Resuscitation of neonates at 23 weeks' gestational age: A cost-effectiveness analysis

J. Colin Partridge, Kathryn R. Robertson, Elizabeth E. Rogers, Geri Ottaviano Landman, Allison J. Allen, Aaron B. Caughey

Research output: Contribution to journalArticle

12 Scopus citations

Abstract

Objective: Resuscitation of infants at 23 weeks' gestation remains controversial; clinical practices vary. We sought to investigate the cost effectiveness of resuscitation of infants born 23 0/7-23 6/7 weeks' gestation. Design: Decision-analytic modeling comparing universal and selective resuscitation to non-resuscitation for 5176 live births at 23 weeks in a theoretic U.S. cohort. Estimates of death (77%) and disability (64-86%) were taken from the literature. Maternal and combined maternal-neonatal utilities were applied to discounted life expectancy to generate QALYs. Incremental cost-effectiveness ratios were calculated, discounting costs and QALYs. Main outcomes included number of survivors, their outcome status and incremental cost-effectiveness ratios for the three strategies. A cost-effectiveness threshold of $100000/QALY was utilized. Results: Universal resuscitation would save 1059 infants: 138 severely disabled, 413 moderately impaired and 508 without significant sequelae. Selective resuscitation would save 717 infants: 93 severely disabled, 279 moderately impaired and 343 without significant sequelae. For mothers, non-resuscitation is less expensive ($19.9 million) and more effective (127844 mQALYs) than universal resuscitation ($1.2 billion; 126574 mQALYs) or selective resuscitation ($845 million; 125966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22256 and 15134 nQALYS, respectively, versus 247 nQALYs for non-resuscitation. In sensitivity analyses, universal resuscitation was cost-effective from a maternal perspective only at utilities for neonatal death <0.42. When analyzed from a maternal-neonatal perspective, universal resuscitation was cost-effective when the probability of neonatal death was <0.95. Conclusions: Over wide ranges of probabilities for survival and disability, universal and selective resuscitation strategies were not cost-effective from a maternal perspective. Both strategies were cost-effective from a maternal-neonatal perspective. This study offers a metric for counseling and decision-making for extreme prematurity. Our results could support a more permissive response to parental requests for aggressive intervention at 23 weeks' gestation.

Original languageEnglish (US)
Pages (from-to)121-130
Number of pages10
JournalJournal of Maternal-Fetal and Neonatal Medicine
Volume28
Issue number2
DOIs
StatePublished - Jan 1 2015

Keywords

  • Cost-effectiveness
  • Death and dying
  • Decision-making
  • Ethics
  • Extreme prematurity
  • Health policy
  • Perinatal care
  • Resuscitation

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Obstetrics and Gynecology

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