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
ww
w.e
uro
peri
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com
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