Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study.

BACKGROUND: Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda. METHODS: A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach. RESULTS: For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system. CONCLUSIONS: Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.

Analysis of hospital cost outcome of DHA-rich fish-oil supplementation in pregnancy: Evidence from a randomized controlled trial.

OBJECTIVE: Recent research emphasized the nutritional benefits of omega-3 long chain polyunsaturated fatty acids (LCPUFAs) during pregnancy. Based on a double-blind randomised controlled trial named "DHA to Optimize Mother and Infant Outcome" (DOMInO), we examined how omega 3 DHA supplementation during pregnancy may affect pregnancy related in-patient hospital costs. METHOD: We conducted an econometric analysis based on ordinary least square and quantile regressions with bootstrapped standard errors. Using these approaches, we also examined whether smoking, drinking, maternal age and BMI could influence the effect of DHA supplementation during pregnancy on hospital costs. RESULTS: Our regressions showed that in-patient hospital costs could decrease by AUD92 (P<0.05) on average per singleton pregnancy when DHA supplements were consumed during pregnancy. Our regression results also showed that the cost savings to the Australian public hospital system could be between AUD15 - AUD51 million / year. CONCLUSION: Given that a simple intervention like DHA-rich fish-oil supplementation could generate savings to the public, it may be worthwhile from a policy perspective to encourage DHA supplementation among pregnant women.

Cost of morbidities in very low birth weight infants.

OBJECTIVE: To determine the association between direct costs for the initial neonatal intensive care unit hospitalization and 4 potentially preventable morbidities in a retrospective cohort of very low birth weight (VLBW) infants (birth weight <1500 g). STUDY DESIGN: The sample included 425 VLBW infants born alive between July 2005 and June 2009 at Rush University Medical Center. Morbidities included brain injury, necrotizing enterocolitis, bronchopulmonary dysplasia, and late-onset sepsis. Clinical and economic data were retrieved from the institution's system-wide data and cost accounting system. A general linear regression model was fit to determine incremental direct costs associated with each morbidity. RESULTS: After controlling for birth weight, gestational age, and sociodemographic characteristics, the presence of brain injury was associated with a $12048 (P = .005) increase in direct costs; necrotizing enterocolitis, with a $15 440 (P = .005) increase; bronchopulmonary dysplasia, with a $31565 (P < .001) increase; and late-onset sepsis, with a $10055 (P < .001) increase. The absolute number of morbidities was also associated with significantly higher costs. CONCLUSION: This study provides collective estimates of the direct costs incurred during neonatal intensive care unit hospitalization for these 4 morbidities in VLBW infants. The incremental costs associated with these morbidities are high, and these data can inform future studies evaluating interventions aimed at preventing or reducing these costly morbidities.

State estimates of neonatal health-care costs associated with maternal smoking--United States, 1996.

Smoking during pregnancy can cause poor outcomes for both the pregnant woman and her unborn child and also result in added health-care expenditures. To characterize costs by state, CDC analyzed pregnancy risk surveillance and birth certificate data to estimate the association between maternal smoking and the probability of infant admission to a neonatal intensive care unit (NICU). Neonatal health-care costs, in 1996 dollars, were assigned on the basis of data from private health insurance claims. This report summarizes the results of that analysis, which estimated smoking-attributable neonatal expenditures (SAEs) of 366 million dollars in the United States in 1996, or 704 dollars per maternal smoker, and indicated wide variations in SAEs among states. These costs are preventable. States can use these data to justify or support their prevention and cessation treatment strategies.

Prevention of congenital toxoplasmosis in Slovenia by serological screening of pregnant women.

A programme for the prevention of congenital toxoplasmosis in Slovenia involving the screening of pregnant women for Toxoplasma infection is presented. Of 21,270 pregnant women screened for toxoplasmosis between, 1996 and the end of 1999, 13,987 (66%) were seronegative, 7,151 (34%) seropositive and 132 had primary infection; approximately 9/1,000 women were at risk of acquiring the primary infection. One hundred live-born infants of primary infected women were available for follow-up. Nine infected but asymptomatic children were born to mothers who were screened and treated in time and two congenitally infected babies were born to mothers in whom infection was detected too late in pregnancy and who therefore received no adequate treatment. It is suggested that the results obtained in this study outweigh the cost of screening for toxoplasmosis in pregnancy. Pregnant women should always be tested at the beginning of pregnancy and, in cases of seronegativity, should be re-tested in the second and third trimesters of the pregnancy. Toxoplasma primary infected pregnant women and neonates should be treated as soon as possible. However, long-term follow-up of children born to primary infected women would be necessary for an accurate evaluation of the effectiveness of the screening because of the possibility of late onset of symptoms.

Birth and first-year costs for mothers and infants attributable to maternal smoking.

Maternal smoking during pregnancy has been linked to high costs. This study estimates the magnitude of excess costs attributable to smoking during pregnancy for mothers and infants. The model estimates smoking-attributable costs for 11 infant and maternal conditions. From a claims database of 7784 mothers and 7901 infants who had deliveries during 1996, we estimated total cost over the infants' first year of life for each mother and infant and identified each complication of interest, based on ICD-9 codes. The average cost for smokers and non-smokers could not be computed directly because smoking status is not available in claims data. Therefore, the population attributable risk percentage (PAR%) due to smoking for each complication was identified from the literature. Multiple linear regression was used to provide estimates of the incremental cost associated with each smoking-related complication. The total cost attributable to smoking was computed as a function of the incremental cost of each complication and the PAR% for each complication. The conditions associated with the largest incremental costs compared to patients without those conditions were abruptio placenta ($23,697) and respiratory distress syndrome ($21,944). Because they were more common, the conditions with the largest smoking-attributable cost were low birth weight ($914) and lower respiratory infection ($428). The sum of the additional costs attributable to smoking for all conditions yielded a total in the first year after birth ranging from $1142 to $1358 per smoking pregnant woman. It was concluded that maternal smoking during pregnancy results in an economic burden to payers and society. These estimates may be useful in formal cost-effectiveness evaluations of individual smoking cessation strategies.

Costs of smoking: a focus on maternal, childhood, and other short-run costs.

Estimating the costs attributable to smoking is helpful for evaluating appropriate tax policy, informing both public and private managers of health care, and evaluating alternative smoking cessation programs. While the smoking-attributable costs of chronic conditions have been well studied, these costs are less relevant to health maintenance organizations (HMOs) and employers whose populations are younger and transient. Costs incurred in the short run, such as those related to smoking during pregnancy and environmental tobacco smoke exposure (ETS) of children, are more relevant. In this article, the authors review studies of these sources of smoking-attributable costs as well as studies that focus on smoking-attributable outcomes and costs from the employer or HMO perspective. Subsidies may be necessary to induce employers to recognize the full social benefits of smoking cessation programs.

Medical-care expenditures attributable to cigarette smoking during pregnancy -- United States, 1995.

An estimated 26% of women of reproductive age (i.e., 18-44 years) smoked in 1993, and approximately 19%-27% of women smoke during pregnancy. Smoking during pregnancy is causally associated with an annual estimated 32,000-61,000 low-birthweight infants and 14,000-26,000 admissions to neonatal intensive-care units. The estimated smoking-attributable direct medical-care costs for chronic conditions in 1993 were $50.0 billion; however, this estimate omitted the direct medical costs of tobacco exposure for infants and children and most of these costs for pregnant women. To derive 1995 estimates of the smoking-attributable costs for direct medical expenditures (i.e., inpatient, physician, hospital outpatient, and emergency department costs) related to pregnancy outcomes, the University of California at Berkeley and CDC analyzed data from the 1987 National Medical Expenditures Survey (NMES-2). This report summarizes the findings, which indicate substantial smoking-attributable direct medical expenditures for pregnant women and newborns.

Effect of surfactant on morbidity, mortality, and resource use in newborn infants weighing 500 to 1500 g.

BACKGROUND: The administration of surfactant decreased mortality, morbidity, and costs of care for very-low-birth-weight infants in clinical trials. The extent to which these benefits can be achieved in the usual clinical settings is not known. METHODS: We analyzed clinical and financial data obtained from 1985 to 1990 at 14 perinatal centers in the United States on 5629 neonates weighing 500 to 1500 g. The infants were divided into groups according to whether they were born before or after surfactant was introduced into clinical practice. Regression models controlling for race, sex, and birth weight were used to assess mortality, morbidity, and use of resources. Mortality rates specific for these variables were projected to the nation as a whole with reference to the 1985 U.S. birth cohort. RESULTS: The odds of death in the hospital for very-low-birth-weight infants were reduced by 30 percent after surfactant was introduced. Among infants with bronchopulmonary dysplasia, mortality declined 40 percent. Projections of mortality nationwide declined 5 percent. Eighty percent of the decline in the U.S. infant mortality rate between 1989 and 1990 could be attributed solely to the use of surfactant. Among the survivors, the overall odds of morbidity did not change, whether or not we adjusted for changes in race, sex, and birth weight. The odds of respiratory distress syndrome and pulmonary interstitial emphysema among the survivors declined by 20 percent and 40 percent, respectively, with surfactant. Inflation-adjusted charges per survivor declined by 10 percent, or $5,800, whereas the cost of care for each infant who died declined by 31 percent, or $4,400. CONCLUSIONS: The introduction of surfactant has led to decreased mortality and morbidity in very-low-birth-weight infants and to decreased use of resources both for infants who survive and for those who die.

The neonatal costs of maternal cocaine use.

OBJECTIVE: --To examine the added neonatal cost and length of hospital stay associated with fetal cocaine exposure. DESIGN: --All cocaine-exposed infants in the study population (n = 355) were compared with a random sample of unexposed infants (n = 199). Regression analysis was used to control for the independent effects of maternal age, smoking, alcohol consumption, prenatal care, race, gravidity, and sex of the infant. SETTING: --A large, public, inner-city hospital studied from 1985 to 1986. PATIENTS: --All infants were routinely tested for illicit substances, records were reviewed for maternal histories of substance abuse, and all known cocaine-exposed singleton infants were included. MAIN OUTCOME MEASURES: --Cost and length of stay until each infant was medically cleared for hospital discharge and cost and length of stay until each infant was actually discharged from the hospital. RESULTS: --Neonatal hospital costs until medically cleared for discharge were $5200 more for cocaine-exposed infants than for unexposed infants (a difference of $7957 vs $2757 [P = .003]). The costs of infants remaining in the nursery while awaiting home and social evaluation or foster care placement increased this difference by more than $3500 (P less than .0001). Compared with other forms of cocaine, fetal exposure to crack was associated with much larger cost increases ($6735 vs $1226). Exposure to other illicit substances in addition to cocaine was also associated with much larger cost increases ($8450 vs $1283). CONCLUSIONS: --At the national level, we estimate that these individual medical costs add up to about $500 million. The large magnitude of these costs indicates that effective treatment programs for maternal cocaine abusers could yield savings within their first year of operation.

Ethical dilemmas of health care in the developing nations.

Limited resources, widespread poverty, and the absence of health insurance pose daily ethical problems for Third World physicians, who must balance their roles as individual patient advocates against a desire to provide health care to the greatest number of children. Pakistan has a per capita income of Rs. 7,220 (US$ 380) per year, or Rs. 800 (US$ 32) per month. The annual population growth of the country is 3.1%, and approximately 360,000 infants are born each year in Karachi, the largest city in the country. The Aga Khan University Hospital, a private teaching institution, is the only hospital in Karachi with a Level III Neonatal Intensive Care Unit (NICU). The financial and medical data of 200 infants admitted to the NICU in 1988 were reviewed retrospectively, and compared with those of two specific subgroups. (1) Among 15 infants who underwent surgical intervention, the average total cost of hospitalization was Rs. 36,040 (US$ 1,900) per patient, with an average daily cost of Rs. 923 (US$ 49). The longest hospital stay was 6 months, for a child who had total colonic aganglionosis associated with a short gut syndrome. There were two deaths in this group. (2) Of the 21 premature neonates admitted having Idiopathic Respiratory Distress Syndrome (IRDS) during this period, the total hospitalization cost per patient was Rs. 23,260 (US$ 788), with a daily cost of Rs. 1,050 (US$ 55). Eleven patients required ventilatory support. There were 16 survivors. Among both groups, 6% of all revenues generated in the NICU were used to help families pay for the bills under a welfare scheme.

Maternal smoking during pregnancy and expenditures on neonatal health care.

Cigarette smoking during pregnancy substantially increases the risk of low-weight birth, and infants born to smokers weigh less, on average, than those born to nonsmokers. Low birth weight is an important predictor of neonatal morbidity and death, and the intensity of neonatal care is significantly higher for low-birth-weight infants. In this study, we estimate expenditures on neonatal care based on the relation between maternal smoking during pregnancy and the incidence of low-weight births. Our results indicate that maternal smoking during pregnancy was responsible for 35,816 low-weight births in the U.S. in 1983, or about 14.5% of all low-weight births. We also estimate that 14,977, or 6.6%, of all admissions to neonatal intensive care units were a result of maternal smoking and that these admissions cost approximately $272 million, representing 8.5% of total national expenditures on neonatal intensive care services. We estimate that the average cost of neonatal care was $288 higher for infants born to smokers than for those born to nonsmokers.

PIP: An estimated 21-39% of low-birthweight births are attributable to maternal smoking during pregnancy. Low birthweight is the single most important predictor of neonatal morbidity and mortality; moreover, the intensity of neonatal care is significantly higher for these infants. Previous studies of the economic burden of cigarette smoking-related morbidity have not considered the costs that arise due to smoking during pregnancy. This study calculated expenditures on neonatal care in the US based on the relationship between maternal smoking and the incidence of low-birthweight deliveries. In 1983, maternal smoking during pregnancy was responsible for 35,816 low-weight births (under 2500 grams) in the US, or 14.5% of the total number of low-weight births in that year. 14,977 (6.6%) of admissions to Neonatal Intensive Care Units in 1983 were attributable to smoking during pregnancy. Total costs for these hospitalized infants were US$272 million--approximately 8.5% of total national expenditures on neonatal intensive care. Of this amount, US$267 million represents costs that would not have been incurred in the absence of maternal smoking during pregnancy. The cost of neonatal care in the US in 1983 was thus an average of US$288 higher for infants born to women who smoked during pregnancy. These findings show that, in addition to representing a significant threat to neonatal health, cigarette smoking during pregnancy also imposes a substantial economic burden on the medical care system. Greater attention to the relationship between maternal smoking and neonatal care expenditures is needed to stimulate health care providers to plan interventions aimed at reducing smoking during pregnancy.