Selected papers on the evaluation of healthcare costs of prematurity and necrotizing enterocolitis using large retrospective databases

Ch2 Objective: This study evaluated the cost-effectiveness of a 100% human milk-based diet composed of mother’s milk fortified with a donor human milk-based human milk fortifier (HMF) versus mother’s milk fortified with bovine milk-based HMF to initiate enteral nutrition among extremely premature infants in the neonatal intensive care unit (NICU). Methods: A net expected costs calculator was developed to compare the total NICU costs among extremely premature infants who were fed either a bovine milk-based HMF-fortified diet or a 100% human milk-based diet, based on the previously observed risks of overall necrotizing enterocolitis (NEC) and surgical NEC in a randomized controlled study that compared outcomes of these two feeding strategies among 207 very low birth weight infants. The average NICU costs for an extremely premature infant without NEC and the incremental costs due to medical and surgical NEC were derived from a separate analysis of hospital discharges in the state of California in 2007. The sensitivity of cost-effectiveness results to the risks and costs of NEC and to prices of milk supplements was studied. Results: The adjusted incremental costs of medical NEC and surgical NEC over and above the average costs incurred for extremely premature infants without NEC, in 2011 US$, were $74,004 (95% confidence interval [CI], $47,051–$100,957) and $198,040 (95% CI, $159,261–$236,819) per infant, respectively. Extremely premature infants fed with 100% human milk-based products had lower expected NICU length of stay and total expected costs of hospitalization, resulting in net direct savings of 3.9 NICU days and $8,167.17 (95% confidence interval, $4,405–$11,930) per extremely premature infant (p<0.0001). Costs savings from the donor HMF strategy were sensitive to price and quantity of donor HMF, percentage reduction in risk of overall NEC and surgical NEC achieved, and incremental costs of surgical NEC. Conclusions: Compared with feeding extremely premature infants with mother’s milk fortified with bovine milk-based supplements, a 100% human milk-based diet that includes mother’s milk fortified with donor human milk-based HMF may result in potential net savings on medical care resources by preventing NEC. ❧ Ch3 Background: Infants who survive advanced necrotizing enterocolitis (NEC) at the time of birth are at increased risk of having poor long term physiological and neurodevelopmental growth. The economic implications of the long term morbidity in these children have not been studied to date. This paper compares the long term healthcare costs beyond the initial hospitalization period incurred by medical and surgical NEC survivors with that of matched controls without a diagnosis of NEC during birth hospitalization. Methods: The longitudinal healthcare utilization claim files of infants born between January 2002 and December 2003 and enrolled in the Texas Medicaid fee-for-service program were used for this research. Propensity scoring was used to match infants diagnosed with NEC during birth hospitalization to infants without a diagnosis of NEC on the basis of gender, race, prematurity, extremely low birth weight status and presence of any major birth defects. The Medicaid paid all-inclusive healthcare costs for the period from 6 months to 3 years of age among children in the medical NEC, surgical NEC and matched control groups were evaluated descriptively, and in a generalized linear regression framework in order to model the impact of NEC over time and by birth weight. Results: Two hundred fifty NEC survivors (73 with surgical NEC) and 2,909 matched controls were available for follow-up. Medical NEC infants incurred significantly higher healthcare costs than matched controls between 6–12 months of age (mean incremental cost = US $5,112 per infant). No significant difference in healthcare costs between medical NEC infants and matched controls was seen after 12 months. Surgical NEC survivors incurred healthcare costs that were consistently higher than that of matched controls through 36 months of age. The mean incremental healthcare costs of surgical NEC infants compared to matched controls between 6–12, 12–24 and 24–36 months of age were US $18,274, $14,067 (p<0.01) and $8,501 (p=0.06) per infant per six month period, respectively. These incremental costs were found to vary between subgroups of infants born with birth weight <1,000 grams versus ≥ 1,000 grams (p<0.05). Conclusions: The all-inclusive healthcare costs of surgical NEC survivors continued to be substantially higher than that of matched controls through the early childhood development period. These results can have important treatment and policy implications. Further research in this topic is needed. ❧ Ch4 Background: The long-term healthcare cost among preterm survivors, classified by gestational age, has not been studied well. Previous studies have largely ignored the role of unobserved heterogeneity, leading to biased inferences regarding the treatment effect of preterm births. Objectives: To evaluate the incremental healthcare costs and drivers of costs, among preterm survivors, within a US public payer population from 6 months to 5 years of age. Study Design & Methods: Children born moderate to late preterm (33-36 weeks of gestational age), very to extremely preterm (< 33 weeks of GA) or full-term and enrolled in the Texas Medicaid fee-for-service program were identified from their birth hospitalization claims. An unbalanced panel structure was used to summarize data on time-varying covariates and outcomes within each period. Two-part model, with fixed effects in each step, was used to estimate logarithm of total healthcare costs, separately, among preterm and control groups. The incremental effect of preterm births was obtained using Blinder-Oaxaca type decompositions and standard errors were estimated by bootstrapping. Attrition weighting was used to account for non-random attrition. Cumulative costs per child were estimated after applying a discount rate of 3% to costs incurred beyond 12 months of age. Results: The incremental impact of moderate to late preterm birth, per se, was not significant beyond 6 months, after controlling for unobserved child specific factors. When combined with an additional risk factor, birth weight < 2,500 grams, the average incremental cost of M/L preterm birth was US$ 560 per child for the total period between 6 and 60 months of age (p < 0.05). Over the same period, the average incremental cost of preterm birth at < 33 weeks of GA was $4,800 per child (p < 0.001). Neurodevelopmental delay, asthma/bronchial disorders, respiratory symptoms and refractory vision disorders were top drivers of the healthcare cost difference between preterm and full-term survivors. Weighting for attrition had a significant impact on the treatment effect estimates. Conclusions: Controlling for unobserved heterogeneity while evaluating the long-term consequences of preterm birth should be considered. M/L preterm with birth weight < 2,500 grams and V/E preterm born children bear significant financial impact to Texas Medicaid program through 5 years of age. These findings have important policy implications.