Cost-Effectiveness of Strategies That Are Intended to Prevent Kernicterus in Newborn Infants

• Published in: Pediatrics (Evanston) 2004-10, Vol.114 (4), p.917-924
• Main Authors: Suresh, Gautham K, Clark, Robin E
• Format: Article
• Language: English
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Babies; Bilirubin - blood; Biological and medical sciences; Blood Chemical Analysis - economics; Cost estimates; Cost-Benefit Analysis; Decision Trees; Delivery. Postpartum. Lactation; Effectiveness studies; Emergency and intensive care: neonates and children. Prematurity. Sudden death; General aspects; Gynecology. Andrology. Obstetrics; Health Care Costs; Hematologic Tests - economics; Hospital Charges; Humans; Hyperbilirubinemia - diagnosis; Hyperbilirubinemia - economics; Hyperbilirubinemia - therapy; Infant, Newborn; Intensive care medicine; Kernicterus; Kernicterus - economics; Kernicterus - prevention & control; Maternal, fetal and perinatal monitoring; Medical disorders; Medical sciences; Pediatrics; Phototherapy - economics; Prevention; Preventive medicine; Quality-Adjusted Life Years
• ISSN: 0031-4005; 1098-4275
• DOI: 10.1542/peds.2004-0899

There is concern about an increasing incidence of kernicterus in healthy term neonates in the United States. Although the incidence of kernicterus is unknown, several potential strategies that are intended to prevent kernicterus have been proposed by experts. It is necessary to assess the costs, benefits, and risks of such strategies before widespread policy changes are made. The objective of this study was to determine the direct costs to prevent a case of kernicterus with the following 3 strategies: (1) universal follow-up in the office or at home within 1 to 2 days of early newborn discharge, (2) routine predischarge serum bilirubin with selective follow-up and laboratory testing, and (3) routine predischarge transcutaneous bilirubin with selective follow-up and laboratory testing. We performed an incremental cost-effectiveness analysis of the 3 strategies compared with current practice. We used a decision analytic model and a spreadsheet to estimate the direct costs and outcomes, including the savings resulting from prevented kernicterus, for an annual cohort of 2,800000 healthy term newborns who are eligible for early discharge. We used a modified societal perspective and 2002 US dollars. With each strategy, the test and treatment thresholds for hyperbilirubinemia are lowered compared with current practice. With the base-case assumptions (current incidence of kernicterus 1:100 000 and a relative risk reduction [RRR] of 0.7 with each strategy), the cost to prevent 1 case of kernicterus was 10,321463 dollars, 5,743905 dollars, and 9,191352 dollars respectively for strategies 1, 2, and 3 listed above. The total annual incremental costs for the cohort were, respectively, 202,300671 dollars, 112,580535 dollars, and 180,150494 dollars. Sensitivity analyses showed that the cost per case is highly dependent on the population incidence of kernicterus and the RRR with each strategy, both of which are currently unknown. In our model, annual cost savings of 46,179465 dollars for the cohort would result with strategy 2, if the incidence of kernicterus is high (1:10,000 births or higher) and the RRR is high (> or =0.7). If the incidence is lower or the RRR is lower, then the cost per case prevented ranged from 4,145676 dollars to as high as 77,650240 dollars. Widespread implementation of these strategies is likely to increase health care costs significantly with uncertain benefits. It is premature to implement routine predischarge serum or transcutaneous bilirubin