Is Neonatal Intensive Care Expensive?

Is Neonatal Intensive Care Expensive?

Liisa Lehtonen, MDHead of Division of Neonatology, Turku University

Hospital

Estonian Perinatal Association 10.-11.12.2010 Tarto, Estonia

Liisa Lehtonen, MDHead of Division of Neonatology, Turku University

Hospital

Estonian Perinatal Association 10.-11.12.2010 Tarto, Estonia

ContentContent• Expenses are affected by prevalence of

prematurity– Preterm infants as a part of other neonatal intensive care – European perspective

• Expenses are affected by e.g.– The length of hospital stay – Longterm outcome

• New knowledge about cost-effectiveness of the care of VLGA/VLBW infants from PERFECT Preterm InfantsStudy

• Theses by Liisi Rautava, MDEmmi Korvenranta MD, MSc

• Expenses are affected by prevalence of prematurity– Preterm infants as a part of other neonatal intensive care – European perspective

• Expenses are affected by e.g.– The length of hospital stay – Longterm outcome

• New knowledge about cost-effectiveness of the care of VLGA/VLBW infants from PERFECT Preterm InfantsStudy

• Theses by Liisi Rautava, MDEmmi Korvenranta MD, MSc

Prevalence of prematurity in Europe

Prevalence of prematurity in Europe

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Prevalence of prematurity in Europe

Prevalence of prematurity in Europe

Multiple births Multiple births

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peri

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20.4/1000

17.8/1000

18.2/1000

17.4/1000

15.2/1000

Newborns in Finland n=60.577 live born in 2009

Newborns in Finland n=60.577 live born in 2009

• 9.6% admitted to neonatal ward• 7.6% in hospital at 1 week of age

NICU Newborn nursery

Neonatal intensive care TYKS 2009Neonatal intensive care TYKS 2009

• Heterogenic patient population• Majority of patient are fullterm infants

MAS

Sepsis

Pneumonia

Breathing problems

Hypoglykemia

Hyperbilirubinemia

Anomalies

Drug withdrawal

Others

Below 1000 g

1000-1500g

1500-2500g

Preterm infants n= 3473 (5.7%) live born below 37

weeks v 2009

Preterm infants n= 3473 (5.7%) live born below 37

weeks v 2009

• Preterm infants are one significant patient group of those needing neonatal intensive care

Preterm Fullterm Newborn nursery

VLGA/VLBW infants n=644 (1.0 %) liveborn <1500 g or <32 weeks v

2009

VLGA/VLBW infants n=644 (1.0 %) liveborn <1500 g or <32 weeks v

2009

• VLGA/VLBW infants need a long initial hospital care

VLGA/VLBW Preterm Fullterm Newborn nursery

The quality of care The quality of care

affects • mortality • length of stay• longterm outcome• costs

the quality of the initial care has large and longterm consequences

affects • mortality • length of stay• longterm outcome• costs

the quality of the initial care has large and longterm consequences

Perfect = PERFormance, Effectiveness and Cost of

Treatment episodes

Perfect = PERFormance, Effectiveness and Cost of

Treatment episodes

• To develop measures for cost-effectiveness based on the existing registers– VLGA/VLBW infants included

• To develop an online database to follow the changes in cost-effectiveness

• www.thl.fi/ search: PERFECT keskoset perusraportti– Last update includes years 2004-2007

• The Institute of Health and Welfare and hospital districts in collaboration

• To develop measures for cost-effectiveness based on the existing registers– VLGA/VLBW infants included

• To develop an online database to follow the changes in cost-effectiveness

• www.thl.fi/ search: PERFECT keskoset perusraportti– Last update includes years 2004-2007

• The Institute of Health and Welfare and hospital districts in collaboration

PERFECT Keskoset Perusraportit

PERFECT Keskoset Perusraportit

The Effect of the Birth Hospital and the Time of Birth on the Outcome of Finnish Very Preterm Infants

The Effect of the Birth Hospital and the Time of Birth on the Outcome of Finnish Very Preterm Infants

• Thesis by Liisi Rautava, MD

• To study the effects of the organisation of the initial care on– mortality, – diagnoses (hospital

discharge register)– child development – quality bof life by 5

years of life

• Thesis by Liisi Rautava, MD

• To study the effects of the organisation of the initial care on– mortality, – diagnoses (hospital

discharge register)– child development – quality bof life by 5

years of life

Very Preterm Infants in Finland – Use of Health Care Services and Econimic Consequences During the First Five Years of Life

Very Preterm Infants in Finland – Use of Health Care Services and Econimic Consequences During the First Five Years of Life

• Thesis by Emmi Korvenranta, MD

• The factors affecting the length of stay, the costs of care and the cost of a quality adjusted life year (QALY) by 4 yr of life

• Thesis by Emmi Korvenranta, MD

• The factors affecting the length of stay, the costs of care and the cost of a quality adjusted life year (QALY) by 4 yr of life

The length of stayThe length of stay

Gestational age at discharge by gest age at birth

Gestational age at discharge by gest age at birth

Alue <28 wk 28-32 wk >32 wk

A 39+6 37+2 38+1

B 38+0 36+4 38+0

C 38+4 37+4 38+6

D 39+2 37+6 39+3

E 41+6 38+3 38+6

Korvenranta E, Linna M, Häkkinen U et al for the PERFECT Preterm Infant Study Group: The differences in the length of stay in very preterm infants. Acta Paediatrica 2007;96:1416-1420.

The factors affecting LOS [days (95% CI)]

The factors affecting LOS [days (95% CI)]

• Previous c/s –1.9 (–3.7; –0.7)• Previous pregnancies –1.1 (–1.9; –0.2)• C/S 2.9 (2.1; 3.6)• Gest age (1 additional day) –1.07 (–1.10; –1.05)• Apgar 1 min (1 additional point) –0.7 (–0.9; –0.5)• Male 1.7 (1.0; 2.4)• Multiple 2.6 (1.8; 3.4) • Ventilator care during the first week 5.0 (4.3; 5.8)• SGA 13.7 (12.7; 14.6)• LGA –7.6 (–9.5; –5.6)• Death –35. 8 (–36.9; –34.6)• Backtransfer to other hospital 1.7 (0.7; 2.7)• Discharge from univ ersity hospital 1.3 (0.4; 2.3)• Distance to home (per 100 km) 1.8 (1.1; 2.4)• Rehospitalization 4.1 (3.3; 4.8)

• Previous c/s –1.9 (–3.7; –0.7)• Previous pregnancies –1.1 (–1.9; –0.2)• C/S 2.9 (2.1; 3.6)• Gest age (1 additional day) –1.07 (–1.10; –1.05)• Apgar 1 min (1 additional point) –0.7 (–0.9; –0.5)• Male 1.7 (1.0; 2.4)• Multiple 2.6 (1.8; 3.4) • Ventilator care during the first week 5.0 (4.3; 5.8)• SGA 13.7 (12.7; 14.6)• LGA –7.6 (–9.5; –5.6)• Death –35. 8 (–36.9; –34.6)• Backtransfer to other hospital 1.7 (0.7; 2.7)• Discharge from univ ersity hospital 1.3 (0.4; 2.3)• Distance to home (per 100 km) 1.8 (1.1; 2.4)• Rehospitalization 4.1 (3.3; 4.8)

Continues…

Independent effect of the university district

on adjusted LOS, days (95% CI)

Independent effect of the university district

on adjusted LOS, days (95% CI)

0 10 20 30 40 50 60

1

2

3

4

5

Reg

ion

LOS (days)

10,5d

–4.6 (–5.6;–3.5)

–10.5 (-11.5;–9.3)

–4.7 (–5.8;–3.5)

–2.3 (–3.6;–1.1)

0Korvenranta E, Linna M, Häkkinen U et al for the PERFECT Preterm Infant Study Group. Acta Paediatrica 2007;96:1416-1420.

Adjusted LOS according to the birth hospital

Adjusted LOS according to the birth hospital

75

80

85

90

95

100

105

110

115

2000-03 2004-06

A B C D E Keskussairaalat

Absolute LOS by districtsAbsolute LOS by districts

40

45

50

55

60

65

70

75

2000-03 2004-06

A B C D E

Care days in survivors by 1 year of age

Care days in survivors by 1 year of age

50

55

60

65

70

75

2000-03 2004-06

A B C D E

The LOS in VLGA/VLBW infants

The LOS in VLGA/VLBW infants

• Decreased by 4 days– 58 days in 2000-2003– 53 days in 2004-2006

• 5 days x 520 = 2600 days – The workload is decreased by in overcrowded

units– Resources to be used in more critical work

• Decreased by 4 days– 58 days in 2000-2003– 53 days in 2004-2006

• 5 days x 520 = 2600 days – The workload is decreased by in overcrowded

units– Resources to be used in more critical work

Quality of Life (17D)Quality of Life (17D)

Rautava L et al for the PERFECT Preterm Infant Study Group. J Pediatr 2009

0

20000

40000

60000

80000

100000

None of thestudied

diagnoses

Seizures Cerebral Palsy Otheropthalmologic

problems

Visual disorder Hearing loss Obstructiveairway

diseases

2 or more ofthe studieddiagnoses

Initial hospitalization 1. year other 2. year 3. year 4. year

The total cost of hospital care by 4 years of age

The total cost of hospital care by 4 years of age

Korvenranta E et al for PERFECT Preterm Infant Study Group Arch Pediatr Adolesc Med 2010;164:657-663.

The costs during the fifth year of life

The costs during the fifth year of life

0

500

1000

1500

2000

2500

3000

3500

1 or moremorbidities

No morbidities Full term

€

OtherSpeech therapistNursePsychologistPT/OTPrimary care & private practHospitalizationsNon-emergencyEmergency

Korvenranta E, Lehtonen L, Rautava L, et al. Pediatrics 2010;125;e1109-e1114.

The costs during the fifth year of life

The costs during the fifth year of life

0

500

1000

1500

2000

2500

3000

3500

24-25 26-27 28-29 30-31 32+ Fullterm

GA

€

OtherSpeech therapistNursePsychologistPT/OTPrimary care & private practHospitalizationsNon-emergencyEmergency

Korvenranta E, Lehtonen L, Rautava L, et al. Pediatrics 2010;125;e1109-e1114.

The cost of a QALY average 19,245€ by 4 years of

age

The cost of a QALY average 19,245€ by 4 years of

age• None of diagnoses 14,066€• Seizures 22,516€• Cerebral Palsy 21,165€• Other ophthalmologic problems

20,472ۥ Visual disorder 20,371ۥ Hearing loss 26,563ۥ Obstructive airway disease

21,682ۥ 2 or more of the above diagnoses

31,991€

• None of diagnoses 14,066€• Seizures 22,516€• Cerebral Palsy 21,165€• Other ophthalmologic problems

20,472ۥ Visual disorder 20,371ۥ Hearing loss 26,563ۥ Obstructive airway disease

21,682ۥ 2 or more of the above diagnoses

31,991€Korvenranta E et al for PERFECT Preterm Infant Study Group Arch Pediatr Adolesc Med 2010;164:657-663.

The total costs of preterm infant care

in Finland

The total costs of preterm infant care

in Finland

• 560 VLGA/VLBW infants survive per year x 65,000 € (4 year total hospital costs)

= 36 milj €/year

Compare to the costs of ambulances/taxi drives for patients more than 200 milj €

• 560 VLGA/VLBW infants survive per year x 65,000 € (4 year total hospital costs)

= 36 milj €/year

Compare to the costs of ambulances/taxi drives for patients more than 200 milj €

Mercedes BenzMercedes Benz

SummarySummary

• Preterm infants comprise one important patient group in neonatal intensive care

• Good quality of care requires resources • Good quality of initial care saves later

costs• The goal of treatment is a healthy child

quality measure which is mandatory to follow

• Preterm infants comprise one important patient group in neonatal intensive care

• Good quality of care requires resources • Good quality of initial care saves later

costs• The goal of treatment is a healthy child

quality measure which is mandatory to follow

How runs on a road?How runs on a road?

How runs on a road?How runs on a road?

Preterm infant care is a good investment

Preterm infant care is a good investment

• Cost-effectiveness can be improved by improving longterm outcome of preterm infats

• Quality improvement based on longterm outcomes should be the mission of all neonatologists

• Cost-effectiveness can be improved by improving longterm outcome of preterm infats

• Quality improvement based on longterm outcomes should be the mission of all neonatologists

CP diagnosis in VLBW infants 2001-2007 (n=14/204). PIPARI Study

CP diagnosis in VLBW infants 2001-2007 (n=14/204). PIPARI Study

0

1

2

3

4

5

6

7

8

9

10

2001-03 2004-06 2007

% p=0.04

PIPARI Study: Cognitive level in VLBW infants at 2 yr of corrected age has improved dramatically

PIPARI Study: Cognitive level in VLBW infants at 2 yr of corrected age has improved dramatically

Cognitive outcome at 5 years of age (WPPSI-R)

/ PIPARI (Munck et al, unpublished)

Cognitive outcome at 5 years of age (WPPSI-R)

/ PIPARI (Munck et al, unpublished)

VLBW (n=89)ka (SD)

Verrokit (n=152)ka (SD)

p

FSIQ 101.9 (15.0) 112.0 (14.6) <0.001

VIQ 104.8 (14.6) 108.2 (13.9) ns

PIQ 99.0 (15.6) 111.7 (13.4) <0.001

Is neonatal intensive care expensive? No!

Is neonatal intensive care expensive? No!

• Preterm infant care is cost-effective already at 4 years of age

• The investment on initial care will be even more beneficial with more follow-up years – The cost of the gained life years decreases as

the divider increases– The costs of later years are small

• Preterm infant care is cost-effective already at 4 years of age

• The investment on initial care will be even more beneficial with more follow-up years – The cost of the gained life years decreases as

the divider increases– The costs of later years are small

PERFECT Preterm Infant StudyPERFECT Preterm Infant StudyRautava L, Lehtonen L, Peltola M, Korvenranta E, Korvenranta H, Linna M, Hallman M,

Andersson S, Gissler M, Leipälä J, Tammela O, Häkkinen U, for the PERFECT Preterm Infant Study Group. The Effect of Birth in Secondary or Tertiary Level Hospitals in Finland on Mortality in Very Preterm Infants: A Birth Register Study. Pediatrics 2007;119:257-263.

Korvenranta E, Linna M, Häkkinen U, Peltola M, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Rautava L, Tammela O, Lehtonen L for the PERFECT Preterm Infant Study Group: Differences in the LOS in very preterm infants. Acta Paediatrica 2007;96:1416-1420.

Korvenranta E, Lehtonen L, Peltola M, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Rautava L, Tammela O, Linna M. Morbidities and hospital resource use during the first 3 years of life among very preterm infants. Pediatrics 2009;124:128-34.

Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Linna M, Peltola M, Tammela O, Lehtonen L. Health-related quality of life in 5-year-old VLBW infants. J Pediatr 2009;155:338-43.

Korvenranta E, Linna M, Rautava L, Andersson S, Gissler M, Hallman M, Häkkinen U, Leipälä J, Peltola M, Tammela O and Lehtonen L for PERFECT Preterm Infant Study Group. The economic impact of a very preterm birth during the first 4 yr of life in Finland. Arch Pediatr Adolesc Med 2010;164:657-663.

Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H,Leipälä J, Peltola M, Tammela O, and Lehtonen L for PERFECT Preterm Infant Study. Health and the Use of Health Care Services in 5-yr-old VLBW Infants. Acta Paediatrica 2010;99:1073-1079.

Korvenranta E, Lehtonen L, Rautava L, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Peltola M, Tammela O, and Linna M. The Impact of Very Preterm Birth on Health Care Costs at Five Years of Age. Pediatrics 2010;125;e1109-e1114.

Rautava L, Andersson S, Gissler, M, Hallman M, Häkkinen U, Korvenranta E, Korvenranta H, Leipälä J, Tammela O, Lehtonen L for PERFECT Preterm Infant Study Group: Development and Behavior of Five-Year-Old VLBW Infants. Eur Child&Adolescent Psychiatr 2010;19:669-677.

Rautava L, Lehtonen L, Peltola M, Korvenranta E, Korvenranta H, Linna M, Hallman M, Andersson S, Gissler M, Leipälä J, Tammela O, Häkkinen U, for the PERFECT Preterm Infant Study Group. The Effect of Birth in Secondary or Tertiary Level Hospitals in Finland on Mortality in Very Preterm Infants: A Birth Register Study. Pediatrics 2007;119:257-263.

Korvenranta E, Linna M, Häkkinen U, Peltola M, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Rautava L, Tammela O, Lehtonen L for the PERFECT Preterm Infant Study Group: Differences in the LOS in very preterm infants. Acta Paediatrica 2007;96:1416-1420.

Korvenranta E, Lehtonen L, Peltola M, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Rautava L, Tammela O, Linna M. Morbidities and hospital resource use during the first 3 years of life among very preterm infants. Pediatrics 2009;124:128-34.

Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Linna M, Peltola M, Tammela O, Lehtonen L. Health-related quality of life in 5-year-old VLBW infants. J Pediatr 2009;155:338-43.

Korvenranta E, Linna M, Rautava L, Andersson S, Gissler M, Hallman M, Häkkinen U, Leipälä J, Peltola M, Tammela O and Lehtonen L for PERFECT Preterm Infant Study Group. The economic impact of a very preterm birth during the first 4 yr of life in Finland. Arch Pediatr Adolesc Med 2010;164:657-663.

Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H,Leipälä J, Peltola M, Tammela O, and Lehtonen L for PERFECT Preterm Infant Study. Health and the Use of Health Care Services in 5-yr-old VLBW Infants. Acta Paediatrica 2010;99:1073-1079.

Korvenranta E, Lehtonen L, Rautava L, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Peltola M, Tammela O, and Linna M. The Impact of Very Preterm Birth on Health Care Costs at Five Years of Age. Pediatrics 2010;125;e1109-e1114.

Rautava L, Andersson S, Gissler, M, Hallman M, Häkkinen U, Korvenranta E, Korvenranta H, Leipälä J, Tammela O, Lehtonen L for PERFECT Preterm Infant Study Group: Development and Behavior of Five-Year-Old VLBW Infants. Eur Child&Adolescent Psychiatr 2010;19:669-677.

The PERFECT Preterm Infant Study Group

The PERFECT Preterm Infant Study Group

• The National Institute of Health and Welfare

• Unto Häkkinen, Professor• Miika Linna, Docent• Mika Gissler, Professor• Mikko Peltola, Researcher• Merja Juntunen, Researcher• Antti Malmivaara, Professor

• Clinical experts• Liisa Lehtonen, MD, Docent, TYKS, the

Principal Investigator• Sture Andersson, MD, Docent, HYKS• Mikko Hallman, MD, Professor, OYS• Heikki Korvenranta, MD, Docent,

TYKS• Ulla Sankilampi, MD, KYS• Jaana Leipälä, MD, Docent, THL• Outi Tammela, MD, Docent, TAYS

• PhD• Emmi Korvenranta, Economist, MD,

Turku University • Liisi Rautava, MD, Turku University

• The National Institute of Health and Welfare

• Unto Häkkinen, Professor• Miika Linna, Docent• Mika Gissler, Professor• Mikko Peltola, Researcher• Merja Juntunen, Researcher• Antti Malmivaara, Professor

• Clinical experts• Liisa Lehtonen, MD, Docent, TYKS, the

Principal Investigator• Sture Andersson, MD, Docent, HYKS• Mikko Hallman, MD, Professor, OYS• Heikki Korvenranta, MD, Docent,

TYKS• Ulla Sankilampi, MD, KYS• Jaana Leipälä, MD, Docent, THL• Outi Tammela, MD, Docent, TAYS

• PhD• Emmi Korvenranta, Economist, MD,

Turku University • Liisi Rautava, MD, Turku University

Quality of Life (17D)Quality of Life (17D)

Rautava L et al for the PERFECT Preterm Infant Study Group. J Pediatr 2009

ICD-10 dg:t5 v ikään mennessä

Pikkukeskoset(%)

Täysiaikaiset(%)

P-value

CP 4.0 0 0.004

Karsastus 8.8 0.6 <0.001

Taittovika 6.7 1.1 0.002

Korvatulehdus (nonsupp)

13.8 5.1 0.001

Märkäinen korvatulehdus

32.0 10.2 <0.001

Ylähengitystieinfektio 24.1 5.7 <0.001

Pneumonia 8.4 1.7 0.001

Akuutti bronkiitti 4.8 0 <0.001

Bronkioliitti 24.4 8.0 <0.001

Astma 18.9 4.6 <0.001

Atooppinen ihottuma 3.8 9.7 0.005

Adjusted mortality by 1 year of age in live born VLGA/VLBW infants by birth hospital level

Adjusted mortality by 1 year of age in live born VLGA/VLBW infants by birth hospital level

0

1

2

3

4

5

6

7

8

22-23 24-25 26-27 28-29 30-31 > 31

Gestational age (weeks)

Mort

ality

Rati

o

Level II hospital Level III hospital

Rautava L, Lehtonen L, Peltola M, et al for the PERFECT Preterm Infant Study Group. Pediatrics 2007;119:257-263.

Mortality in live born VLGA/VLBW infants according to the birth hospital level and time of

birth in 2000-05(n=3070)

Mortality in live born VLGA/VLBW infants according to the birth hospital level and time of

birth in 2000-05(n=3070)

The proportion of VLGA/VLBW infants

born in university hospitals by districts The proportion of VLGA/VLBW infants

born in university hospitals by districts

0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006 2007 2008

HYKS

TYKS

TAYS

KYS

OYS

0

50

100

150

200

250

a b c d e f g h i j k l m n o p A B C D E

2005

2006

2007

2008

Live born VLBW/VLGA inafnts by hospitals (15 hospitals excluded with ≤2/yr)

Outcome of VLBW infants at 2 years of corrected age PIPARI Study

Munck P et al: Acta Paediatrica 2010;99:359-366

Outcome of VLBW infants at 2 years of corrected age PIPARI Study

Munck P et al: Acta Paediatrica 2010;99:359-366

GA 23

24 25 26 27 28 29 30 31 32 33 34 35

n 3 10 18 19 14 29 24 26 12 10 8 6 3

MDI 73 92 98 100

95 104

105

109

105

101

102

106

96

Delay%

33

10 0 5 7 3 4 0 0 0 0 0 0

Disability(%)

67 20 17 5 14 14 4 0 0 10 13 0 33