Short term cost of care for the surviving periviable neonate

Costs of Neonatal Medical Complexity: Impact on New Parent Stress and Decision-Making

OBJECTIVE

Parents of children with medical complexity experience substantial financial burdens. It is unclear how neonatal intensive care unit (NICU) clinicians prepare new parents of medically complex infants for this reality. This study explored new parent awareness of health care costs, desire to discuss costs with clinicians, and impact of costs on parents' medical decision-making.

STUDY DESIGN

The study design comprised semistructured interviews and surveys of parents of infants with medical complexity currently or previously in a NICU. Conventional content analysis was performed on interview transcripts, and descriptive analyses were applied to surveys.

RESULTS

Thematic saturation was reached with 27 families (15 NICU families and 12 post-NICU families) of diverse race/ethnicity/education/household income. Most were worried about their infants' current/future medical expenses and approximately half wanted to discuss finances with clinicians, only one parent had. While finances were not part of most parent's NICU decision-making, some later regretted this and wished cost had been incorporated into treatment choices. The family desire to discuss costs did not vary by family financial status. Parents described their infant's health care costs as: "We are drowning"; and "We'll never pay it off."

CONCLUSION

Most parents were worried about current and future medical expenses related to their infant's evolving medical complexity. Many wanted to discuss costs with clinicians; almost none had. NICU clinicians should prepare families for the future financial realities of pediatric medical complexity.

KEY POINTS

· Many families want to discuss costs with NICU clinicians.. · Some families want costs to be a part of medical decisions.. · Few families currently discuss costs with NICU providers..

National Trends in Survival and Short-Term Outcomes of Periviable Births ≤24 Weeks Gestation in the United States, 2009 to 2018

OBJECTIVE

Data from the academic medical centers in the United States showing improvements in survival of periviable infants born at 22 to 24 weeks GA may not be nationally representative since a substantial proportion of preterm infants are cared for in community hospital-based neonatal intensive care units. Our objective was to examine the national trends in survival and other short-term outcomes among preterm infants born at ≤24 weeks gestational age (GA) in the United States from 2009 to 2018.

STUDY DESIGN

This was a retrospective, repeated cross-sectional analysis of the National Inpatient Sample for preterm infants ≤24 weeks GA. The primary outcome was the trends in survival to discharge. Secondary outcomes were the trends in the composite outcome of death or one or more major morbidity (bronchopulmonary dysplasia, necrotizing enterocolitis stage ≥2, periventricular leukomalacia, severe intraventricular hemorrhage, and severe retinopathy of prematurity). The Cochran-Armitage trend test was used for trend analysis. p-Value <0.05 was considered significant.

RESULTS

Among 71,854 infants born at ≤24 weeks GA, 34,251 (47.6%) survived less than 1 day and were excluded. Almost 93% of those who survived <1 day were of ≤23 weeks GA. Among the 37,603 infants included in the study cohort, 48.1% were born at 24 weeks GA. Survival to discharge at GA ≤ 23 weeks increased from 29.6% in 2009 to 41.7% in 2018 (p < 0.001), while survival to discharge at GA 24 weeks increased from 58.3 to 65.9% (p < 0.001). There was a significant decline in the secondary outcomes among all the periviable infants who survived ≥1 day of life.

CONCLUSION

Survival to discharge among preterm infants ≤24 weeks GA significantly increased, while death or major morbidities significantly decreased from 2009 to 2018. The postdischarge survival, health care resource use, and long neurodevelopmental outcomes of these infants need further investigation.

KEY POINTS

· Survival increased significantly in infants ≤24 weeks GA in the United States from 2009 to 2018.. · Death or major morbidity in infants ≤24 weeks GA decreased significantly from 2009 to 2018.. · Death or surgical procedures including tracheostomy, VP shunt placement, and PDA surgical closure in infants <=24 weeks GA decreased significantly from 2009 to 2018..

Nanotechnologies in Obstetrics and Cancer during Pregnancy: A Narrative Review

Nanotechnology, the art of engineering structures on a molecular level, offers the opportunity to implement new strategies for the diagnosis and management of pregnancy-related disorders. This review aims to summarize the current state of nanotechnology in obstetrics and cancer in pregnancy, focusing on existing and potential applications, and provides insights on safety and future directions. A systematic and comprehensive literature assessment was performed, querying the following databases: PubMed/Medline, Scopus, and Endbase. The databases were searched from their inception to 22 March 2022. Five independent reviewers screened the items and extracted those which were more pertinent within the scope of this review. Although nanotechnology has been on the bench for many years, most of the studies in obstetrics are preclinical. Ongoing research spans from the development of diagnostic tools, including optimized strategies to selectively confine contrast agents in the maternal bloodstream and approaches to improve diagnostics tests to be used in obstetrics, to the synthesis of innovative delivery nanosystems for therapeutic interventions. Using nanotechnology to achieve spatial and temporal control over the delivery of therapeutic agents (e.g., commonly used drugs, more recently defined formulations, or gene therapy-based approaches) offers significant advantages, including the possibility to target specific cells/tissues of interest (e.g., the maternal bloodstream, uterus wall, or fetal compartment). This characteristic of nanotechnology-driven therapy reduces side effects and the amount of therapeutic agent used. However, nanotoxicology appears to be a significant obstacle to adopting these technologies in clinical therapeutic praxis. Further research is needed in order to improve these techniques, as they have tremendous potential to improve the accuracy of the tests applied in clinical praxis. This review showed the increasing interest in nanotechnology applications in obstetrics disorders and pregnancy-related pathologies to improve the diagnostic algorithms, monitor pregnancy-related diseases, and implement new treatment strategies.

Medications and in-hospital outcomes in infants born at 22-24 weeks of gestation

OBJECTIVE

To evaluate the most commonly used medications and in-hospital morbidities and mortality in infants born 22-24 weeks of gestation.

STUDY DESIGN

Multicenter retrospective cohort study of infants born 22-24 weeks of gestation (2006-2016), without major congenital anomalies and with available medication data obtained from neonatal intensive care units managed by the Pediatrix Medical Group.

RESULTS

This study included 7578 infants from 195 sites. Median (25th, 75th percentile): birthweight was 610 g (540, 680); the number of distinct medications used was 13 (8, 18); and different antimicrobial exposure was 4 (2, 5). The most common morbidities were BPD (41%) and grade III or IV IVH (20%), and overall survival varied from 46% (2006) to 57% (2016).

CONCLUSIONS

A large number of medications were used in periviable infants. There was a high prevalence of in-hospital morbidities, and survival of this population increased over the study period.

Economic consequences of preterm birth: a systematic review of the recent literature (2009-2017)

BACKGROUND

Despite extensive knowledge on the functional, neurodevelopmental, behavioural and educational sequelae of preterm birth, relatively little is known about its economic consequences.

OBJECTIVE

To systematically review evidence around the economic consequences of preterm birth for the health services, for other sectors of the economy, for families and carers, and more broadly for society.

METHODS

Updating previous reviews, systematic searches of Medline, EconLit, Web of Science, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Embase and Scopus were performed using broad search terms, covering the literature from 1 January 2009 to 28 June 2017. Studies reporting economic consequences, published in the English language and conducted in a developed country were included. Economic consequences are presented in a descriptive manner according to study time horizon, cost category and differential denominators (live births or survivors).

RESULTS

Of 4384 unique articles retrieved, 43 articles met the inclusion criteria. Of these, 27 reported resource use or cost estimates associated with the initial period of hospitalisation, while 26 reported resource use or costs incurred following the initial hospital discharge, 10 of which also reported resource use or costs associated with the initial period of hospitalisation. Only two studies reported resource use or costs incurred throughout the childhood years. Initial hospitalisation costs varied between $576 972 (range $111 152-$576 972) per infant born at 24 weeks' gestation and $930 (range $930-$7114) per infant born at term (US$, 2015 prices). The review also revealed a consistent inverse association between gestational age at birth and economic costs regardless of date of publication, country of publication, underpinning study design, follow-up period, age of assessment or costing approach, and a paucity of evidence on non-healthcare costs. Several categories of economic costs, such as additional costs borne by families as a result of modifications to their everyday activities, are largely overlooked by this body of literature. Moreover, the number and coverage of economic assessments have not increased in comparison with previous review periods.

CONCLUSION

Evidence identified by this review can be used to inform clinical and budgetary service planning and act as data inputs into future economic evaluations of preventive or treatment interventions. Future research should focus particularly on valuing the economic consequences of preterm birth in adulthood.