Inhaled nitric oxide in term/late preterm neonates with hypoxic respiratory failure: estimating the financial impact of earlier use

Figures & data

Figure 1. Model structure. ECMO: extracorporeal membrane oxygenation; HRF: hypoxic respiratory failure; iNO: inhaled nitric oxide; OI: oxygenation index.

Table 1. Clinical and resource use inputs.

Input	Early iNO	Standard iNO	P-Value
N patients in trial	88	92
Efficacy and mortality, %
Alive without ECMO	89.77	82.61
Alive with ECMO	6.82	8.70
Death	3.41	8.70	0.2132
Resource use
Death, median (10% of median)
N	3	8
Hospital days with ventilation	19.3 (1.9)	20.6 (2.1)
Hospital days without ventilation	5.7 (0.6)	0.4 (0.0)
iNO hours	111.5 (11.1)	167.5 (16.8)
ECMO hours	59.7 (6.0)	159.8 (16.0)
Alive with ECMO, median (10% of median)
N	6	8
Hospital days with ventilation	21.5 (2.2)	14.5 (1.5)
Hospital days without ventilation	15 (1.5)	8 (0.8)
iNO hours	117.9 (11.8)	44 (4.4)
ECMO hours	202.2 (20.2)	121 (12.1)
Alive without ECMO, mean (SD)
N	79	76
Hospital days with ventilation	10.5 (8.8)	9.7 (5.7)	0.5046
Hospital days without ventilation	17.9 (43.7)	27.6 (65.1)	0.2761
iNO hours	113.9 (102.2)	50.4 (82.3)	<0.0001
ECMO hours	N/A	N/A

ECMO: extracorporeal membrane oxygenation; iNO: inhaled nitric oxide; SD: standard deviation.

Data in table are from a custom analysis of trial data originally reported in Konduri et al. (2013)5.

Table 2. Cost inputs.

	Base case	Low estimate	High estimate
Cost per hospital day with ventilation, mean
First day (survivors)	$8485	$4243	$16,970
Subsequent days (survivors)	$3573	$1787	$7146
First day (non-survivors)	$13,248	$6624	$26,496
Subsequent days (non-survivors)	$4019	$2010	$8038
Cost per hospital day without ventilation, mean	$1429	$715	$2858
Cost per hour with ECMO, mean
Within first 24 hours (survivors)	$378	–	–
Within subsequent hours (survivors)	$261	–	–
Within first 24 hours (non-survivors)	$416	–	–
Within subsequent hours (non-survivors)	$267	–	–
Cost per hour with iNO	$115	$100	$130

Costs of hospital days and ECMO from Angus et al. (2003)6; cost of iNO provided by manufacturer; hospital cost ranges based on 0.5× and 2.0 × the base case; iNO range based on expected price variations.

ECMO: extracorporeal membrane oxygenation; iNO: inhaled nitric oxide.

Figure 2. Incremental cost-effectiveness scatterplot. ECMO: extracorporeal membrane oxygenation; iNO: inhaled nitric oxide.

Figure 3. Willingness to pay and cost-effectiveness. ECMO: extracorporeal membrane oxygenation.

Table 3. Base case model outputs.

	Early iNO	Standard iNO	Difference
N patients in base case	1000	1000
Clinical Outcomes
Patients with death	34	87	−53
Patients alive with ECMO	68	87	−19
Patients alive without ECMO	898	826	72
Resource Use
Hospital days	28.8	34.6	−5.8
Ventilation days	11.5	11.1	0.4
Non-ventilation days	17.3	23.5	−6.2
iNO hours	114.1	60.1	54.0
ECMO hours	15.8	24.4	−8.6
Costs
Hospital day costs	$71,236	$79,259	−$8023
Ventilation day costs	$46,497	$45,661	$836
Non-ventilation day costs	$24,739	$33,599	−$8859
ECMO costs	$4146	$6470	−$2324
iNO costs	$13,118	$6907	$6211
Total costs	$88,501	$92,636	−$4136

ECMO: extracorporeal membrane oxygenation; iNO: inhaled nitric oxide.

Figure 4. Cost savings. iNO: inhaled nitric oxide.

Table 4. Deterministic sensitivity analysis results.

	Early iNO	Standard iNO	Difference
Hospital Costs
Base Case	$88,501	$92,636	−$4136
Low Estimate	$52,882	$53,007	−$124
High Estimate	$159,737	$171,896	−$12,159
iNO Cost
Base Case ($115/hour)	$88,501	$92,636	−$4136
Low Estimate ($100/hour)	$86,790	$91,735	−$4946
High Estimate ($130/hour)	$90,212	$93,537	−$3325

iNO: inhaled nitric oxide.

Table 5. Probabilistic sensitivity analysis results.

	Early iNO	Standard iNO
N patients per simulation	1000	1000
Patients alive without ECMO
Mean	898	827
SD	37	43
Minimum	835	749
2.5 Percentile	837	753
Median	898	827
97.5 Percentile	958	899
Maximum	961	904
Total costs per patient
Mean	$88,518	$92,581
SD	$7574	$9664
Minimum	$65,894	$65,480
2.5 Percentile	$74,867	$74,539
Median	$87,990	$92,219
97.5 Percentile	$104,544	$113,677
Maximum	$110,648	$127,267

ECMO: extracorporeal membrane oxygenation; iNO: inhaled nitric oxide; SD: standard deviation.

Konduri GG, Sokol GM, Van Meurs KP, et al. Impact of early surfactant and inhaled nitric oxide therapies on outcomes in term/late preterm neonates with moderate hypoxic respiratory failure. J Perinatol 2013;33:944-9

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Angus DC, Clermont G, Watson RS, et al. Cost-effectiveness of inhaled nitric oxide in the treatment of neonatal respiratory failure in the United States. Pediatrics 2003;112(6 Pt 1):1351-60

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