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Is Neonatal Intensive Care Expensive?

Is Neonatal Intensive Care Expensive?. Liisa Lehtonen, MD Head of Division of Neonatology, Turku University Hospital Estonian Perinatal Association 10.-11.12.2010 Tarto, Estonia. Content. Expenses are affected by prevalence of prematurity

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Is Neonatal Intensive Care Expensive?

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  1. Is Neonatal Intensive Care Expensive? Liisa Lehtonen, MD Head of Division of Neonatology, Turku University Hospital Estonian Perinatal Association 10.-11.12.2010 Tarto, Estonia

  2. Content • Expensesareaffectedbyprevalence of prematurity • Preterminfants as a part of otherneonatalintensivecare • Europeanperspective • Expensesareaffectedbye.g. • The length of hospitalstay • Longtermoutcome • New knowledgeaboutcost-effectiveness of the care of VLGA/VLBW infantsfrom PERFECT PretermInfantsStudy • Thesesby Liisi Rautava, MD Emmi Korvenranta MD, MSc

  3. Prevalence of prematurity in Europe www.europeristat.com

  4. Prevalence of prematurity in Europe www.europeristat.com

  5. Multiplebirths 18.2/1000 17.8/1000 www.europeristat.com 17.4/1000 20.4/1000 15.2/1000

  6. 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

  7. Neonatalintensivecare TYKS 2009 • Heterogenic patient population • Majority of patient are fullterm infants

  8. Preterminfantsn= 3473 (5.7%) live born below 37 weeks v 2009 • Preterm infants are one significant patient group of those needing neonatal intensive care

  9. VLGA/VLBW infantsn=644 (1.0 %) liveborn <1500 g or <32 weeks v 2009 • VLGA/VLBW infants need a long initial hospital care

  10. The quality of care affects • mortality • length of stay • longtermoutcome • costs  the quality of the initialcarehaslarge and longtermconsequences

  11. Perfect = PERFormance, Effectiveness and Cost of Treatmentepisodes • 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

  12. PERFECT Keskoset Perusraportit

  13. The Effect of the BirthHospital and the Time of Birth on the Outcome of FinnishVeryPretermInfants • Thesisby Liisi Rautava, MD • To study the effects of the organisation of the initialcare on • mortality, • diagnoses (hospitaldischargeregister) • childdevelopment • qualitybof life by 5 years of life

  14. VeryPretermInfants in Finland – Use of Health Care Services and EconimicConsequencesDuring the FirstFiveYears of Life • Thesisby Emmi Korvenranta, MD • The factorsaffecting the length of stay, the costs of care and the cost of a qualityadjusted life year (QALY) by 4 yr of life

  15. The length of stay

  16. Gestationalage at dischargebygestage at birth 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.

  17. The factorsaffecting LOS [days (95% CI)] • Previous c/s –1.9 (–3.7; –0.7) • Previouspregnancies –1.1 (–1.9; –0.2) • C/S 2.9 (2.1; 3.6) • Gestage (1 additionalday) –1.07 (–1.10; –1.05) • Apgar 1 min (1 additionalpoint) –0.7 (–0.9; –0.5) • Male 1.7 (1.0; 2.4) • Multiple 2.6 (1.8; 3.4) • Ventilatorcareduring the firstweek 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 otherhospital 1.7 (0.7; 2.7) • Dischargefromuniversityhospital 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…

  18. Independenteffect of the universitydistricton adjusted LOS, days (95% CI) –4.6 (–5.6;–3.5) –10.5 (-11.5;–9.3) –4.7 (–5.8;–3.5) –2.3 (–3.6;–1.1) 0 10,5d Korvenranta E, Linna M, Häkkinen U et al for the PERFECT Preterm Infant Study Group. Acta Paediatrica 2007;96:1416-1420.

  19. Adjusted LOS according to the birthhospital

  20. Absolute LOS bydistricts

  21. Caredays in survivorsby 1 year of age

  22. The LOS in VLGA/VLBW infants • Decreasedby 4 days • 58 days in 2000-2003 • 53 days in 2004-2006 • 5 days x 520 = 2600 days • The workload is decreasedby in overcrowdedunits • Resources to beused in morecriticalwork

  23. Quality of Life (17D) Rautava L et al for the PERFECT Preterm Infant Study Group. J Pediatr 2009

  24. The totalcost of hospitalcare by4 years of age Korvenranta E et al for PERFECT Preterm Infant Study Group Arch Pediatr Adolesc Med 2010;164:657-663.

  25. The costsduring the fifthyear of life Korvenranta E, Lehtonen L, Rautava L, et al. Pediatrics 2010;125;e1109-e1114.

  26. The costsduring the fifthyear of life Korvenranta E, Lehtonen L, Rautava L, et al. Pediatrics 2010;125;e1109-e1114.

  27. The cost of a QALY average19,245€by 4 years of age • None of diagnoses 14,066€ • Seizures 22,516€ • Cerebral Palsy 21,165€ • Other ophthalmologic problems 20,472€ • Visual disorder 20,371€ • Hearing loss 26,563€ • Obstructive airway disease 21,682€ • 2 or more of the above diagnoses 31,991€ Korvenranta E et al for PERFECT Preterm Infant Study GroupArch Pediatr Adolesc Med 2010;164:657-663.

  28. The totalcosts of preterminfantcarein 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 €

  29. Mercedes Benz

  30. Summary • Preterminfantscompriseoneimportantpatientgroup in neonatalintensivecare • Goodquality of carerequiresresources • Goodquality of initialcaresaveslatercosts • The goal of treatment is a healthychild qualitymeasurewhich is mandatory to follow

  31. Howruns on a road?

  32. Howruns on a road?

  33. Preterminfantcare is a goodinvestment • Cost-effectivenesscanbeimprovedbyimprovinglongtermoutcome of preterminfats • Qualityimprovementbased on longtermoutcomesshouldbe the mission of allneonatologists

  34. CP diagnosis in VLBW infants 2001-2007 (n=14/204). PIPARI Study % p=0.04

  35. PIPARI Study: Cognitivelevel in VLBW infants at 2 yr of correctedagehasimproveddramatically

  36. Cognitiveoutcome at 5 years of age (WPPSI-R) / PIPARI (Munck et al, unpublished)

  37. Is neonatal intensive care expensive? No! • Preterminfantcare is cost-effectivealready at 4 years of age • The investment on initialcarewillbeevenmorebeneficialwithmorefollow-upyears • The cost of the gained life yearsdecreases as the dividerincreases • The costs of lateryearsaresmall

  38. PERFECT PretermInfantStudy 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. ActaPaediatrica 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 PediatrAdolesc 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. ActaPaediatrica 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. EurChild&AdolescentPsychiatr 2010;19:669-677.

  39. 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

  40. Quality of Life (17D) Rautava L et al for the PERFECT Preterm Infant Study Group. J Pediatr 2009

  41. 8 7 6 5 4 3 Mortality Ratio 2 1 0 22-23 24-25 26-27 28-29 30-31 > 31 Gestational age (weeks) Level II hospital Level III hospital Adjusted mortality by 1 year of age in live born VLGA/VLBW infants by birth hospital level Rautava L, Lehtonen L, Peltola M, et al for the PERFECT Preterm Infant Study Group. Pediatrics 2007;119:257-263.

  42. Mortality in live born VLGA/VLBW infants according to the birth hospital level and time of birth in 2000-05(n=3070)

  43. The proportion of VLGA/VLBW infantsborn in universityhospitalsbydistricts

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

  45. Outcome of VLBW infantsat 2 years of correctedage PIPARI StudyMunck P et al: ActaPaediatrica 2010;99:359-366

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