TY - JOUR
T1 - Resuscitation of neonates at 23 weeks' gestational age
T2 - A cost-effectiveness analysis
AU - Colin Partridge, J.
AU - Robertson, Kathryn R.
AU - Rogers, Elizabeth E.
AU - Landman, Geri Ottaviano
AU - Allen, Allison J.
AU - Caughey, Aaron B.
N1 - Publisher Copyright:
© 2014 Informa UK Ltd. All rights reserved.
PY - 2015/1/1
Y1 - 2015/1/1
N2 - Objective: Resuscitation of infants at 23 weeks' gestation remains controversial; clinical practices vary. We sought to investigate the cost effectiveness of resuscitation of infants born 23 0/7-23 6/7 weeks' gestation. Design: Decision-analytic modeling comparing universal and selective resuscitation to non-resuscitation for 5176 live births at 23 weeks in a theoretic U.S. cohort. Estimates of death (77%) and disability (64-86%) were taken from the literature. Maternal and combined maternal-neonatal utilities were applied to discounted life expectancy to generate QALYs. Incremental cost-effectiveness ratios were calculated, discounting costs and QALYs. Main outcomes included number of survivors, their outcome status and incremental cost-effectiveness ratios for the three strategies. A cost-effectiveness threshold of $100000/QALY was utilized. Results: Universal resuscitation would save 1059 infants: 138 severely disabled, 413 moderately impaired and 508 without significant sequelae. Selective resuscitation would save 717 infants: 93 severely disabled, 279 moderately impaired and 343 without significant sequelae. For mothers, non-resuscitation is less expensive ($19.9 million) and more effective (127844 mQALYs) than universal resuscitation ($1.2 billion; 126574 mQALYs) or selective resuscitation ($845 million; 125966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22256 and 15134 nQALYS, respectively, versus 247 nQALYs for non-resuscitation. In sensitivity analyses, universal resuscitation was cost-effective from a maternal perspective only at utilities for neonatal death <0.42. When analyzed from a maternal-neonatal perspective, universal resuscitation was cost-effective when the probability of neonatal death was <0.95. Conclusions: Over wide ranges of probabilities for survival and disability, universal and selective resuscitation strategies were not cost-effective from a maternal perspective. Both strategies were cost-effective from a maternal-neonatal perspective. This study offers a metric for counseling and decision-making for extreme prematurity. Our results could support a more permissive response to parental requests for aggressive intervention at 23 weeks' gestation.
AB - Objective: Resuscitation of infants at 23 weeks' gestation remains controversial; clinical practices vary. We sought to investigate the cost effectiveness of resuscitation of infants born 23 0/7-23 6/7 weeks' gestation. Design: Decision-analytic modeling comparing universal and selective resuscitation to non-resuscitation for 5176 live births at 23 weeks in a theoretic U.S. cohort. Estimates of death (77%) and disability (64-86%) were taken from the literature. Maternal and combined maternal-neonatal utilities were applied to discounted life expectancy to generate QALYs. Incremental cost-effectiveness ratios were calculated, discounting costs and QALYs. Main outcomes included number of survivors, their outcome status and incremental cost-effectiveness ratios for the three strategies. A cost-effectiveness threshold of $100000/QALY was utilized. Results: Universal resuscitation would save 1059 infants: 138 severely disabled, 413 moderately impaired and 508 without significant sequelae. Selective resuscitation would save 717 infants: 93 severely disabled, 279 moderately impaired and 343 without significant sequelae. For mothers, non-resuscitation is less expensive ($19.9 million) and more effective (127844 mQALYs) than universal resuscitation ($1.2 billion; 126574 mQALYs) or selective resuscitation ($845 million; 125966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22256 and 15134 nQALYS, respectively, versus 247 nQALYs for non-resuscitation. In sensitivity analyses, universal resuscitation was cost-effective from a maternal perspective only at utilities for neonatal death <0.42. When analyzed from a maternal-neonatal perspective, universal resuscitation was cost-effective when the probability of neonatal death was <0.95. Conclusions: Over wide ranges of probabilities for survival and disability, universal and selective resuscitation strategies were not cost-effective from a maternal perspective. Both strategies were cost-effective from a maternal-neonatal perspective. This study offers a metric for counseling and decision-making for extreme prematurity. Our results could support a more permissive response to parental requests for aggressive intervention at 23 weeks' gestation.
KW - Cost-effectiveness
KW - Death and dying
KW - Decision-making
KW - Ethics
KW - Extreme prematurity
KW - Health policy
KW - Perinatal care
KW - Resuscitation
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U2 - 10.3109/14767058.2014.909803
DO - 10.3109/14767058.2014.909803
M3 - Article
C2 - 24684658
AN - SCOPUS:84919999141
SN - 1476-7058
VL - 28
SP - 121
EP - 130
JO - Journal of Maternal-Fetal and Neonatal Medicine
JF - Journal of Maternal-Fetal and Neonatal Medicine
IS - 2
ER -