Prevalence and burden of illness of treated hemolytic neonatal hyperbilirubinemia in a privately insured population in the United States.

BACKGROUND: Prevalence of hemolytic neonatal hyperbilirubinemia (NHB) is not well characterized, and economic burden at the population level is poorly understood. This study evaluated the prevalence, clinical characteristics, and economic burden of hemolytic NHB newborns receiving treatment in U.S. real-world settings. METHODS: This cohort study used administrative claims from 01/01/2011 to 08/31/2017. The treated cohort had hemolytic NHB diagnosis and received phototherapy, intravenous immunoglobulin, and/or exchange transfusions. They were matched with non-NHB newborns who had neither NHB nor related treatments on the following: delivery hospital/area, gender, delivery route, estimated gestational age (GA), health plan eligibility, and closest date of birth within 5 years. Inferential statistics were reported. RESULTS: The annual NHB prevalence was 29.6 to 31.7%; hemolytic NHB, 1.8 to 2.4%; treated hemolytic NHB, 0.46 to 0.55%, between 2011 and 2016. The matched analysis included 1373 pairs ≥35 weeks GA. The treated hemolytic NHB cohort had significantly more birth trauma and hemorrhage (4.5% vs. 2.4%, p = 0.003), vacuum extractor affecting newborn (1.9% vs. 0.8%, p = 0.014), and polycythemia neonatorum (0.8% vs. 0%, p = 0.001) than the matched non-NHB cohort. The treated hemolytic NHB cohort also had significantly longer mean birth hospital stays (4.5 vs. 3.0 days, p < 0.001), higher level 2-4 neonatal intensive care admissions (15.7% vs. 2.4, 15.9% vs. 2.8 and 10.6% vs. 2.5%, respectively, all p < 0.001) and higher 30-day readmission (8.7% vs. 1.7%, p < 0.001). One-month and one-year average total costs of care were significantly higher for the treated hemolytic NHB cohort vs. the matched non-NHB cohort, $14,405 vs. $5527 (p < 0.001) and $21,556 vs. $12,986 (p < 0.001), respectively. The average costs for 30-day readmission among newborns who readmitted were $13,593 for the treated hemolytic NHB cohort and $3638 for the matched non-NHB cohort, p < 0.001. The authors extrapolated GA-adjusted prevalence of treated hemolytic NHB in the U.S. newborn population ≥ 35 weeks GA and estimated an incremental healthcare expenditure of $177.0 million during the first month after birth in 2016. CONCLUSIONS: The prevalence of treated hemolytic NHB was 4.6-5.5 patients per 1000 newborns. This high-risk hemolytic NHB imposed substantial burdens of healthcare resource utilization and incremental costs on newborns, their caregivers, and the healthcare system.

Phototherapy for Neonatal Unconjugated Hyperbilirubinemia: Examining Outcomes by Level of Care.

OBJECTIVES: Newborns hospitalized with unconjugated hyperbilirubinemia without critical comorbidities may receive intensive phototherapy (IP) in non-ICU levels of care, such as a mother-newborn unit, or ICU levels of care. Our aim was to compare outcomes between each level. METHODS: Using hospital discharge data from 2005 to 2011 in New York's State Inpatient Database, we performed multivariate analyses to compare outcomes that included total cost of hospitalization, length of stay, 30-day readmission rate after IP, and the number of cases of death, exchange transfusion, and γ globulin infusion. We included term newborns treated with IP in their first 30 days of life and without diagnosis codes for other critical illnesses. Explanatory variables included level of care, sex, race, insurance type, presence or absence of hemolysis, hospital, volume of IP performed at each hospital, and year of hospitalization. RESULTS: Ninety-nine percent of IP was delivered in non-ICU levels of care. Incidence of major complications was rare (≤0.1%). After adjusting for confounders, ICU level of care was not associated with difference in length of stay (relative risk: 1.2; 95% confidence interval [CI]: 0.91 to 1.15) or 30-day readmission rate (odds ratio: 0.74; 95% CI: 0.50 to 1.09) but was associated with 1.51 (95% CI: 1.47 to 1.56) times higher costs. CONCLUSIONS: For otherwise healthy term newborns with jaundice requiring IP, most received treatment in a non-ICU level of care, and those in intensive care had no difference in outcomes but incurred higher costs. IP guideline authors may want to be more prescriptive about IP level of care to improve value.

Family Integrated Care (FICare) in Level II Neonatal Intensive Care Units: study protocol for a cluster randomized controlled trial.

BACKGROUND: Every year, about 15 million of the world's infants are born preterm (before 37 weeks gestation). In Alberta, the preterm birth rate was 8.7% in 2015, the second highest among Canadian provinces. Approximately 20% of preterm infants are born before 32 weeks gestation (early preterm), and require care in a Level III neonatal intensive care unit (NICU); 80% are born moderate (32 weeks and zero days [320/7] to 336/7 weeks) and late preterm (340/7 to 366/7 weeks), and require care in a Level II NICU. Preterm birth and experiences in the NICU disrupt early parent-infant relationships and induce parental psychosocial distress. Family Integrated Care (FICare) shows promise as a model of care in Level III NICUs. The purpose of this study is to evaluate length of stay, infant and maternal clinical outcomes, and costs following adaptation and implementation of FICare in Level II NICUs. METHODS: We will conduct a pragmatic, cluster randomized controlled trial (cRCT) in ten Alberta Level II NICUs allocated to one of two groups: FICare or standard care. The FICare Alberta model involves three theoretically-based, standardized components: information sharing, parenting education, and family support. Our sample size of 181 mother-infant dyads per group is based on the primary outcome of NICU length of stay, 80% participation, and 80% retention at follow-up. Secondary outcomes (e.g., infant clinical outcomes and maternal psychosocial distress) will be assessed shortly after admission to NICU, at discharge and 2 months corrected age. We will conduct economic analysis from two perspectives: the public healthcare payer and society. To understand the utility, acceptability, and impact of FICare, qualitative interviews will be conducted with a subset of mothers at the 2-month follow-up, and with hospital administrators and healthcare providers near the end of the study. DISCUSSION: Results of this pragmatic cRCT of FICare in Alberta Level II NICUs will inform policy decisions by providing evidence about the clinical effectiveness and costs of FICare. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02879799 . Registered on 27 May 2016. Protocol version: 9 June 2016; version 2.

Mother's breast milk supplemented with donor milk reduces hospital and health service usage costs in low-birthweight infants.

OBJECTIVE: to compare hospital and health service usage costs of feeding low-birthweight (LBW) infants predominantly with their mother's milk, supplemented with donor milk, with donor milk and preterm formula. DESIGN: prospective matching study. SETTING: tertiary public perinatal centre, neonatal intensive care unit (NICU) and donor human milk bank. PARTICIPANTS: 100LBW infants (Group I) fed predominantly with their mother's milk from the first hour of life, supplemented (mainly for the first week of life) with donor milk, were matched on a 1:1 basis with 100LBW infants (Group II) who were fed with donor milk for the first 3 weeks of life followed by preterm formula until hospital discharge. Individualised targeted fortification of human milk was implemented in both study groups. FINDINGS: the costs of hospitalisation, doctor visits and prescription drugs for viral infections until 8 months of age were calculated for each infant. Infants fed predominantly with their mother's milk had significantly shorter hospital stays and lower hospitalisation costs. In Group I infants, the duration of enteral gavage feeding was shorter, resulting in significantly lower costs. Up to 8 months of age, Group I infants experienced fewer episodes of viral infections, and the cost of each doctor visit and drug prescription was lower for these infants. CONCLUSIONS: feeding LBW infants predominantly with their mother's milk reduces hospital and health service usage costs. IMPLICATIONS FOR PRACTICE: feeding LBW infants predominantly with their mother's milk, supplemented with donor milk, followed by exclusive breast feeding seems to result in potential savings in hospital and health service usage costs.

Effects of parenteral phosphorus dose restriction in preterm infants.

BACKGROUND: In response to a national shortage of parenteral phosphorus solutions (2013), a hospital-wide phosphorus dose restriction strategies was implemented which included judicious use of phosphorus in preterm infants <1250 g birth weight and no parenteral phosphorus in preterm infants >1250 g birth weight unless they have a critically low phosphorus level. OBJECTIVE: To study the effect of parenteral phosphorus dose restriction in preterm infants admitted to the neonatal intensive care unit. METHODS: Preterm infants (≤35 weeks birth gestation and ≤2500 g birth weight) who received parenteral nutrition, survived >1 week and had no major congenital anomalies were studied. Clinical and laboratory data in the first 4 weeks of life of infants admitted during the parenteral phosphorus shortage (cases) were compared to infants who were admitted 6 months prior to the shortage (controls). RESULTS: Twenty consecutive cases were compared to 40 consecutive controls. Cases had lower serum phosphorus levels, higher serum alkaline phosphatase levels, and need for greater inotropic support compared to controls. These differences were significant only in preterm infants with birth weight >1250 g, the group who received more parenteral phosphorus dose restriction while they were similar in preterm infants with birth weight <1250 g. CONCLUSION: The modest effects of phosphorus dose restriction may become more clinically important if shortage is prolonged or severe or if it involves extreme preterm infants.

Establishment of a family-centred care programme with follow-up home visits: implications for clinical care and economic characteristics.

BACKGROUND: Elternberatung Frühstart is a family-centred care programme for very preterm infants and seriously ill neonates and their parents. The uniqueness of this programme is in its consistency and continuity in parental counselling from pregnancy at risk to follow-up home visits. PATIENTS AND METHODS: Family-centred care is provided by specialised nurses, a social education worker, a case manager, a psychologist and neonatologists. They give support and information to parents and facilitate transition to home including co-ordination of health care services and support networks. The programme starts with information for parents at risk of preterm delivery to lessen their anxieties and worries. After birth, parental bonding is encouraged and parents are involved in daily care procedures. The following weeks focus on communication, information and education in order to enhance parental competence. Discharge planning and coordinated follow-up visits involve the family doctor and several members of the welfare and health care system. One of the key objectives is to prevent re-hospitalisation. Over a 4 year period 330 families participated. Funding is provided by: 1) the hospital, from admission to discharge equivalent to one full-time nursing staff, 2) charity donations for follow-up visits and 3) health care insurance for social medical aftercare (Bunter Kreis) following §43, 2 SGB V in severe cases. RESULTS: As a result of this programme, the median length of stay was reduced by 24 days; the number of patients that stayed longer than average were reduced by 64% in the group of patients born < 1 500 g. At the same time the patient throughput increased from 243 to 413. CONCLUSION: To conclude, a family-centred care programme with coordinated follow-up increases parental satisfaction, reduces the length of the hospital stay and is therefore profitable.

A critical review of cost reduction in neonatal intensive care. I. The structure of costs.

Neonatal intensive care is expensive. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under intense pressure to find strategies for cost reduction for neonatal services. Few neonatal clinicians are trained in economics, management, or accounting, and few hospital administrators are familiar with neonatal intensive care. In this review, we describe the structure and sources of hospital costs and the accounting systems needed to isolate and measure such costs. We discuss where efficiencies might be found and consider specific issues in capitated settings such as health maintenance organizations in the United States, the Canadian health care system and the National Health System in the United Kingdom.

Glutamine supplementation in low-birth-weight infants: mechanisms of action.

Very low-birth-weight infants have minimal endogenous nutritional reserves and are at high risk for stresses that induce further breakdown of these diminished reserves. They frequently receive very little glutamine because enteral feedings are often delayed and glutamine is not included in parenteral nutrition. Here we describe studies of glutamine supplementation in very low-birth-weight infants and discuss potential mechanisms for the beneficial effects.

Reasons for admission, causes of death and costs of admission to a tertiary referral neonatal unit in India.

The aim of this study was to determine the reasons for admission, charges made, and causes of death in a tertiary referral neonatal unit in India. Records of the Christian Medical College Hospital, Vellore, Tamil Nadu, India, were reviewed for the period 1 January-31 December 1992. The principal cause of death was ascertained with reference to predetermined diagnostic criteria. There were 5592 livebirths, 138 stillbirths and 1809 admissions to the nurseries (1603 inborn, 206 outborn). Suspected sepsis accounted for 24 per cent of admissions, 14 per cent required preterm care, 13 per cent phototherapy and 8 per cent were full term low birth weight babies admitted for observation. There were 87 early neonatal deaths, 4 per cent (49) of inborn admissions and 18 per cent (38) of outborn admissions. A further 11 babies were discharged to receive terminal care at home and nine were discharged, critically ill, against medical advice. Causes of death were respiratory problems of prematurity (49 per cent), lethal congenital malformations (22 per cent), complications of asphyxia (20 per cent) and sepsis (5 per cent). The median duration of nursery care was 2 days (range 1-21) and the median charge made Rs 714 (range 122-5036). Although the pattern of admissions and deaths still reflects the substantial problems of suspected sepsis, asphyxia, and congenital malformations, problems of immaturity may be on the increase. We caution against hospital-based statistics that fail to take account of babies who are discharged alive in the knowledge that death is imminent. Considered strategies for the provision or selective provision, of neonatal care in India, are called for.

Quality of outcome and cost in an obstetric and neonatal service.

A review has been made of the outcome and efficiency of the obstetric and neonatal service, St Helen's Hospital, Auckland. In the last seven years there has been a 33% fall in perinatal mortality rates to 5.88 per 1000 births in 1987. The average perinatal death rate for Maori infants was low, 4.81 per 1000 compared to 7.43 per 1000 for Europeans over this period. There has been a 38% increase in births to 3597 a year while the total hospital staffing has only risen 9%. Thus the ratio of births to staff has increased by 26.6% to 15.6. The cost per infant delivered in constant dollars has fallen 18.7% in the same period to $2432. The postnatal bed occupancy was 101% in 1987 and the average day stay fell to 5.7 days. An extra 61 full time staff would be needed to reduce the workload to that of 1981 and the staff is now unable to give the family focused holistic care that is needed.