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King WE, Carlo WA, O'Shea TM, Schelonka RL. Cost-effectiveness analysis of heart rate characteristics monitoring to improve survival for very low birth weight infants. FRONTIERS IN HEALTH SERVICES 2022; 2:960945. [PMID: 36925786 PMCID: PMC10012671 DOI: 10.3389/frhs.2022.960945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022]
Abstract
Introduction Over 50,000 very low birth weight (VLBW) infants are born each year in the United States. Despite advances in care, these premature babies are subjected to long stays in a neonatal intensive care unit (NICU), and experience high rates of morbidity and mortality. In a large randomized controlled trial (RCT), heart rate characteristics (HRC) monitoring in addition to standard monitoring decreased all-cause mortality among VLBW infants by 22%. We sought to understand the cost-effectiveness of HRC monitoring to improve survival among VLBW infants. Methods We performed a secondary analysis of cost-effectiveness of heart rate characteristics (HRC) monitoring to improve survival from birth to NICU discharge, up to 120 days using data and outcomes from an RCT of 3,003 VLBW patients. We estimated each patient's cost from a third-party perspective in 2021 USD using the resource utilization data gathered during the RCT (NCT00307333) during their initial stay in the NICU and applied to specific per diem rates. We computed the incremental cost-effectiveness ratio and used non-parametric boot-strapping to evaluate uncertainty. Results The incremental cost-effectiveness ratio of HRC-monitoring was $34,720 per life saved. The 95th percentile of cost to save one additional life through HRC-monitoring was $449,291. Conclusion HRC-monitoring appears cost-effective for increasing survival among VLBW infants.
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Affiliation(s)
- William E King
- Medical Predictive Science Corporation, Charlottesville, VA, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - T Michael O'Shea
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Robert L Schelonka
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States
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Evers PD, Critser PJ, Cash M, Magness M, Hoelle S, Hirsch R. Cost-Utility of Sildenafil for Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2021; 38:1505-1512. [PMID: 32615617 DOI: 10.1055/s-0040-1713819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE While advanced therapies for severe persistent pulmonary hypertension of the newborn (PPHN) such as inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) are standard treatments in high-income countries, these therapies are often unavailable in resource-limited settings such as middle-income countries. However, there are small clinical trials illustrating the efficacy of sildenafil at reducing mortality in PPHN. This analysis sought to determine the cost-utility of enteral sildenafil for the treatment of severe PPHN. STUDY DESIGN A Markov-state transition model was constructed for the two clinical approaches to compare costs, clinical outcomes, and quality of life: (1) "conventional," (2) "sildenafil." The impact of sildenafil was modeled as a relative risk modifier of the conventional strategy's mortality risk. Transitional probabilities, costs, and utility metrics were extracted from the literature. Sensitivity analyses for each model input as well as 100-patient Monte Carlo simulations were used to test the durability of the model conclusion. RESULTS The sildenafil strategy was cost-effective for upper but not lower middle-income countries with an incremental cost-effectiveness ratio of $2,339 per quality-adjusted life year. This conclusion was durable across a wide-range of model assumptions; the sildenafil strategy only failed to meet criteria for cost-effectiveness when sildenafil therapy had a mortality relative risk efficacy of >0.89, if life expectancy in that country is <40 years, or if the lifetime forecasted costs of a survivor's life was quite high. CONCLUSION Enteral sildenafil is a cost-effective intervention for severe PPHN for upper middle-income countries where ECMO and iNO are not available. KEY POINTS · PPHN is a common life-threatening condition in newborns.. · Sildenafil improves survival of PPHN.. · Sildenafil is cost-effective for upper-middle income countries..
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Affiliation(s)
- Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, Oregon
| | - Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michelle Cash
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Melissa Magness
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Susan Hoelle
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Russel Hirsch
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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3
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A quality improvement project improving the value of iNO utilization in preterm and term infants. J Perinatol 2021; 41:164-172. [PMID: 32770031 DOI: 10.1038/s41372-020-0768-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/26/2020] [Accepted: 07/28/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Inhaled NO (iNO) is used in the NICU for management of hypoxemic respiratory failure. The cost of iNO is significant and does not consistently improve outcomes in infants <34 weeks. PROJECT DESIGN Our team used The Model for Improvement to design a quality improvement project to utilize iNO for appropriate indications, ensure response to therapy and initiate timely weaning. The project was carried out at a Level IV NICU and successful interventions spread to a smaller Level III NICU. RESULTS This project demonstrated significant improvement in all measures; total iNO hours per month, average iNO hours per patient, and the percentage of prolonged iNO courses. With an estimated cost of $115/h, the cost per patient for iNO use declined by half from $21,620 to $10,580. CONCLUSIONS Our team improved the value of iNO utilization at our institution and spread successful interventions to another NICU in our network.
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Bearl DW, Dodd DA, Thurm C, Hall M, Soslow JH, Feingold B, Godown J. Practice Variation, Costs and Outcomes Associated with the Use of Inhaled Nitric Oxide in Pediatric Heart Transplant Recipients. Pediatr Cardiol 2019; 40:650-657. [PMID: 30547294 PMCID: PMC6855671 DOI: 10.1007/s00246-018-2042-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/08/2018] [Indexed: 01/06/2023]
Abstract
Right ventricular (RV) failure is a potentially fatal complication following heart transplantation (HTx). Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator that is used to decrease pulmonary vascular resistance immediately post-HTx to reduce the risk of RV failure. The aim of this study was to describe utilization patterns, costs, and outcomes associated with post-transplant iNO use in children. All pediatric HTx recipients (2002-2016) were identified from a unique linked PHIS/SRTR dataset. Post-HTx iNO use was determined based on hospital billing data. Utilization patterns and associated costs were described. The association of iNO support with post-HTx survival was assessed using the Kaplan-Meier method and a multivariable Cox proportional hazards model was used to adjust for risk factors. A total of 2833 pediatric HTx recipients from 28 centers were identified with 1057 (36.5%) receiving iNO post-HTx. Post-HTx iNO use showed significant increase overall (17.2-54.7%, p < 0.001) and wide variation among centers (9-100%, p < 0.001). Patients with congenital heart disease (aOR 1.4, 95% CI 1.2, 1.6), requiring mechanical ventilation at HTx (aOR 1.3, 95% CI 1.1, 1.6), and pre-transplant iNO (aOR 9.3, 95% CI 5.4, 16) were more likely to receive iNO post-HTx. The median daily cost of iNO was $2617 (IQR $1843-$3646). Patients who required > 5 days of iNO post-HTx demonstrated inferior 1-year post-HTx survival (p < 0.001) and iNO use > 5 days was independently associated with worse post-HTx survival (AHR 1.6, 95% CI 1.2, 2.1; p < 0.001). There is wide variation in iNO use among centers following pediatric HTx with use increasing over time despite significant incremental cost. Prolonged iNO use post-HTx is associated with worse survival, likely serving as a marker of residual illness severity. Further research is needed to define the populations that derive the greatest benefit from this costly therapy.
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Affiliation(s)
- David W Bearl
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA.
| | - Debra A Dodd
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA
| | - Cary Thurm
- Children's Hospital Association, Lenexa, KS, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Jonathan H Soslow
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA
| | - Brian Feingold
- Pediatrics and Clinical and Translational Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Godown
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA
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Kilchemmann Fuentes C, Vallejos Vallejos C, Román Navarro A. Costo efectividad y análisis de impacto presupuestario del óxido nítrico inhalatorio neonatal en un hospital, desde la perspectiva del sistema público de salud. ACTA ACUST UNITED AC 2016; 87:463-467. [DOI: 10.1016/j.rchipe.2016.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/30/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
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Dukhovny D, Pursley DM, Kirpalani HM, Horbar JH, Zupancic JAF. Evidence, Quality, and Waste: Solving the Value Equation in Neonatology. Pediatrics 2016; 137:e20150312. [PMID: 26908677 DOI: 10.1542/peds.2015-0312] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2015] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Dmitry Dukhovny
- Department of Pediatrics and Doernbecher Neonatal Care Center, Oregon Health and Science University, Portland, Oregon; Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts;
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Haresh M Kirpalani
- Division of Neonatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; and
| | - Jeffrey H Horbar
- University of Vermont and Vermont Oxford Network, Burlington, Vermont
| | - John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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7
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Konduri GG, Menzin J, Frean M, Lee T, Potenziano J, Singer J. Inhaled nitric oxide in term/late preterm neonates with hypoxic respiratory failure: estimating the financial impact of earlier use. J Med Econ 2015; 18:612-8. [PMID: 25853867 DOI: 10.3111/13696998.2015.1038270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We reported recently that early use of inhaled nitric oxide therapy (iNO) for term and late preterm infants with hypoxic respiratory failure (HRF) at an oxygenation index (OI) of ≥15 and <20 is associated with earlier discharge from the hospital, relative to babies treated at OI ≥25. The objective of the present analysis is to determine whether earlier use of iNO in this cohort leads to lower cost of medical care. METHODS We used a decision-analytic model, which was developed to compare hospital resource use and costs associated with early versus standard use of iNO in HRF. The model population included infants with moderate HRF caused by primary pulmonary hypertension with an OI ≥15 and <20. A hypothetical case population of 1000 patients was assumed and probabilistic sensitivity analyses were completed where all the clinical inputs into the model were varied. Two deterministic sensitivity analyses were also completed, one surrounding the hospital cost inputs and another surrounding the cost of iNO. RESULTS Early iNO was associated with fewer hospital days, fewer days of ventilation and fewer hours on extracorporeal membrane oxygenation (ECMO). In probabilistic sensitivity analyses, total costs per patient were $88,518 ± $7574 and $92,581 ± $9664 for early iNO and standard iNO, respectively. The probability of early iNO being cost-effective was approximately 72%, based on a willingness to pay $100,000 or less to prevent ECMO therapy and/or death. In both deterministic sensitivity analyses, early iNO was cost-saving. CONCLUSION Our analysis shows that early use of iNO at an OI of ≥15 and <20 may be associated with shorter hospitalizations and a decreased cost of care for term/late preterm infants with HRF associated with pulmonary hypertension. Our results are based on clinical data from a single trial; future research using data from real-world practice is warranted.
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Affiliation(s)
- G Ganesh Konduri
- a a Division of Neonatology, Department of Pediatrics and Children's Research Institute , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Joseph Menzin
- b b Boston Health Economics Inc. , Waltham , MA , USA
| | - Molly Frean
- b b Boston Health Economics Inc. , Waltham , MA , USA
| | - Terry Lee
- c c Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital , Vancouver , BC , Canada
| | | | - Joel Singer
- c c Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital , Vancouver , BC , Canada
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Yaseen H, Darwich M, Hamdy H. Is sildenafil an effective therapy in the management of persistent pulmonary hypertension? J Clin Neonatol 2014; 1:171-5. [PMID: 24027721 PMCID: PMC3762043 DOI: 10.4103/2249-4847.105958] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a life-threatening neonatal pathology resulting from poor hemodynamic and respiratory transition to extra uterine life. Inhaled nitric oxide (iNO) is a current, commonly used treatment of PPHN. However, iNO is not available therapy in many developing countries and around 50% of infants with PPHN do not respond to iNO therapy. Sildenafil is a phosphodiesterase inhibitor type 5 (PDE5) that has been shown to selectively reduce pulmonary vascular resistance in both animal models and adult humans. Recent studies have found that in PPHN, administration of Sildenafil was associated with a significant increase in the oxygenation and a reduction in mortality with no clinically important side effects.
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Affiliation(s)
- Hakam Yaseen
- Department of Pediatric, University Hospital Sharjah, Sharjah, United Arab Emirates
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9
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Abstract
OBJECTIVES To determine the effect of vasopressin therapy on the efficacy of oxygenation and arterial pressure in infants with severe persistent pulmonary hypertension of the newborn. DESIGN Retrospective case study. SETTING Neonatal ICU, Hospital for Sick Children, Toronto, Canada. SUBJECTS Neonates with severe persistent pulmonary hypertension. INTERVENTION Intravenous infusion of vasopressin. MEASUREMENTS AND MAIN RESULTS Ten infants satisfied the inclusion criteria. Inhaled nitric oxide was used for median (interquartile range) duration of 15 hours (11-28 hr) prior to vasopressin commencement. Vasopressin was initiated at a mean dose of 0.0002 ± 0.0002 U/kg/min for a median (interquartile range) duration of 49 hours (13-95 hr). Administration of vasopressin was associated with an improvement in oxygenation index, peak effect 6 hours after drug initiation (p = 0.01), and a reduction in inhaled nitric oxide dose (p < 0.05). There was a concomitant improvement in blood pressure (p < 0.05) and urine output (p < 0.05), without drop in the serum sodium level or worsening in serum lactate level. CONCLUSIONS Although there is limited experience of vasopressin use in persistent pulmonary hypertension of the newborn infants, our case series suggests it to be a potential adjunctive therapy for improving the efficacy of oxygenation and systemic hypotension. A prospective randomized trial is needed to confirm its efficacy and safety in the management of severe persistent pulmonary hypertension of the newborn.
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10
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Son SB, Kim KA, Yun SY, Ko SY, Lee YK, Shin SM. Oral Sildenafil in Persistent Pulmonary Hypertension of the Newborn. ACTA ACUST UNITED AC 2011. [DOI: 10.5385/jksn.2011.18.1.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Su Bin Son
- Department of Pediatrics, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
| | - Kyung Ah Kim
- Department of Pediatrics, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
| | - So Young Yun
- Department of Pediatrics, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
| | - Sun Young Ko
- Department of Pediatrics, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
| | - Yeon Kyung Lee
- Department of Pediatrics, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
| | - Son Moon Shin
- Department of Pediatrics, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
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11
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Armstrong EP, Dhanda R. Cost-effectiveness of early compared to late inhaled nitric oxide therapy in near-term infants. Curr Med Res Opin 2010; 26:2795-800. [PMID: 21050057 DOI: 10.1185/03007995.2010.533649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the cost-effectiveness of early versus late inhaled nitric oxide (INO) therapy in neonates with hypoxic respiratory failure initially managed on conventional mechanical ventilation. RESEARCH DESIGN A decision analytic model was created to compare the use of early INO compared to delayed INO for neonates receiving mechanical ventilation due to hypoxic respiratory failure. The perspective of the model was that of a hospital. Patients who did not respond to either early or delayed INO were assumed to have been treated with extracorporeal membrane oxygenation (ECMO). The effectiveness measure was defined as a neonate discharged alive without requiring ECMO therapy. A Monte Carlo simulation of 10,000 cases was conducted using first and second order probabilistic analysis. Direct medical costs that differed between early versus delayed INO treatment were estimated until time to hospital discharge. The proportion of successfully treated patients and costs were determined from the probabilistic sensitivity analysis. RESULTS The mean (± SD) effectiveness rate for early INO was 0.75 (± 0.08) and 0.61 (± 0.09) for delayed INO. The mean hospital cost for early INO was $21,462 (± $2695) and $27,226 (± $3532) for delayed INO. In 87% of scenarios, early INO dominated delayed INO by being both more effective and less costly. The acceptability curve between products demonstrated that early INO had over a 90% probability of being the most cost-effective treatment across a wide range of willingness to pay values. CONCLUSIONS This analysis indicated that early INO therapy was cost-effective in neonates with hypoxic respiratory failure requiring mechanical ventilation compared to delayed INO by reducing the probability of developing severe hypoxic respiratory failure. There was a 90% or higher probability that early INO was more cost-effective than delayed INO across a wide range of willingness to pay values in this analysis.
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MESH Headings
- Administration, Inhalation
- Algorithms
- Cost-Benefit Analysis
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/economics
- Infant, Newborn, Diseases/therapy
- Nitric Oxide/administration & dosage
- Nitric Oxide/economics
- Respiration, Artificial/economics
- Respiratory Distress Syndrome, Newborn/economics
- Respiratory Distress Syndrome, Newborn/epidemiology
- Respiratory Distress Syndrome, Newborn/therapy
- Respiratory Therapy/economics
- Respiratory Therapy/methods
- Term Birth/physiology
- Time Factors
- Treatment Outcome
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Watson RS, Clermont G, Kinsella JP, Kong L, Arendt RE, Cutter G, Linde-Zwirble WT, Abman SH, Angus DC. Clinical and economic effects of iNO in premature newborns with respiratory failure at 1 year. Pediatrics 2009; 124:1333-43. [PMID: 19841128 DOI: 10.1542/peds.2009-0114] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The long-term consequences of inhaled nitric oxide (iNO) use in premature newborns with respiratory failure are unknown. We therefore studied the clinical and economic outcomes to 1 year of corrected age after a randomized controlled trial of prophylactic iNO. METHODS Premature newborns (gestational age <or=34 w, birth weight 500-1250 g) with respiratory failure randomly received 5 ppm iNO or placebo within 48 h of birth until 21 d or extubation. We assessed clinical outcomes via in-person neurodevelopmental evaluation at 1 y corrected age and telephone interviews every 3 m. We estimated costs from detailed hospital bills and interviews, converting all costs to 2008 US$. Of 793 trial subjects, 631 (79.6%) contributed economic data, and 455 (77.1% of survivors) underwent neurodevelopmental evaluation. RESULTS At 1 y corrected age, survival was not different by treatment arm (79.2% iNO vs. 74.5% placebo, P = .12), nor were other post-discharge outcomes. For subjects weighing 750-999 g, those receiving iNO had greater survival free from neurodevelopmental impairment (67.9% vs. 55.6%, P = .04). However, in subjects weighing 500-749 g, iNO led to greater oxygen dependency (11.7% vs. 4.0%, P = .04). Median total costs were similar ($235,800 iNO vs. $198,300 placebo, P = .19). Quality-adjusted survival was marginally better with iNO (by 0.011 quality-adjusted life-years/subject). The incremental cost-effectiveness ratio was $2.25 million/quality-adjusted life-year. CONCLUSIONS Subjects in both arms commonly experienced neurodevelopmental and pulmonary morbidity, consuming substantial health care resources. Prophylactic iNO beginning in the first days of life did not lower costs and had a poor cost-effectiveness profile.
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Affiliation(s)
- R Scott Watson
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
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13
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Zupancic JAF, Hibbs AM, Palermo L, Truog WE, Cnaan A, Black DM, Ballard PL, Wadlinger SR, Ballard RA. Economic evaluation of inhaled nitric oxide in preterm infants undergoing mechanical ventilation. Pediatrics 2009; 124:1325-32. [PMID: 19841125 DOI: 10.1542/peds.2008-3214] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- John A F Zupancic
- Division of Newborn Medicine, Harvard Medical School, Boston, Massachusetts, USA.
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14
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McBride JA, Parad RB, Davis JM, Zheng Z, Zupancic JAF. Economic evaluation of recombinant human copper zinc superoxide dismutase administered at birth to premature infants. J Perinatol 2009; 29:364-71. [PMID: 19225525 DOI: 10.1038/jp.2008.225] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of recombinant human superoxide dismutase (rhSOD) in the prevention of chronic respiratory morbidity, defined as use of respiratory medications, in preterm infants. STUDY DESIGN This retrospective economic evaluation was undertaken using data from a previously published randomized controlled trial of the use of rhSOD in neonates of birthweight 600 to 1200 g. This ancillary study measured all relevant direct medical costs from birth to 1 year corrected age using resource data collected for infants from the clinical trial. Unit costs were derived from secondary datasets in similar populations, stratified by level of care or diagnosis. All costs were expressed in 2003 US dollars. RESULT rhSOD was associated with a highly favorable incremental cost of only $378 per chronic respiratory morbidity averted at 1 year corrected age. There was a 95% probability that the therapy would be considered cost-effective if a decision maker was willing to pay $7000 to avert one infant with long-term significant respiratory illness, and a 52% probability that it would actually reduce costs while improving outcomes. These results were more pronounced among infants <27 weeks gestational age at birth. CONCLUSION Based on resource data from a single randomized trial, this retrospective analysis supports the potential economic desirability of rhSOD treatment in this population.
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Affiliation(s)
- J A McBride
- Division of Newborn Medicine, Harvard Medical School, Boston, MA, USA
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15
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Kamholz KL, Cole CH, Gray JE, Zupancic JAF. Cost-effectiveness of early treatment for retinopathy of prematurity. Pediatrics 2009; 123:262-9. [PMID: 19117891 DOI: 10.1542/peds.2007-2725] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Early Treatment for Retinopathy of Prematurity trial demonstrated that peripheral retinal ablation of eyes with high-risk prethreshold retinopathy of prematurity (early treatment) is associated with improved visual outcomes at 9 months' corrected gestational age compared with treatment at threshold disease (conventional management). However, early treatment increased the frequency of laser therapy, anesthesia with intubation, treatment-related systemic complications, and the need for repeat treatments. OBJECTIVE To determine the cost-effectiveness of an early treatment strategy for retinopathy of prematurity compared with conventional management. DESIGN/METHODS We developed a stochastic decision analytic model to assess the incremental cost of early treatment per eye with severe visual impairment prevented. We derived resource-use and efficacy estimates from the Early Treatment for Retinopathy of Prematurity trial's published outcome data. We used a third-party payer perspective. Our primary analysis focused on outcomes from birth through 9 months' corrected gestational age. A secondary analysis used a lifetime horizon. Parameter uncertainty was quantified by using probabilistic and deterministic sensitivity analyses. RESULTS The incremental cost-effectiveness of early treatment was $14,200 per eye with severe visual impairment prevented. There was a 90% probability that the cost-effectiveness of early treatment would be less than $40,000 per eye with severe visual impairment prevented and a 0.5% probability that early treatment would be cost-saving (less costly and more effective). Limiting early treatment to more severely affected eyes (eyes with "type 1 retinopathy of prematurity" as defined by the Early Treatment for Retinopathy of Prematurity trial) had a cost-effectiveness of $6,200 per eye with severe visual impairment prevented. Analyses that considered long-term costs and outcomes found that early treatment was cost-saving. CONCLUSIONS Early treatment of retinopathy of prematurity is both efficacious and economically desirable. Because of the high lifetime costs of severe visual impairment, the early treatment strategy provides long-term cost savings.
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Affiliation(s)
- Karen L Kamholz
- Department of Pediatrics, Boston Medical Center, Boston, MA 02118, USA.
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Herrera EA, Ebensperger G, Krause BJ, Riquelme RA, Reyes RV, Capetillo M, González S, Parer JT, Llanos AJ. Sildenafil reverses hypoxic pulmonary hypertension in highland and lowland newborn sheep. Pediatr Res 2008; 63:169-75. [PMID: 18091352 DOI: 10.1203/pdr.0b013e31815ef71c] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Perinatal exposure to chronic hypoxia induces sustained hypertension and structural and functional changes in the pulmonary vascular bed. We hypothesized that highland newborn lambs (HLNB, 3600 m) have a higher pulmonary arterial pressure (PAP) due in part to a higher activity/expression of phosphodiesterase 5 (PDE5). We administered sildenafil, a PDE5 inhibitor, during basal and hypoxic conditions in the pulmonary hypertensive HLNB and compared them to lowland newborn lambs (LLNB, 580 m). Additionally, we compared the vasodilator responses to sildenafil in isolated small pulmonary arteries and the PDE5 mRNA expression and evaluated the vascular remodeling by histomorphometric analysis in these newborn lambs. Under basal conditions, HLNB had a higher PAP and cardiac output compared with LLNB. Sildenafil decreased the PAP during basal conditions and completely prevented the PAP increase during hypoxia in both groups. HLNB showed a greater contractile capacity and a higher maximal dilation to sildenafil. PDE5 mRNA expression did not show significant differences between HLNB and LLNB. The distal pulmonary arteries showed an increased wall thickness in HLNB. Our results showed that HLNB are more sensitive to sildenafil and therefore could be useful for treatment of pulmonary hypertension in high-altitude neonates.
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Affiliation(s)
- Emilio A Herrera
- Program in Pathophysiology, University of Chile, CP 6640871, Santiago, Chile
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Eugênio GDR, Georgetti FCD. Uso de milrinona no tratamento da hipertensão pulmonar persistente do recém-nascido. REVISTA PAULISTA DE PEDIATRIA 2007. [DOI: 10.1590/s0103-05822007000400012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Descrever uma série de casos de recém-nascidos com hipertensão pulmonar persistente grave, que receberam milrinona para promover a vasodilatação pulmonar. MÉTODOS: Análise retrospectiva de prontuários de 28 pacientes com diagnóstico de hipertensão pulmonar persistente do recém-nascido (HPPRN). Após o diagnóstico, todos os pacientes receberam uma dose de ataque de 50mcg/kg de milrinona, seguida por 0,75mcg/kg/min. O índice de oxigenação (IO) foi calculado no início da infusão e 72 horas após o início da medicação. RESULTADOS: Todos os neonatos receberam milrinona e o sildenafil foi associado em 54%. O uso de dopamina assegurou a manutenção da pressão arterial em nível adequado em todos os casos. Sedação contínua, alcalinização e surfactante foram medidas coadjuvantes no tratamento. Durante a internação, sete pacientes (25%) evoluíram a óbito e todos eles apresentaram aumento do IO, com elevação da média de 25 para 38 com a milrinona. Os sobreviventes, com exceção de um neonato, apresentaram redução do IO em uso de milrinona, com queda da média de 19 para 7. CONCLUSÕES: O uso da milrinona parece ser uma alternativa para o tratamento da HPPRN, na ausência do óxido nítrico. A redução do IO com a medicação foi fator determinante da boa evolução dos pacientes. O índice de falha no tratamento com a milrinona nesta casuística foi semelhante ao encontrado na literatura para o uso de óxido nítrico.
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Dani C, Pavoni V, Corsini I, Longini M, Gori G, Giannesello L, Perna A, Gritti G, Paternostro F, Forestieri A, Buonocore G, Rubaltelli FF. Inhaled nitric oxide combined with prostacyclin and adrenomedullin in acute respiratory failure with pulmonary hypertension in piglets. Pediatr Pulmonol 2007; 42:1048-56. [PMID: 17902148 DOI: 10.1002/ppul.20695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Our aim was to evaluate if the combined inhalation of both nitric oxide (iNO) and aerosolized prostacyclin or iNO and adrenomedullin (ADM) is more effective in lowering pulmonary arterial pressure (PAP) and improving oxygenation than nitric oxide alone in an animal model with pulmonary hypertension (PH). Moreover, we studied the effect on pulmonary mechanics, surfactant activity, and pulmonary oxidative stress of the different treatments. Twenty-eight piglets with acute lung injury induced by lung lavages with saline were randomized to receive nitric oxide, nitric oxide plus prostacyclin, nitric oxide plus ADM or saline, after. Dynamic compliance, tidal volume, and airway resistance were measured. Lung tissue oxidation was evaluated by measuring total hydroperoxide and advanced oxidation protein products in bronchial aspirate samples. Surface surfactant activity was studied using Capillary Surfactometer. Inhaled nitric oxide combined with prostacyclin or ADM was more effective than nitric oxide alone in lowering PAP and improving oxygenation. Nitric oxide alone or combined increased lung compliance and tidal volume, and decreased airway resistance. No effects on surfactant surface activity and lung tissue oxidation were observed. The treatment with nitric oxide alone or combined with prostacyclin or ADM were effective in decreasing mean PAP and improving oxygenation in a piglet model of PH. However, nitric oxide plus prostacyclin and nitric oxide plus ADM were more effective than nitric oxide alone. The combination of aerosolized prostacyclin and ADM with nitric oxide might have a role in the treatment of infants with PH refractory to nitric oxide alone.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital of Florence, Florence, Italy.
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Sola A, Baquero H. [Oral sildenafil in neonatal medicine: ''tested in adults also used in neonates'']. An Pediatr (Barc) 2007; 66:167-76. [PMID: 17306104 DOI: 10.1157/13098935] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- A Sola
- Mid Atlantic Neonatology Associates, Morristown Memorial Hospital, Morristown, NJ, USA.
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Baquero H, Soliz A, Neira F, Venegas ME, Sola A. Oral sildenafil in infants with persistent pulmonary hypertension of the newborn: a pilot randomized blinded study. Pediatrics 2006; 117:1077-83. [PMID: 16585301 DOI: 10.1542/peds.2005-0523] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Persistent pulmonary hypertension (PPHN) occurs in as many as 6.8 of 1000 live births. Mortality is approximately 10% to 20% with high-frequency ventilation, surfactant, inhaled nitric oxide, and extracorporeal membrane oxygenation but is much higher when these therapies are not available. Sildenafil is a phosphodiesterase inhibitor type 5 that selectively reduces pulmonary vascular resistance. OBJECTIVE Our goal was to evaluate the feasibility of using oral sildenafil and its effect on oxygenation in PPHN. DESIGN This study was a proof-of-concept, randomized, masked study in infants >35.5 weeks' gestation and <3 days old with severe PPHN and oxygenation index (OI) >25 admitted to the NICU (Hospital Niño Jesús, Barranquilla, Colombia). The sildenafil solution was prepared from a 50-mg tablet. The first dose (1 mg/kg) or placebo was given by orogastric tube <30 minutes after randomization and every 6 hours. Preductal saturation and blood pressure were monitored continuously. OI was calculated every 6 hours. The main outcome variable was the effect of oral sildenafil on oxygenation. Sildenafil or placebo was discontinued when OI was <20 or if there was no significant change in OI after 36 hours. RESULTS Six infants with an OI of >25 received placebo, and 7 received oral sildenafil at a median age of 25 hours. All infants were severely ill, on fraction of inspired oxygen 1.0, and with similar ventilatory parameters. Intragastric sildenafil and placebo were well tolerated. In the treatment group, OI improved in all infants within 6 to 30 hours, all showed a steady improvement in pulse oxygen saturation over time, and none had noticeable effect on blood pressure; 6 of 7 survived. In the placebo group, 1 of 6 infants survived. CONCLUSIONS Oral sildenafil was administered easily and tolerated as well as placebo and improved OI in infants with severe PPHN, which suggests that oral sildenafil may be effective in the treatment of PPHN and underscores the need for a large, controlled trial.
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Affiliation(s)
- Hernando Baquero
- Division of Neonatology, Universidad del Norte, Barranquilla, Colombia
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Figueras Aloy J, Castillo Salinas F, Elorza Fernández D, Sánchez-Luna M, Pérez Rodríguez J. [Recommendations for inhaled nitric oxide treatment in the newborn]. An Pediatr (Barc) 2006; 64:260-6. [PMID: 16527094 DOI: 10.1157/13085514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The recommendations in this document describe the current indications for inhaled nitric oxide (iNO) treatment in the newborn and clearly distinguish between those supported by scientific evidence and those for which evidence is still lacking, such as its use in preterm infants. The methodology for iNO administration, its dosage and the main secondary effects are discussed, and the reasons for lack of response to this treatment are analyzed.
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Affiliation(s)
- J Figueras Aloy
- Hospital Clínico, Instituto Clínico de Ginecología, Obstetricia y Neonatología, Unidad Integrada de Pediatría, Universidad de Barcelona, Spain.
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