Pushing the boundaries of viability: The economic impact of extreme preterm birth
Introduction
The adverse sequelae resulting from preterm birth impose a considerable burden on finite healthcare resources. Preterm infants are at an increased risk of a range of adverse neonatal outcomes including chronic lung disease [1], severe brain injury [2], retinopathy of prematurity [3], necrotising enterocolitis [4], and neonatal sepsis [5]. In later life, preterm infants are at an increased risk of motor and sensory impairment [6], [7], learning difficulties [8], [9], [10], [11], [12], and behavioural problems [13], [14], [15], [16].
Assessments of the economic consequences of preterm birth could provide an invaluable resource for clinical decision-makers and budgetary or service planners, and might also provide a framework for identifying priorities in research and development. Previous economic assessments of preterm birth have focussed mainly on the neonatal sequelae. These studies revealed an inverse relationship between hospital costs during the neonatal period and gestational age at birth [17].
Relatively few studies have documented the economic costs of preterm birth or low birth weight following the infant's initial discharge from the neonatal unit. Brooten et al. [18] and McCormick et al. [19] report that preterm or low birth weight infants are significantly more likely to consume hospital and community health services during the early years of life than infants born at full term or at normal birth weight. Some studies have attached a monetary value to the additional health care resources consumed by infants following their discharge from the neonatal unit. However, they are of varying methodological quality and differ with regard to the nature of their comparison and control groups, duration of follow-up, and the measurement and classification of outcomes. Rogowski [20] limited her analysis to medical costs incurred during the first year after birth. She reported a 24-fold differential in costs between very low birth weight single live births (< 1500 g) in the state of California Medicaid programme between 1986 and 1987 and all US births in 1989. In contrast, Stevenson et al. [21] followed up a cohort of very low birth weight infants (< 1500 g) born in 1979–1981 and recorded their use of hospital and family practitioner services up to age 8–9 years. When compared to a group of controls, matched for age, sex and school class, it was found that the low birth weight children used hospital and family practitioner services more intensively throughout the follow-up period. Indeed, there was a five-fold differential in mean total costs per child between low birth weight infants without disability and the control infants they were matched to. This differential increased to 16-fold amongst the lowest birth weight group (< 1000 g). Amongst infants with disability, mean health service costs for the entire follow-up period were estimated at £14,510 for the lowest birth weight group (< 1000 g), £12,051 for the intermediate birth weight group (1000–1500 g) and £7178 for the highest birth weight group (> 1500 g) (1998 £ sterling).
Two recent cohort analyses explored the long term hospital service utilisation and costs attributable to preterm birth. The analyses were based on data extracted from the Oxford Record Linkage Study, a large collection of linked, anonymised birth registrations, death certificates and statistical abstracts of NHS hospital inpatient and day case admissions for part of southern England. A multivariate negative binomial regression performed on the 5-year hospital service utilisation profile of 239,694 infants born in Oxfordshire and West Berkshire during the period 1970–1993 revealed that the total duration of hospital admissions for infants born at < 28 and at 28–31 gestational weeks was, respectively, 85 and 16 times that for term infants, once duration of life had been taken into account [22]. A subsequent multi-level multiple regression model revealed that the adjusted effect of birth at < 28 gestational weeks on cumulative hospital inpatient admissions, days and costs over the first 10 years after birth was 2.30, 1.77 and 5.43, respectively, when compared to children born at term [23].
Relatively little is known about the economic impact of preterm birth outside of the health sector [17]. Moreover, there is no empirical evidence that focuses on the economic impact of extreme preterm birth, which is of increasing relevance in the modern perinatal care context. In this paper, we report the results of a comprehensive assessment of the economic impact of extreme preterm birth during the sixth year after birth. The specific hypothesis tested was that extreme preterm birth is associated with significantly increased health service and broader societal costs during mid-childhood.
Section snippets
Study population
EPICure is a national cohort study of all infants born at 20 through 25 completed weeks of gestation in all 276 maternity units in the United Kingdom and Republic of Ireland from March through December 1995. A full description of the study population, recruitment methods and assessment procedures is available elsewhere [24], [25]. In brief, of 308 surviving children, 241 (78.2%) were assessed at a median age of six years and four months (range: five years and two months to seven years and three
Results
The clinical and sociodemographic characteristics of the 241 extreme preterm and 160 term children who participated in the six year follow-up study are reported in detail elsewhere [25].
Table 1 presents the mean cost per child over a 12 month period according to cost category for the extreme preterm and term study groups. Mean societal costs over the 12 month period were £11,982 (standard deviation: £13,660) among children born at ≤ 23 completed weeks, £11,308 (£13,334) among children born at 24+
Discussion
A previous review of the published and unpublished medical and health economics literature revealed that relatively few studies have estimated the long-term economic impact of preterm birth [17]. The vast majority of those studies adopted a narrow health service perspective and, therefore, overlooked the broader societal impacts of the condition. Moreover, none focussed on the economic impact of birth at borderline viability, which is of increasing relevance in the modern perinatal care context.
Acknowledgements
We would like to thank the children who participated in EPICure Study and the parents who completed the relevant research instruments. The six year follow-up study was supported by BLISS, the premature baby charity; the Health Foundation; and Well-Being of Women. The views contained in this paper are those of the authors and, not necessarily, of the funding bodies.
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