Quality, outcome, and cost of care provided to very low birth weight infants in California.

OBJECTIVE: To examine association of costs with quality of care and patient outcome across hospitals in California. METHODS: Retrospective study of very low birth weight (VLBW) births from 2014-2018 linking birth certificate, hospital discharge records and clinical data. Quality was measured using the Baby-MONITOR score. Clinical outcome was measured using survival without major morbidity (SWMM). Hierarchical generalized linear models, adjusting for clinical factors, were used to estimate risk-adjusted measures of costs, quality, and outcome for each hospital. Association between these measures was evaluated using Pearson correlation coefficient. RESULTS: In total, 15,415 infants from 104 NICUs were included. Risk-adjusted Baby-MONITOR score, SWMM rate, and costs varied substantially. There was no correlation between risk-adjusted cost and Baby-MONITOR score (r = 0, p = 0.998). Correlation between risk-adjusted cost and SWMM rate was inverse and not significant (r = -0.07, p = 0.48). CONCLUSIONS: With the metrics used, we found no correlation between cost, quality, and outcomes in the care of VLBW infants.

Effectiveness of an Enhanced Community Doula Intervention in a Safety Net Setting: A Randomized Controlled Trial.

Background: Racial inequities in maternal health outcomes, the result of systemic racism and social determinants of health, require maternity care systems to implement interventions that reduce disparities. One such approach may be support from a community doula, a health worker who provides emotional support, peer education, navigation, and advocacy for pregnant, birthing, and postpartum people who share similar racial identities, cultural backgrounds, and/or lived experiences. While community support during birth has a long tradition within communities of Black Indigenous and People of Color (BIPOC), the reframing of community doula support as a social intervention that reduces disparities in clinical outcomes is recent. Methods: We conducted a pragmatic randomized trial at an urban safety net hospital, comparing standard maternity care with standard care plus enhanced community doula support. We tested the effectiveness of a community doula program embedded in a safety net hospital in improving birth outcomes and explored the association between community doula support and health equity. Participants were nulliparous, insured by publicly funded health plans, and had lower risk pregnancies. The primary outcome was cesarean birth. Secondary outcomes included preterm birth and breastfeeding outcomes. Exploratory subgroup analysis was conducted by race-ethnicity. Results: Three hundred sixty-seven participants were included in the primary analysis. In the intent-to-treat analysis, outcomes were similar between groups. There was a trend toward increased breastfeeding initiation (p=0.08). There was a statistically nonsignificant 12% absolute reduction in cesarean birth and 11.5% increase in exclusive breastfeeding during delivery hospitalization among Black non-Hispanic participants. Discussion: While outcomes for the study sample were similar between randomization groups, health outcomes were improved for Black birthing people in cesarean and breastfeeding rates. Conclusion: This study demonstrates the need for larger studies of community doula support for Black birthing people. Clinicaltrials.gov ID: NCT02550730.

Knowledge, Attitudes, and Perceptions about Antibiotic Stewardship Programs among Neonatology Trainees.

OBJECTIVE: Antibiotic stewardship should be an essential component of neonatology training as neonatal intensive care units (NICU) have unique stewardship needs. Our aim was to assess neonatology fellowship trainees' knowledge, attitudes, and perceptions about antibiotic stewardship to inform sustainable curriculum development. STUDY DESIGN: We distributed an electronic survey to neonatology fellows in the United States over 4 months (January-April 2018) via Accreditation Council for Graduate Medical Education program directors. RESULTS: Of 99 programs in the United States with an estimated 700 fellows, 159 (23%) fellows from 52 training programs (53%) responded to the survey and 139 (87%) provided analyzed responses. Majority of respondents were training in southern (59; 42%) and northeastern (43; 31%) regions and were equally spread across all 3 years of training. One hundred (72%) respondents reported an antibiotic stewardship program (ASP) in their institution. While 86% (120/139) were able to identify the components of an ASP, 59% (82/139) either did not or were unsure if they had received antibiotic stewardship training during fellowship.Furthermore, while answering case studies, 124 (89%) respondents identified the optimal antibiotic for methicillin susceptible Staphylococcus aureus (MSSA) infection and 69 (50%) respondents chose appropriate empiric antibiotics for neonatal meningitis. Notably, fellowship training year was not significantly related to the proportion of incorrect knowledge responses (p = 0.40). Most survey respondents (81; 59%) identified small group sessions as the most useful teaching format, while others chose audit and feedback of individual prescribing behavior (52; 38%) and didactic lectures (52; 38%). Finally, ninety-five (69%) respondents preferred trainee-led ASP interventions targeting focal areas such as antifungal and surgical prophylaxis. CONCLUSION: Antibiotic stewardship is a critical part of neonatology training. Neonatology fellows report variation in access to ASP during their training. Fellows prefer dedicated trainee-led interventions and stewardship curriculum taught within small group settings to promote targeted NICU ASP. KEY POINTS: · Most neonatology programs expose trainees to internal or external antibiotic stewardship programs.. · Over half of fellow trainees are unsure about receiving targeted antibiotic stewardship training.. · Most neonatology fellows prefer a trainee-led antibiotic stewardship intervention..

"All these people saved her life, but she needs me too": Understanding and responding to parental mental health in the NICU.

OBJECTIVE: To explore the mental health needs of parents of infants in a neonatal intensive care unit (NICU), as well as barriers and solutions to meeting these needs. DESIGN: Qualitative interviews conducted with parents and staff (n = 15) from a level IV NICU in the Northwestern United States. Thematic analysis completed using an inductive approach, at a semantic level. RESULTS: (1) Information and mental health needs change over time, (2) Staff-parent relationships buffer trauma and distress, (3) Lack of continuity of care impacts response to mental health concerns, (4) NICU has a critical role in addressing parental mental health. CONCLUSION: Mental health support should be embedded and tailored to the NICU trajectory, with special attention to the discharge transition, parents living in rural areas, and non-English-speaking parents. Research should address structural factors that may impact mental health such as integration of wholistic services, language barriers, and staff capacity.

The Clinical and Cost Utility of Cardiac Catheterizations in Infants with Bronchopulmonary Dysplasia.

OBJECTIVE: To evaluate the cost-utility of catheterization-obligate treatment in preterm infants with pulmonary hypertension, as compared with empiric initiation of sildenafil based on echocardiographic findings alone. STUDY DESIGN: A Markov state transition model was constructed to simulate the clinical scenario of a preterm infant with echocardiographic evidence of pulmonary hypertension associated with bronchopulmonary dysplasia (BPD) and without congenital heart disease under consideration for the initiation of pulmonary vasodilator therapy via one of two modeled treatment strategies-empiric or catheterization-obligate. Transitional probabilities, costs and utilities were extracted from the literature. Forecast quality-adjusted life-years was the metric for strategy effectiveness. Sensitivity analyses for each variable were performed. A 1000-patient Monte Carlo microsimulation was used to test the durability of our findings. RESULTS: The catheterization-obligate strategy resulted in an increased cost of $10 778 and 0.02 fewer quality-adjusted life-years compared with the empiric treatment strategy. Empiric treatment remained the more cost-effective paradigm across all scenarios modeled through one-way sensitivity analyses and the Monte Carlo microsimulation (cost-effective in 98% of cases). CONCLUSIONS: Empiric treatment with sildenafil in infants with pulmonary hypertension associated with BPD is a superior strategy with both decreased costs and increased effectiveness when compared with catheterization-obligate treatment. These findings suggest that foregoing catheterization before the initiation of sildenafil is a reasonable strategy in preterm infants with uncomplicated pulmonary hypertension associated with BPD.

Cost-effectiveness of Artificial Intelligence-Based Retinopathy of Prematurity Screening.

Importance: Artificial intelligence (AI)-based retinopathy of prematurity (ROP) screening may improve ROP care, but its cost-effectiveness is unknown. Objective: To evaluate the relative cost-effectiveness of autonomous and assistive AI-based ROP screening compared with telemedicine and ophthalmoscopic screening over a range of estimated probabilities, costs, and outcomes. Design, Setting, and Participants: A cost-effectiveness analysis of AI ROP screening compared with ophthalmoscopy and telemedicine via economic modeling was conducted. Decision trees created and analyzed modeled outcomes and costs of 4 possible ROP screening strategies: ophthalmoscopy, telemedicine, assistive AI with telemedicine review, and autonomous AI with only positive screen results reviewed. A theoretical cohort of infants requiring ROP screening in the United States each year was analyzed. Main Outcomes and Measures: Screening and treatment costs were based on Current Procedural Terminology codes and included estimated opportunity costs for physicians. Outcomes were based on the Early Treatment of ROP study, defined as timely treatment, late treatment, or correctly untreated. Incremental cost-effectiveness ratios were calculated at a willingness-to-pay threshold of $100 000. One-way and probabilistic sensitivity analyses were performed comparing AI strategies to telemedicine and ophthalmoscopy to evaluate the cost-effectiveness across a range of assumptions. In a secondary analysis, the modeling was repeated and assumed a higher sensitivity for detection of severe ROP using AI compared with ophthalmoscopy. Results: This theoretical cohort included 52 000 infants born 30 weeks' gestation or earlier or weighed 1500 g or less at birth. Autonomous AI was as effective and less costly than any other screening strategy. AI-based ROP screening was cost-effective up to $7 for assistive and $34 for autonomous screening compared with telemedicine and $64 and $91 compared with ophthalmoscopy in the primary analysis. In the probabilistic sensitivity analysis, autonomous AI screening was more than 60% likely to be cost-effective at all willingness-to-pay levels vs other modalities. In a second simulated cohort with 99% sensitivity for AI, the number of late treatments for ROP decreased from 265 when ROP screening was performed with ophthalmoscopy to 40 using autonomous AI. Conclusions and Relevance: AI-based screening for ROP may be more cost-effective than telemedicine and ophthalmoscopy, depending on the added cost of AI and the relative performance of AI vs human examiners detecting severe ROP. As AI-based screening for ROP is commercialized, care must be given to appropriately price the technology to ensure its benefits are fully realized.

The financial burden experienced by families of preterm infants after NICU discharge.

BACKGROUND AND OBJECTIVES: Describe the financial burden and worry that families of preterm infants experience after discharge from the neonatal intensive care unit (NICU). METHODS: We surveyed 365 parents of preterm infants in a cross-sectional study regarding socio-demographics, supplemental security income (SSI), and financial worry. We completed a multivariable logistic regression model to examine the adjusted association of financial worry with modifiable factors. RESULTS: We found that 53% of participants worried about healthcare costs after NICU discharge. After adjusting for socio-demographic and infant characteristics, we identified that, aOR (95% CI), out-of-pocket costs from the NICU index hospitalization, 3.51 (1.7, 7.26) and durable medical equipment use, 2.41 (1.11, 5.23) was associated with increased financial worry while enrollment in SSI, 0.38 (0.19, 0.76) was associated with decreased financial worry. CONCLUSIONS: We identified factors that could contribute to financial burden after NICU discharge that may advise future work to target financial support systems.

Economic considerations at the threshold of viability.

Neonatal intensive care for infants born at 22-24 weeks has become more prevalent in the past three decades, but outcomes remain highly variable between centers, in part due to different approaches in management. With this increased frequency of intervention, there has been concern for a concurrent increase in costs of care for survivors. This article reviews the direct medical, direct non-medical, and indirect costs of care for periviable infants and their families, as well as the current limitations of published data. In addition, we highlight the cost-effectiveness of neonatal intensive care and various therapies offered to extremely preterm infants, while also considering the ethical dilemmas inherently tied to periviable decision-making. Strategies to improve the gaps in knowledge on the economic impact of the smallest infants are discussed.

Perils and pitfalls for evaluating economic studies in neonatology.

Health care economics has become an essential topic for all clinicians. Rising health care costs and continued limited resources force hospitals, health networks, and payers to make difficult choices. Economic studies range from those that only focus on costs to those that include costs and outcomes in a single metric, allowing for an assessment of incremental benefit gained from the incremental investment made. This article takes a step by step approach to interpreting the results of an economic evaluation, allowing the reader to critically appraise the results and to understand the implications for their specific patient population.

Unbiasing costs? An appraisal of economic assessment alongside randomized trials in neonatology.

Economic evaluations performed alongside randomized controlled trials benefit from the protections against bias inherent in randomization. In this systematic review, we assessed the frequency and quality of economic assessments alongside randomized controlled trials of interventions in neonates published between 1990 and 2016. Over that period, 58 economic assessments were published, corresponding to approximately 2% of RCTs. We noted significant methodological limitations of these studies, including limitation of included costs to the health sector or payer rather than broader categories such as family or community expenditures (81%), short time horizon for cost measurement (less than one year in 60%), lack of reporting of uncertainty (26%), and infrequent analysis of costs and effects in a single metric (combined in 45%). Strategies for improving the quality and frequency of economic evaluations in neonatology are discussed, including selection of appropriate trials, funding, and peer review.

Examining the Relationship between Cost and Quality of Care in the Neonatal Intensive Care Unit and Beyond.

There is tremendous variation in costs of delivering health care, whether by country, hospital, or patient. However, the questions remain: what costs are reasonable? How does spending affect patient outcomes? We look to explore the relationship between cost and quality of care in adult, pediatric and neonatal literature. Health care stewardship initiatives attempt to address the issue of lowering costs while maintaining the same quality of care; but how do we define and deliver high value care to our patients? Ultimately, these questions remain challenging to tackle due to the heterogeneous definitions of cost and quality. Further standardization of these terms, as well as studying the variations of both costs and quality, may benefit future research on value in health care.

Cost-effectiveness of probiotics for necrotizing enterocolitis prevention in very low birth weight infants.

OBJECTIVE: To examine the cost-effectiveness of prophylactic probiotics on necrotizing enterocolitis (NEC) prevention in very low birth weight (VLBW) infants. STUDY DESIGN: We built a decision-analytic model using TreeAge. Effectiveness was assessed using quality-adjusted life-years (QALY). Primary outcome was an incremental cost-effectiveness ratio (ICER) expressed as cost per QALY gained. Costs were expressed in 2017 US dollars. Deterministic and probabilistic sensitivity analyses (SA) were performed. RESULTS: For the base case analysis, the ICER of probiotics versus no probiotics for the prevention of NEC in VLBW infants was $1868/QALY. SA revealed that probiotics became cost-saving at a NEC rate of 6.5% and higher or with incremental NEC cost of $37,500 or higher. CONCLUSIONS: Our model demonstrated that prophylactic probiotics were a cost-effective strategy in NEC reduction. SA confirmed that the model is customizable to various clinical settings and thus, can aid in understanding the economic impact of this intervention.

A Cost-Effectiveness Analysis of Rooming-in and Breastfeeding in Neonatal Opioid Withdrawal.

OBJECTIVE: Our cost-effectiveness analysis investigated rooming-in versus not rooming-in to determine optimal management of neonates with neonatal opioid withdrawal (NOW). STUDY DESIGN: A decision-analytic model was constructed using TreeAge to compare rooming-in versus not rooming-in in a theoretical cohort of 23,200 newborns, the estimated annual number affected by NOW in the United States. Additional considerations included the effect of breast milk versus formula milk in evaluating the need for pharmacotherapy. Primary outcomes were needed for pharmacotherapy and neurodevelopment. We assumed a societal perspective in evaluating costs and maternal-neonatal quality-adjusted life years (QALYs) using a willingness-to-pay threshold of $100,000/QALY. Model inputs were derived from literature and varied in sensitivity analyses. RESULTS: Rooming-in resulted in fewer neonates requiring pharmacotherapy when compared with not rooming-in. The rooming-in group had more neonates with intact/mild neurodevelopmental impairment and fewer cases of moderate to severe impairment. Rooming-in resulted in cost savings of $509,652,728 and 12,333 additional QALYs per annual cohort. When the risk ratio of need for pharmacotherapy in rooming-in was varied across a clinically plausible range, rooming-in remained the cost-effective strategy. CONCLUSION: Maternal rooming-in with newborns affected by NOW leads to reduced costs and increased effectiveness. Management strategies should optimize nonpharmacological interventions as first-line treatment.

Hospitalization costs associated with bronchopulmonary dysplasia in the first year of life.

OBJECTIVE: To determine costs of hospitalization associated with bronchopulmonary dysplasia (BPD) during the first year in very low birth weight infants. STUDY DESIGN: Retrospective cohort study of California births from 2008 to 2011 linking birth certificate, discharge records, and clinical data from California Perinatal Quality Care Collaborative. Inclusion: birth weight 401-1500 g, gestational age < 30 weeks, inborn or transferred within 2 days, alive at 36 weeks corrected, and without major congenital anomalies. Outcomes included cost and length of stay of initial hospitalization and rehospitalizations. RESULT: Out of 7998 eligible infants, 2696 (33.7%) developed BPD. Median hospitalization cost in the first year was $377,871 per infant with BPD compared with $175,836 per infant without BPD (adjusted cost ratio 1.54, 95% confidence interval (CI) 1.49-1.59). Infants with BPD also had longer length of stay and a higher likelihood of rehospitalization. CONCLUSION: BPD is associated with substantial resource utilization. Prevention strategies could help conserve healthcare resources.

Cost Effectiveness of Neonatal Resuscitation at 22 Weeks of Gestation.

OBJECTIVE: To evaluate the cost effectiveness of three different approaches to the care of neonates born at 22 weeks of gestation: universal resuscitation, selective resuscitation, or no resuscitation. METHODS: We constructed a decision-analytic model using TreeAge to compare the outcomes of death and survival with and without neurodevelopmental impairment in a theoretical cohort of 5,176 neonates (an estimate of the annual number of deliveries that occur in the 22nd week of gestation in the United States). We took a societal perspective using a lifetime horizon, and all costs were expressed in 2017 U.S. dollars. Effectiveness was based on combined maternal and neonatal quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio was determined (cost/QALY) for each additional survivor. The willingness to pay threshold was set at $100,000/QALY. All model inputs were derived from the literature. Deterministic and probabilistic sensitivity analyses were performed to interrogate model assumptions. RESULTS: Universal resuscitation would result in 373 survivors, 123 of whom would have severe disability. Selective resuscitation would produce 78 survivors with 26 affected by severe impairments. No resuscitation would result in only eight survivors and three neonates with severe sequelae. Selective resuscitation was eliminated by extended dominance because this strategy had a higher incremental cost-effectiveness ratio than universal resuscitation, which was a more effective intervention. The incremental cost-effectiveness ratio of universal resuscitation compared with no resuscitation was not cost effective at $106,691/QALY. Monte Carlo simulations demonstrated that universal resuscitation is more effective but also more expensive compared with no resuscitation, with only 35% of simulations below the willingness to pay threshold. CONCLUSION: In our model, neither selective nor universal resuscitation of 22-week neonates is a cost-effective strategy compared with no resuscitation.

Factors influencing decision making in neonatology: inhaled nitric oxide in preterm infants.

OBJECTIVE: We studied decision making regarding inhaled nitric oxide (iNO) in preterm infants with Pulmonary Hypertension (PH). STUDY DESIGN: We asked members of the AAP-Society of Neonatal-Perinatal Medicine and Division-Chiefs to select from three management options- initiate iNO, engage parents in shared decision making or not consider iNO in an extremely preterm with PH followed by rating of factors influencing their decision. RESULTS: Three hundred and four respondents (9%) completed the survey; 36.5% chose to initiate iNO, 42% to engage parents, and 21.5% did not consider iNO. Provider's prior experience, safety, and patient-centered care were rated higher by those who initiated or offered iNO; lack of effectiveness and cost considerations by participants who did not chose iNO. CONCLUSIONS: Most neonatologists offer or initiate iNO therapy based on their individual experience. The minority who chose not to consider iNO placed higher value on lack of effectiveness and cost. These results demonstrate a tension between evidence and pathophysiology-based-therapy/personal experience.

Assessing Student Attitudes Regarding Cost-Consciousness in Medical Education.

This article was migrated. The article was marked as recommended. Purpose: The purpose of this study was to compare attitudes regarding cost-consciousness between student populations at two medical schools in the United States and Canada. Method: We conducted a cross-sectional survey of students at Harvard Medical School and University of Toronto. We performed chi-square analyses comparing responses from the two institutions. Results: Response rates were 48% (n=162) and 45% (n=228) at Harvard and the University of Toronto, respectively. At both institutions, >96% of students agreed clinicians at all stages of training should be familiar with cost-conscious decision-making, 80% agreed physicians are responsible for discussing healthcare costs with patients, and over 80% felt they had too little education on the topic in medical school. Students differed in opinions about the extent to which patients should inquire about costs, with students at Harvard more likely to endorse this opinion compared with those from Toronto (51% vs 28%, respectively), and differed over whether cost-consciousness led to rationing of healthcare (Harvard 30% vs Toronto 51%). Fewer than 10% of all students expressed concerns that incorporating costs into care was unethical. Overall, 85% of students from both countries would like more formal teaching on this topic. Discussion: Students from both schools strongly endorsed a need to learn more about cost-conscious decision-making. Findings suggest students in both systems can benefit from learning similar core concepts related to high-value, cost-conscious care, and teaching in this topic can be customized to reflect specific differences in expectations and practices in the two healthcare systems.

Length of stay and cost of birth hospitalization: effects of subfertility and ART.

OBJECTIVE: The objective of this study is to measure delivery length of stay (LOS) and cost as proxies for infant morbidity in assisted reproductive technology (ART) and subfertile deliveries. STUDY DESIGN: Massachusetts singleton births, ≥ 23 weeks gestational age (GA) between 2004 and 2010, were linked with ART data, vital records, and hospital discharges. LOS and costs (2010 US dollars) of infants born to fertile (no ART or indicators of infertility), subfertile (indicators of infertility but no ART), and ART-treated (linked to ART data) deliveries were compared. Least-square means and SE were calculated. RESULTS: Of 345,756 singletons (fertile n = 332,481, subfertile n = 4987, and ART-treated n = 8288), overall LOS was 3.79 ± 0.01, 4.32 ± 0.15, and 4.90 ± 0.04 days, and costs were $2980 ± 6, $3217 ± 58, and $4483 ± 62, respectively. GA and birthweight predicted much of the intergroup difference. CONCLUSION: Maternal fertility group was not an independent predictor of infant LOS and costs. Prematurity and birthweight were driving factors in resource utilization.