Resuscitation of neonates at 23 weeks’ gestational age: a cost-effectiveness analysis

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 $100 000/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 (127 844 mQALYs) than universal resuscitation ($1.2 billion; 126 574 mQALYs) or selective resuscitation ($845 million; 125 966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22 256 and 15 134 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.

• Cost-effectiveness
• death and dying
• decision-making
• ethics
• extreme prematurity
• health policy
• perinatal care
• resuscitation

Declaration of interest

None of the authors have disclosures or conflicts of interest. As lead author, I (JCP) have had full access to all of the data in the study and I take responsibility for the integrity of the data and the accuracy of the data analysis. Preliminary data were presented at the 30th meeting of the Society of Maternal-Fetal Medicine meeting in Chicago, in February 2010 (GOL), the 4th Congress of the European Academy of Pediatric Societies, in October 2012 (KRR), and the meeting of the Pediatric Academic Societies, in May 2014 (KRR). This study was supported in part by funds from the Haile T. Debas Academy of Medical Educators Academy Chair in Pediatric Education (JCP). The funds had no impact on design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.