 for 2-3 weeks, and $2955 for >3 weeks. In probabilistic simulations, a duration of ≤2 weeks is dominated by a duration of 2-3 weeks in 65.3% of cases and dominated by > 3 weeks in 60.2% of cases. A duration of 2-3 weeks is more cost-effective than >3 weeks in 68.6% of simulations.

CONCLUSION

Our findings suggest that 2-3 weeks of ECMO may be the most cost-effective for CDH infants that are unable to wean off at 2 weeks from the US societal perspective. Regardless of ECMO duration, ECMO use generates positive incremental NMB at WTP of $200,000 if the survival probability is greater than 0.3. Future research must be conducted to evaluate the long-term outcomes and sequelae of CDH patients post-discharge to better inform the clinical decision-making in neonatal intensive care unit.

Short- and Long-Term Complications of Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in preterm infants of low birthweight who required postnatal respiratory support. Although overall incidence rates have not changed, recent advancements in medical care have resulted in lower mortality rates, and those affected are beginning to live longer. As a result, the long-term repercussions of BPD are becoming more apparent. Whereas BPD has been thought of as a disease of just the lungs, resulting in abnormalities such as increased susceptibility to pulmonary infections, impaired exercise tolerance, and pulmonary hypertension, the enduring complications of BPD have been found to extend much further. This includes an increased risk for cerebral palsy and developmental delays, lower intelligence quotient (IQ) scores, impaired executive functioning, behavioral challenges, delays in expressive and receptive language development, and an increased risk of growth failure. In addition, the deficits of BPD have been found to influence much more than just physical health; BPD survivors have been noted to have higher rates of health care use, starting with the initial hospitalization and continuing with therapy and specialist follow-up, as well as impairments in quality of life, both physical and psychological, that continue into adulthood. The long-term consequences of BPD may best be addressed through future research, including better understanding of the pathophysiologic mechanisms leading to BPD, further comparisons between newborns with BPD and those without, and long-term assessment and management of BPD patients as adults.

Systematic review of the healthcare cost of bronchopulmonary dysplasia

OBJECTIVES

To determine the costs directly or indirectly related to bronchopulmonary dysplasia (BPD) in preterm infants. The secondary objective was to stratify the costs based on gestational age and/or birth weight.

DESIGN

Systematic literature review.

SETTING

PubMed and Scopus were searched on 3 February 2020. Studies were selected based on eligibility criteria by two independent reviewers. Included studies were further searched to identify eligible references and citations.Two independent reviewers extracted data with a prespecified data extraction sheet, including items from a published checklist for quality assessment. The costs in the included studies are reported descriptively.

PRIMARY OUTCOME MEASURE

Costs of BPD.

RESULTS

The 13 included studies reported the total costs or marginal costs of BPD. Most studies reported costs during birth hospitalisation (cost range: Int$21 392-Int$1 094 509 per child, equivalent to €19 103-€977 397, in 2019) and/or during the first year of life. One study reported costs during the first 2 years; two other studies reported costs later, during the preschool period and one study included a long-term follow-up. The highest mean costs were associated with infants born at extremely low gestational ages. The quality assessment indicated a low risk of bias in the reported findings of included studies.

CONCLUSIONS

This study was the first systematic review of costs associated with BPD. We confirmed previous reports of high costs and described the long-term follow-up necessary for preterm infants with BPD, particularly infants of very low gestational age. Moreover, we identified a need for studies that estimate costs outside hospitals and after the first year of life.

PROSPERO REGISTRATION NUMBER

CRD42020173234.

Medication utilization in children born preterm in the first two years of life

OBJECTIVE

To compare medications dispensed during the first 2 years in children born preterm and full-term.

STUDY DESIGN

Retrospective analysis of claims data from a commercial national managed care plan 2008-2019. 329,855 beneficiaries were enrolled from birth through 2 years, of which 25,408 (7.7%) were preterm (<37 weeks). Filled prescription claims and paid amount over 2 years were identified.

RESULTS

In preterm children, the number of filled prescriptions was 1.4 times and cost was 3.8 times that of full-term children. Number and cost of medications were inversely related to gestational age. Differences peak at 4-9 months and resolve by 19 months after discharge. Palivizumab, ranitidine, albuterol, lansoprazole, budesonide, and prednisolone had the greatest differences in utilization.

CONCLUSION

Prescription medication utilization among preterm children under 2 years is driven by palivizumab, anti-reflux, and respiratory medications, despite little evidence regarding efficacy for many medications and concern for harm with certain classes.

Increasing Volume-Targeted Ventilation Use in the NICU

BACKGROUND

In preterm infants who require mechanical ventilation (MV), volume-targeted ventilation (VTV) modes are associated with lower rates of bronchopulmonary dysplasia compared with pressure-limited ventilation. Bronchopulmonary dysplasia rates in our NICU were higher than desired, prompting quality improvement initiatives to improve MV by increasing the use of VTV.

METHODS

We implemented and tested interventions over a 3-year period. Primary outcomes were the percentage of conventional MV hours when any-VTV mode was used and the percentage of conventional MV hours when an exclusively VTV mode was used. Exclusively VTV modes were modes in which all breaths were volume targeted. We evaluated outcomes during 3 project periods: baseline (May 2016-December 2016); epoch 1 (December 2016-October 2018), increasing the use of any-VTV mode; and epoch 2 (October 2018-November 2019), increasing the use of exclusively VTV modes.

RESULTS

Use of any-VTV mode increased from 18 694 of 22 387 (83%) MV hours during baseline to 72 846 of 77 264 (94%) and 58 174 of 60 605 (96%) MV hours during epochs 1 and 2, respectively (P < .001). Use of exclusively VTV increased from 5967 of 22 387 (27%) during baseline to 47 364 of 77 264 (61%) and 46 091 of 60 605 (76%) of all conventional MV hours during epochs 1 and 2, respectively (P < .001). In statistical process control analyses, multiple interventions were associated with improvements in primary outcomes. Measured clinical outcomes were unchanged.

CONCLUSIONS

Quality improvement interventions were associated with improved use of VTV but no change in measured clinical outcomes.

Three biomarker tests to help diagnose preterm labour: a systematic review and economic evaluation

BACKGROUND

Preterm birth may result in short- and long-term health problems for the child. Accurate diagnoses of preterm births could prevent unnecessary (or ensure appropriate) admissions into hospitals or transfers to specialist units.

OBJECTIVES

The purpose of this report is to assess the test accuracy, clinical effectiveness and cost-effectiveness of the diagnostic tests PartoSure™ (Parsagen Diagnostics Inc., Boston, MA, USA), Actim^® Partus (Medix Biochemica, Espoo, Finland) and the Rapid Fetal Fibronectin (fFN)^® 10Q Cassette Kit (Hologic, Inc., Marlborough, MA, USA) at thresholds ≠50 ng/ml [quantitative fFN (qfFN)] for women presenting with signs and symptoms of preterm labour relative to fFN at 50 ng/ml.

METHODS

Systematic reviews of the published literature were conducted for diagnostic test accuracy (DTA) studies of PartoSure, Actim Partus and qfFN for predicting preterm birth, the clinical effectiveness following treatment decisions informed by test results and economic evaluations of the tests. A model-based economic evaluation was also conducted to extrapolate long-term outcomes from the results of the diagnostic tests. The model followed the structure of the model that informed the 2015 National Institute for Health and Care Excellence guidelines on preterm labour diagnosis and treatment, but with antenatal steroids use, as opposed to tocolysis, driving health outcomes.

RESULTS

Twenty studies were identified evaluating DTA against the reference standard of delivery within 7 days and seven studies were identified evaluating DTA against the reference standard of delivery within 48 hours. Two studies assessed two of the index tests within the same population. One study demonstrated that depending on the threshold used, qfFN was more or less accurate than Actim Partus, whereas the other indicated little difference between PartoSure and Actim Partus. No study assessing qfFN and PartoSure in the same population was identified. The test accuracy results from the other included studies revealed a high level of uncertainty, primarily attributable to substantial methodological, clinical and statistical heterogeneity between studies. No study compared all three tests simultaneously. No clinical effectiveness studies evaluating any of the three biomarker tests were identified. One partial economic evaluation was identified for predicting preterm birth. It assessed the number needed to treat to prevent a respiratory distress syndrome case with a 'treat-all' strategy, relative to testing with qualitative fFN. Because of the lack of data, our de novo model involved the assumption that management of pregnant women fully adhered to the results of the tests. In the base-case analysis for a woman at 30 weeks' gestation, Actim Partus had lower health-care costs and fewer quality-adjusted life-years (QALYs) than qfFN at 50 ng/ml, reducing costs at a rate of £56,030 per QALY lost compared with qfFN at 50 ng/ml. PartoSure is less costly than Actim Partus while being equally effective, but this is based on diagnostic accuracy data from a small study. Treatment with qfFN at 200 ng/ml and 500 ng/ml resulted in lower cost savings per QALY lost relative to fFN at 50 ng/ml than treatment with Actim Partus. In contrast, qfFN at 10 ng/ml increased QALYs, by 0.002, and had a cost per QALY gained of £140,267 relative to fFN at 50 ng/ml. Similar qualitative results were obtained for women presenting at different gestational ages.

CONCLUSION

There is a high degree of uncertainty surrounding the test accuracy and cost-effectiveness results. We are aware of four ongoing UK trials, two of which plan to enrol > 1000 participants. The results of these trials may significantly alter the findings presented here.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42017072696.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Lifelong pulmonary sequelae of bronchopulmonary dysplasia

PURPOSE OF REVIEW

To summarize the current literature evaluating long-term pulmonary morbidity among surviving very preterm infants with bronchopulmonary dysplasia (BPD).

RECENT FINDINGS

BPD predisposes very preterm infants to adverse respiratory signs and symptoms, greater respiratory medication use, and more frequent need for rehospitalization throughout early childhood. Reassuringly, studies also indicate that older children and adolescents with BPD experience, on average, similar functional status and quality of life when compared to former very preterm infants without BPD. However, measured deficits in pulmonary function may persist in those with BPD and indicate an increased susceptibility to early-onset chronic obstructive pulmonary disease during adulthood. Moreover, subtle differences in exercise tolerance and activity may put survivors with BPD at further risk of future morbidity in later life.

SUMMARY

Despite advances in neonatal respiratory care, a diagnosis of BPD continues to be associated with significant pulmonary morbidity over the first two decades of life. Long-term longitudinal studies are needed to determine if recent survivors of BPD will also be at increased risk of debilitating pulmonary disease in adulthood.

Lifetime patient outcomes and healthcare utilization for Bronchopulmonary dysplasia (BPD) and extreme preterm infants: a microsimulation study

BACKGROUND

Bronchopulmonary dysplasia (BPD) is among the most severe chronic lung diseases and predominantly affects premature infants. There is a general understanding of BPD's significant impact on the short-term outcomes however there is little evidence on long-term outcomes. Our study estimates the lifetime clinical outcomes, quality of life, and healthcare costs of BPD and associated complications.

METHODS

We developed a microsimulation model to estimate lifetime clinical and economic burden of BPD among extreme preterm infants (≤28 weeks gestational age at birth) and validated it against the best available Canadian data. We further estimate the cumulative incidence of major complications associated with BPD, differentiated by BPD severity and gestational age category.

RESULTS

We find, on average, patients with BPD and resulting complications will incur over CAD$700,000 in lifetime health systems costs. We also find the average life expectancy of BPD patients to be moderately less than that of the general population and significant reductions in quality-adjusted life year due to major complications. Healthcare utilization and quality of life measures vary dramatically according to BPD severity, suggesting significant therapeutic headroom for interventions that can prevent or mitigate the effects of BPD for patients.

CONCLUSIONS

Our study adds a significant expansion of existing evidence by presenting the lifetime burden of BPD based on key patient characteristics. Given the extreme cost burden at the earliest stage of life and lifetime negative impact on quality of life, there is larger headroom for investment in prevention and mitigation of severe BPD than is currently available.

Respiratory Medications in Infants <29 Weeks during the First Year Postdischarge: The Prematurity and Respiratory Outcomes Program (PROP) Consortium

OBJECTIVE

To determine patterns of respiratory medications used in neonatal intensive care unit graduates.

STUDY DESIGN

The Prematurity Respiratory Outcomes Program enrolled 835 babies <29 weeks of gestation in the first week. Of 751 survivors, 738 (98%) completed at least 1, and 85% completed all 4, postdischarge medication usage in-person/telephone parental questionnaires requested at 3, 6, 9, and 12 months of corrected age. Respiratory drug usage over the first year of life after in neonatal intensive care unit discharge was analyzed.

RESULTS

During any given quarter, 66%-75% of the babies received no respiratory medication and 45% of the infants received no respiratory drug over the first year. The most common postdischarge medication was the inhaled bronchodilator albuterol; its use increased significantly from 13% to 31%. Diuretic usage decreased significantly from 11% to 2% over the first year. Systemic steroids (prednisone, most commonly) were used in approximately 5% of subjects in any one quarter. Inhaled steroids significantly increased over the first year from 9% to 14% at 12 months. Drug exposure changed significantly based on gestational age with 72% of babies born at 23-24 weeks receiving at least 1 respiratory medication but only 40% of babies born at 28 weeks. Overall, at some time in the first year, 55% of infants received at least 1 drug including an inhaled bronchodilator (45%), an inhaled steroid (22%), a systemic steroid (15%), or diuretic (12%).

CONCLUSION

Many babies born at <29 weeks have no respiratory medication exposure postdischarge during the first year of life. Inhaled medications, including bronchodilators and steroids, increase over the first year.

Health Care and Societal Costs of Bronchopulmonary Dysplasia

Despite significant technological advances and increasing survival of premature infants, bronchopulmonary dysplasia (BPD) continues to be the most prevalent major morbidity in surviving very low-birthweight infants. Infants with BPD are often sicker, require longer stays in the NICU, and accumulate greater hospital costs. However, care of the infant with BPD extends beyond the time spent in the NICU. This article reviews the costs of BPD in the health-care setting, during the initial hospitalization and beyond, and the long-term neurodevelopmental impact of BPD, as well as the impact on a family caring for a child with BPD.

Comparison of Follow-up Courses after Discharge from Neonatal Intensive Care Unit between Very Low Birth Weight Infants with and without Home Oxygen

In order to investigate the clinical impact of home oxygen use for care of premature infants, we compared the follow-up courses after neonatal intensive care unit (NICU) discharge between very low birth weight infants (VLBWIs) with and without home oxygen. We retrospectively identified 1,232 VLBWIs born at 22 to 32 weeks of gestation, discharged from the NICU of 43 hospitals in Korea between April 2009 and March 2010, and followed them up until April 2011. Clinical outcomes, medical service uses, and readmission and death rates during follow-up after the NICU discharge were compared between VLBWIs with (HO, n = 167) and those without (CON, n = 1,056) home oxygen at discharge. The HO infants comprised 13.7% of the total VLBWIs with significant institutional variations and showed a lower gestational age (GA) and birth weight than the CON infants. The HO infants had more frequent regular pediatric outpatient clinic visits (12.7 ± 7.5 vs. 9.5 ± 6.6; P < 0.010) and emergency center visits related to respiratory problems (2.5 ± 2.2 vs. 1.8 ± 1.4; P < 0.010) than the CON infants. The HO infants also had significantly increased readmission (adjusted hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.25-2.04) and death risks (adjusted HR, 7.40; 95% CI, 2.06-26.50) during up to 2 years following the NICU discharge. These increased readmission and death risks in the HO infants were not related to their prematurity degree. In conclusion, home oxygen use after discharge increases the risks for healthcare utilization, readmission, and death after NICU discharge in VLBWIs, regardless of GA, requiring more careful health care monitoring during their follow-up.

Hospital Admission and Emergency Department Utilization in an Infant Medicaid Population

BACKGROUND AND OBJECTIVE

In the first year of life, the rate of rehospitalization for infants has been shown to be between 4.4% and 9.5%. Reducing avoidable health care utilization is a population health priority. The goal of this study was to identify maternal and infant factors associated with rehospitalization and emergency department (ED) utilization in a cohort of newborn Medicaid recipients.

METHODS

A longitudinal database was created by linking mother-infant dyads giving birth at a regional perinatal referral center with Delaware state Medicaid data. Multivariable logistic regression and negative binomial regression were used to examine inpatient hospitalization and ED utilization within 6 months after birth.

RESULTS

The study cohort included 4112 infants; 452 (11.0%) were rehospitalized, and 1680 (41%) used the ED within 6 months of birth. Variables independently associated with inpatient rehospitalization included NICU admission (odds ratio [OR]: 1.7 [95% confidence interval (CI): 1.3-2.3]), maternal bipolar diagnosis (OR: 1.5 [95% CI: 1.1-2.2]), count of maternal prenatal hospital admissions (OR: 1.3 [95% CI: 1.1-1.5]), and count of maternal ED visits (OR: 1.08 [95% CI: 1.04-1.1]). Black race (incident rate ratio [IRR]: 1.2 [95% CI: 1.1-1.3]), fall birth (IRR: 1.2 [95% CI: 1.01-1.3]), count of maternal ED visits (IRR: 1.1 [95% CI: 1.09-1.12]), number of maternal medications (IRR: 1.02 [95% CI: 1.01-1.03]), and maternal age (IRR: 0.97 [95% CI: 0.96-0.98]) were associated with ED utilization.

CONCLUSIONS

In this newborn Medicaid population, multiple maternal factors (including age, race, and mental health diagnoses) were associated with health care utilization in the 6 months after initial hospital discharge. Our data provide potential risk factors for targeted intervention and suggest that maternal factors should be considered in identifying a population at risk for rehospitalization and ED utilization.

Should we still use vitamin A to prevent bronchopulmonary dysplasia?

Bronchopulmonary dysplasia (BPD) is associated with significant short- and long-term morbidity in preterm infants, and it can be prevented in some infants with vitamin A prophylaxis. Vitamin A, once widely used in neonatal intensive care, was scarce for the last few years, but has become available again at a much higher price, leading to dilemmas about its routine use. In this review we discuss experimental, clinical and socioeconomic evidence related to BPD, and provide a framework for clinicians and policy-makers to evaluate the value of vitamin A treatment and make decisions about its use for prevention of BPD.

Sustained Reduction in Bloodstream Infections in Infants at a Large Tertiary Care Neonatal Intensive Care Unit

BACKGROUND

Bloodstream infections (BSI) cause significant morbidity and mortality among hospitalized infants.

PURPOSE

Reduction of BSIs has emerged as an important patient safety goal. Implementation of central line insertion bundles, standardized line care protocols, and health care provider education programs have reduced BSI in NICUs around the country. The ability of large tertiary care centers to decrease nosocomial infections, including BSI, has been demonstrated. However, long-term BSI reductions in infants are not well documented. We sought to demonstrate that a low incidence of BSI can be maintained over time in a tertiary care NICU.

RESULTS

Baseline BSI incidence for infants admitted to the NICU was 5.15 and 6.08 episodes per 1000 infant-days in 2005 and 2006, respectively. After protocol implementation, the incidence of BSI decreased to 2.14/1000 infant-days and 2.44/1000 infant-days in 2008 and 2009, respectively. Yearly incidence remained low over the next 4 years and decreased even further to 0.20 to 0.45 infections per 1000 infant-days. This represents a 92% decrease in BSI over a period of more than 5 years.

IMPLICATIONS FOR PRACTICE

Implementation of a nursing-led comprehensive infection control initiative can effectively produce and maintain a reduction in the incidence of BSI in infants at a large tertiary care NICU.

IMPLICATIONS FOR RESEARCH

Additional research is needed to effectively expand prevention of central line-associated BSIs to BSIs of all etiologies.

Does chronic oxygen dependency in preterm infants with bronchopulmonary dysplasia at NICU discharge predict respiratory outcomes at 3 years of age?

OBJECTIVE

To determine whether chronic oxygen dependency at the time of discharge from the neonatal intensive care unit (NICU) in infants with bronchopulmonary dysplasia (BPD) predicts respiratory outcomes at 3 years.

STUDY DESIGN

Preterm infants ⩽1250 g without BPD, BPD and BPD with chronic oxygen dependency were identified from the Southern Alberta Perinatal Follow-up clinic database (1995-2007). Respiratory outcomes at 4, 8, 18 and 36 months corrected age following NICU discharge were examined. Univariate analyses were done.

RESULTS

Out of 1563 infants admitted to the NICU, 1212 survived. Complete follow-up data at 36 months were available for 1030 (85%) children. Children with BPD with or without chronic oxygen dependency had significantly (P<0.001) lower birth weights and gestational ages, and greater post-natal steroid use, compared with those with no BPD. At 4, 8 and 18 months follow-up, the use of respiratory medications and supplemental oxygen were both significantly higher in the BPD infants with chronic oxygen dependency group compared with the no-BPD group and BPD group. At 36 months, children in the BPD with chronic oxygen dependency group were more likely to use respiratory medications and supplemental oxygen vs the no-BPD or the BPD groups. At 4, 8 and 36 months of age, more children in the BPD with chronic oxygen dependency group had post-neonatal chronic lung disease (PNCLD) than children in the other groups, but at 36 months the difference was significant only for the BPD with chronic oxygen dependency vs no-BPD group (P<0.001).

CONCLUSIONS

At 36 months, children diagnosed with BPD with chronic oxygen dependency at NICU discharge were more likely to need respiratory medications and supplemental oxygen in the previous 12 months, as compared with no-BPD or BPD groups. They were also more likely to require frequent physician visits and have PNCLD at 3 years, as compared with the no-BPD group.

Resolvin D1 and lipoxin A4 improve alveolarization and normalize septal wall thickness in a neonatal murine model of hyperoxia-induced lung injury

Background

The critical fatty acids Docosahexaenoic Acid (DHA) and Arachidonic Acid (AA) decline in preterm infants within the first postnatal week and are associated with neonatal morbidities, including bronchopulmonary dysplasia (BPD). DHA and AA are precursors to downstream metabolites that terminate the inflammatory response. We hypothesized that treatment with Resolvin D1 and/or Lipoxin A₄ would prevent lung injury in a murine model of BPD.

Objective

To determine the effect of Resolvin D1 and/or Lipoxin A4 on hyperoxia-induced lung injury.

Methods

C57/BL6 pups were randomized at birth to Room Air, Hyperoxia (>90% oxygen), Hyperoxia + Resolvin D1, Hyperoxia + Lipoxin A₄, or Hyperoxia + Resolvin D1/Lipoxin A₄. Resolvin D1 and/or Lipoxin A₄ (2 ng/g) were given IP on days 0, 3, 6, and 9. On day 10, mice were sacrificed and lungs collected for morphometric analyses including Mean Linear Intercept (MLI), Radial Alveolar Count (RAC), and Septal Thickness (ST); RT-PCR analyses of biomarkers of lung development and inflammation; and ELISA for TGFβ₁ and TGFβ₂.

Result

The increased ST observed with hyperoxia exposure was normalized by both Resolvin D1 and Lipoxin A₄; while, hyperoxia-induced alveolar simplification was attenuated by Lipoxin A₄. Relative to hyperoxia, Resolvin D1 reduced the gene expression of CXCL2 (2.9 fold), TIMP1 (6.7 fold), and PPARγ (4.8 fold). Treatment with Lipoxin A₄ also led to a reduction of CXCL2 (2.4 fold) while selectively increasing TGFβ₂ (2.1 fold) and Smad3 (1.58 fold).

Conclusion

The histologic and biochemical changes seen in hyperoxia-induced lung injury in this murine model can be reversed by the addition of DHA and AA fatty acid downstream metabolites that terminate the inflammatory pathways and modulate growth factors. These fatty acids or their metabolites may be novel therapies to prevent or treat lung injury in preterm infants.

The economic burden of prematurity in Canada

Background

Preterm birth is a major risk factor for morbidity and mortality among infants worldwide, and imposes considerable burden on health, education and social services, as well as on families and caregivers. Morbidity and mortality resulting from preterm birth is highest among early (< 28 weeks gestational age) and moderate (28–32 weeks) preterm infants, relative to late preterm infants (33–36 weeks). However, substantial societal burden is associated with late prematurity due to the larger number of late preterm infants relative to early and moderate preterm infants.

Methods

The aim in this study was to characterize the burden of premature birth in Canada for early, moderate, and late premature infants, including resource utilization, direct medical costs, parental out-of-pocket costs, education costs, and mortality, using a validated and published decision model from the UK, and adapting it to a Canadian setting based on analysis of administrative, population-based data from Québec.

Results

Two-year survival was estimated at 56.0% for early preterm infants, 92.8% for moderate preterm infants, and 98.4% for late preterm infants. Per infant resource utilization consistently decreased with age. For moderately preterm infants, hospital days ranged from 1.6 at age two to 0.09 at age ten. Cost per infant over the first ten years of life was estimated to be $67,467 for early preterm infants, $52,796 for moderate preterm infants, and $10,010 for late preterm infants. Based on population sizes this corresponds to total national costs of $123.3 million for early preterm infants, $255.6 million for moderate preterm infants, $208.2 million for late preterm infants, and $587.1 million for all infants.

Conclusion

Premature birth results in significant infant morbidity, mortality, healthcare utilization and costs in Canada. A comprehensive decision-model based on analysis of a Canadian population-based administrative data source suggested that the greatest national-level burden is associated with moderate preterm infants due to both a large cost per infant and population size while the highest individual-level burden is in early preterm infants and the largest total population size is in late preterm infants. Although the highest medical costs are incurred during the neonatal period, greater resource utilization and costs extend into childhood.

Healthcare utilization and health-related quality of life of adult survivors of preterm birth complicated by bronchopulmonary dysplasia

AIM

This study aims to characterize the impact of preterm birth, respiratory distress syndrome and bronchopulmonary dysplasia on quality of life and healthcare utilization in adulthood.

METHODS

A mail survey on quality of life and respiratory health was sent to a list of potential subjects identified using the databases of the Régie de l'asssurance maladie du Québec. Four groups of adults born between 1987 and 1993 were compared: (i) preterm with bronchopulmonary dysplasia, (ii) preterm with respiratory distress syndrome, (iii) preterm without respiratory complications and (iv) term controls. As a complement, data from the governmental healthcare administrative databases were extracted for responders.

RESULTS

Although the groups differed in their use of healthcare services and prescription drugs, no clinically significant difference was observed for Saint George's Respiratory Questionnaire (SGRQ), SF-36v2 and Medical Research Council (MRC) Dyspnea Scale scores. However, compared to term subjects, bronchopulmonary dysplasia subjects were less likely to access higher education and more likely to be either invalid or unemployed.

CONCLUSION

Compared to term subjects, subjects with a history of prematurity and respiratory distress syndrome or bronchopulmonary dysplasia had similar health-related quality of life and respiratory symptoms despite greater use of healthcare services and prescription drugs.