Cost of neonatal abstinence syndrome: an economic analysis of English national data held in the National Neonatal Research Database.

OBJECTIVE: To determine the incidence of neonatal abstinence syndrome (NAS) across neonatal units, explore healthcare utilisation and estimate the direct cost to the NHS. DESIGN: Population cohort study. SETTING: NHS neonatal units, using data held in the National Neonatal Research Database. PARTICIPANTS: Infants born between 2012 and 2017, admitted to a neonatal unit in England, receiving a diagnosis of NAS (n=6411). MAIN OUTCOME MEASURES: Incidence, direct annual cost of care (£, 2016-2017 prices), duration of neonatal unit stay (discharge HR), predicted additional cost of care, and odds of receiving pharmacotherapy. RESULTS: Of 524 334 infants admitted during the study period, 6411 had NAS. The incidence (1.6/1000 live births) increased between 2012 and 2017 (ß=0.07, 95% CI (0 to 0.14)) accounting for 12/1000 admissions and 23/1000 cot days nationally. The direct cost of care was £62 646 661 over the study period. Almost half of infants received pharmacotherapy (n=2631; 49%) and their time-to-discharge was significantly longer (median 18.2 vs 5.1 days; adjusted HR (aHR) 0.16, 95% CI (0.15 to 0.17)). Time-to-discharge was longer for formula-fed infants (aHR 0.73 (0.66 to 0.81)) and those discharged to foster care (aHR 0.77 (0.72 to 0.82)). The greatest predictor of additional care costs was receipt of pharmacotherapy (additional mean adjusted cost of £8420 per infant). CONCLUSIONS: This population study highlights the substantial cot usage and economic costs of caring for infants with NAS on neonatal units. A shift in how healthcare systems provide routine care for NAS could benefit infants and families while alleviating the burden on services.

A Cost-Effectiveness Analysis of Rooming-in and Breastfeeding in Neonatal Opioid Withdrawal.

OBJECTIVE: Our cost-effectiveness analysis investigated rooming-in versus not rooming-in to determine optimal management of neonates with neonatal opioid withdrawal (NOW). STUDY DESIGN: A decision-analytic model was constructed using TreeAge to compare rooming-in versus not rooming-in in a theoretical cohort of 23,200 newborns, the estimated annual number affected by NOW in the United States. Additional considerations included the effect of breast milk versus formula milk in evaluating the need for pharmacotherapy. Primary outcomes were needed for pharmacotherapy and neurodevelopment. We assumed a societal perspective in evaluating costs and maternal-neonatal quality-adjusted life years (QALYs) using a willingness-to-pay threshold of $100,000/QALY. Model inputs were derived from literature and varied in sensitivity analyses. RESULTS: Rooming-in resulted in fewer neonates requiring pharmacotherapy when compared with not rooming-in. The rooming-in group had more neonates with intact/mild neurodevelopmental impairment and fewer cases of moderate to severe impairment. Rooming-in resulted in cost savings of $509,652,728 and 12,333 additional QALYs per annual cohort. When the risk ratio of need for pharmacotherapy in rooming-in was varied across a clinically plausible range, rooming-in remained the cost-effective strategy. CONCLUSION: Maternal rooming-in with newborns affected by NOW leads to reduced costs and increased effectiveness. Management strategies should optimize nonpharmacological interventions as first-line treatment.

Treating Neonatal Abstinence Syndrome in a Rural Hospital: Lessons Learned.

OBJECTIVE: Our level 1 nursery and pediatric unit in a rural hospital adopted a family-centered, symptom-based oral morphine weaning protocol for neonatal abstinence syndrome (NAS) in 2009. Length of stay (LOS), treatment duration (TD), and hospital charges for infants treated for NAS were then compared to published data in neonatal intensive care units (NICUs) nationwide. METHODS: The electronic medical records of infants born January 1, 2011, to April 1, 2017, whose discharge diagnosis included an ICD-9 or ICD-10 code for NAS or prenatal drug exposure were paired with maternal electronic medical record and reviewed. TD was calculated by subtracting the last day morphine was provided from the day it was started, and LOS was calculated by subtracting the discharge date from the date of birth. Infant characteristics, maximum Finnegan score, breastfeeding, discharge disposition, maternal demographics, prenatal use of drugs or medications, and toxicology results were abstracted. Predictors of TD and LOS were analyzed, and hospital charges were enumerated. RESULTS: Chart review identified 167 infants with prenatal drug exposure, 33 of whom were treated for NAS. Median TD for infants with NAS was 18 days (range, 9-37 days) compared to 15 days (range, 9-25 days) in NICUs. Median LOS for infants treated for NAS was 22 days (range, 12-41 days) compared to 20 days (range, 12-32 days) in NICUs, but hospital charges were less. Maternal prenatal use of cocaine (P = .016) predicted LOS. CONCLUSIONS: Family-centered NAS treatment in a rural hospital lasted 2 to 3 days longer than in NICUs, largely as a result of social issues; however, hospital charges were less.

Cost effectiveness of universal umbilical cord blood gas and lactate analysis in a tertiary level maternity unit.

OBJECTIVE: There is an increasing body of literature supporting universal umbilical cord blood gas analysis (UCBGA) into all maternity units. A significant impediment to UCBGA's introduction is the perceived expense of the introduction and associated ongoing costs. Consequently, this study set out to conduct the first cost-effectiveness analysis of introducing universal UCBGA. METHODS: Analysis was based on 42,100 consecutive deliveries ≥23 weeks of gestation at a single tertiary obstetric unit. Within 4 years of UCBGA's introduction there was a 45% reduction in term special care nursery (SCN) admissions >2499 g. Incurred costs included initial and ongoing costs associated with universal UCBGA. Averted costs were based on local diagnosis-related grouping costs for reduction in term SCN admissions. Incremental cost-effectiveness ratio (ICER) and sensitivity analysis results were reported. RESULTS: Under the base-case scenario, the adoption of universal UCBGA was less costly and more effective than selective UCBGA over 4 years and resulted in saving of AU$641,532 while adverting 376 SCN admissions. Sensitivity analysis showed that UCBGA was cost-effective in 51.8%, 83.3%, 99.6% and 100% of simulations in years 1, 2, 3 and 4. These conclusions were not sensitive to wide, clinically possible variations in parameter values for neonatal intensive care unit and SCN admissions, magnitude of averted SCN admissions, cumulative delivery numbers, and SCN admission costs. CONCLUSIONS: Universal UCBGA is associated with significant initial and ongoing costs; however, potential averted costs (due to reduced SCN admissions) exceed incurred costs in most scenarios.

Implementing the Use of Chemical-Free Products in a Perinatal Unit.

OBJECTIVE: To develop a process to identify, adopt, and increase individual awareness of the use of chemical-free products in perinatal hospital units and to develop leadership skills of the fellow/mentor pair through the Sigma Theta Tau International Maternal-Child Health Nurse Leadership Academy (STTI MCHNLA). DESIGN: Pretest/posttest quality improvement project. SETTING: Tertiary care 80-bed perinatal unit. PATIENTS: Mothers and newborns on perinatal unit. INTERVENTIONS/MEASUREMENTS: The chemical hazard ratings of products currently in use and new products were examined and compared. Chemical-free products were selected and introduced to the hospital system, and education programs were provided for staff and patients. We implemented leadership tools taught at the STTI MCHNLA to facilitate project success. Pre- and postproject evaluations were used to determine interest in the use of chemical-free products and satisfaction with use of the new products. Cost savings were measured. RESULTS: Products currently in use contained potentially harmful chemicals. New, chemical-free products were identified and adopted into practice. Participants were interested in using chemical-free products. Once new products were available, 71% of participants were positive about using them. The fellow and mentor experienced valuable leadership growth throughout the project. CONCLUSIONS: The change to chemical-free products has positioned the organization and partner hospitals as community leaders that set a health standard to reduce environmental exposure for patients, families, and staff. The fellow and mentor learned new skills to assist in practice changes in a large organization by using the tools shared in the STTI MCHNLA.

The role of the neonatal nurse practitioner in the community hospital level I nursery.

Neonatal nurse practitioners (NNPs) have played a significant role in providing medical coverage to many of the country's Level III neonatal intensive care units (NICUs). Extensive education and experience are required for a nurse practitioner (NP) to become competent in caring for these critically ill newborns. The NNP can take this competence and experience and expand her role out into the community Level I nurseries. Clinical care of the infants and close communication with parents, pediatricians, and the area tertiary center provide a community service with the goal of keeping parents and babies together in the community hospital without compromising the health of the baby. The NNP service, with 24-hour nursery and delivery coverage, supports an ongoing obstetric service to the community hospital. The NNP's experience enables her to provide a neonatal service that encompasses a multitude of advanced practice nursing roles.

Cost comparison of baby friendly and non-baby friendly hospitals in the United States.

OBJECTIVES: The objectives of this study were to provide an economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Children's Emergency Fund designation as a Infant-Friendly hospital. We hypothesized that baby-friendly hospitals will have higher costs than similar non-baby-friendly hospitals. METHODS: Data from the 2007 American Hospital Association and the 2007 Centers for Medicare and Medicaid Cost Reports were used to compare labor and delivery costs in baby-friendly and non-baby-friendly hospitals. Operational costs per delivery were calculated using a matched-pairs analysis of a sample of baby-friendly and non-baby-friendly hospitals in the United States. Costs associated with labor-and-delivery diagnosis-related codes were analyzed for each baby-friendly hospital and compared with the mean and median costs incurred by non-baby-friendly hospitals. RESULTS: Nursery plus labor-and-delivery costs for the baby-friendly sites were $2205 per delivery, compared with $2170 for the non-baby-friendly matched pair. Baby-friendly facilities have slightly higher costs than non-baby-friendly facilities, ranging from 1.6% to 5%, but these costs were not statistically significant (P > .05). CONCLUSIONS: These results suggest that becoming baby-friendly is relatively cost-neutral for a typical acute care hospital. Although the overall expense of providing baby-friendly hospital nursery services is greater than nursery service costs of non-baby-friendly hospitals, the cost difference was not statistically significant. Additional research is needed to compare the economic impact of maternal and infant health benefits from breastfeeding versus the incremental expenses of becoming a baby-friendly hospital.

Using the medicare cost report to improve financial performance.

The Medicare cost report can help you understand your organization's financial performance by providing a means to: Analyze costs. Assess departmental and payer margins. Compare performance with the competition.

Is 34 weeks an acceptable goal for a complicated singleton pregnancy?

PURPOSE: To examine neonatal risk and associated nursery costs for infants with delivery following untreated preterm labor at 34, 35, or 36 weeks' gestation, by assessing the incidence of neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), and need for ventilatory assistance. DESIGN: Infants with preterm birth at 34, 35, or 36 weeks were identified from a database of prospectively collected clinical information and pregnancy outcomes of women receiving outpatient preterm-labor management services, in addition to routine prenatal care. Cases of singleton gestations with delivery related to spontaneous preterm labor were analyzed. Data were divided into three groups by gestational week at delivery. METHODOLOGY: Descriptive and statistical methods were used to compare maternal demographics, pregnancy outcome, and nursery costs. A cost model was utilized. PRINCIPAL FINDINGS: 2849 infants were studied. Risk of NICU admission decreased by 47.4 percent from weeks 34 to 35 and 41.8 percent from weeks 35 to 36. Risk of RDS decreased by 25.4 percent from weeks 34 to 35, and 40.7 percent from weeks 35 to 36. Mean nursery costs per infant delivering at 34, 35, and 36 weeks were $11,439 +/- $19,774, $5,796 +/- $11,858, and $3,824 +/- $9,135, respectively (p < .001). CONCLUSION: Rates of NICU admission, RDS, ventilator use, and nursery-related costs decreased significantly with each week gained. The data indicate that benefit is derived in prolonging pregnancy beyond 34 weeks.

Use of an oxygen concentrator in a Nigerian neonatal unit: economic implications and reliability.

A 3-year experience of using an oxygen concentrator in a Nigerian newborn unit and economic appraisal of its effectiveness is reported. The oxygen concentrator is a device that absorbs nitrogen from ambient air, with a resultant oxygen concentration of 85 to 95% at different flow rates. The oxygen concentrator met our oxygen needs which averaged 18 hours a day, and had a huge cost advantage over the oxygen cylinders. The cost of oxygen via cylinder for just one patient for a year exceeds the initial capital outlay for a concentrator. The Puritan-Bennett oxygen concentrator has a lifespan of at least 7 years and is virtually maintenance-free for the 1st 26,400 hours of use, after which some major components might need replacement. We conclude that in developing countries oxygen concentrators are a more cost-effective, reliable and convenient means of oxygen supply than oxygen cylinders, and recommend their use where there is a high demand for oxygen.

Effect of state vaccine-financing strategy on hepatitis B immunization in hospital nurseries.

OBJECTIVE: Changes in recommendations for newborn hepatitis B vaccination offer an opportunity to examine the association between newborn hepatitis B vaccination in hospital nurseries and state vaccine-financing strategies, which include the Vaccines for Children (VFC) program alone, an enhanced VFC program, and universal purchase. METHODS: We conducted a cross-sectional telephone survey of nursery directors from a national random sample of 290 hospital nurseries. RESULTS: Directors at 207 (71%) of 290 eligible nurseries responded. After the end of the temporary suspension of the hepatitis B vaccine birth dose, 59 (29%) of the 207 nurseries did not return to their previous policy and adopted a less strict policy for offering this vaccination to low-risk infants. In logistic regression analysis, compared with nurseries in states with VFC-only financing, nurseries in states with universal purchase financing were more likely to return a strict policy of routinely offering hepatitis B vaccination (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.11-0.78), and nurseries in states with enhanced VFC financing were less likely to return to a strict policy of routinely offering hepatitis B vaccination (OR, 3.00; 95% CI, 1.14-7.88). The presence of residents or students in the nursery was associated with a lower likelihood of not returning to a strict policy of routinely offering hepatitis B vaccination (OR, 0.32; 95% CI, 0.10-0.97). CONCLUSIONS: State vaccine-financing strategy for the birth dose of hepatitis B vaccine is associated with nursery policy to routinely offer this vaccine in the nursery. The temporary change in national hepatitis B vaccination recommendations in 1999 served as a window of opportunity for the adoption of new hospital nursery policies and showed the effects of state vaccine financing on the adoption of newborn immunization recommendations.

Neonatal health care costs related to smoking during pregnancy.

RESEARCH OBJECTIVE: Much of the work on estimating health care costs attributable to smoking has failed to capture the effects and related costs of smoking during pregnancy. The goal of this study is to use data on smoking behavior, birth outcomes and resource utilization to estimate neonatal costs attributable to maternal smoking during pregnancy. STUDY DESIGN: We use 1995 data from the Center for Disease Control's (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) database. The PRAMS collects representative samples of births from 13 states (Alabama, Alaska, California, Florida, Georgia, Indiana, Maine, Michigan, New York (excluding New York City), Oklahoma, South Carolina, Washington, and West Virginia), and the District of Columbia. The 1995 PRAMS sample is approximately 25 000. Multivariate analysis is used to estimate the relationship of smoking to probability of admission to an NICU and, separately, the length of stay for those admitted or not admitted to an NICU. Neonatal costs are predicted for infants 'as is' and 'as if' their mother did not smoke. The difference between these constitutes smoking attributable neonatal costs; this divided by total neonatal costs constitutes the smoking attributable fraction (SAF). We use data from the MarketScantrade mark database of the MedStattrade mark Corporation to attach average dollar amounts to NICU and non-NICU nursery nights and data from the 1997 birth certificates to extrapolate the SAFs and attributable expenses to all states. PRINCIPAL FINDINGS: The analysis showed that maternal smoking increased the relative risk of admission to an NICU by almost 20%. For infants admitted to the NICU, maternal smoking increased length of stay while for non- NICU infants it appeared to lower it. Over all births, however, smoking increased infant length of stay by 1.1%. NICU infants cost $2496 per night while in the NICU and $1796 while in a regular nursery compared to only $748 for non-NICU infants. The combination of the increased NICU use, longer stays and higher costs result in a positive smoking attributable fraction (SAF) for neonatal costs. The SAF across all states is 2.2%. Across the states, the SAF varied from a low of 1.3% in Texas to a high of 4.6% in Indiana. CONCLUSIONS: These results further confirm the adverse effects of smoking. Among mothers who smoke, smoking adds over $700 in neonatal costs. The smoking attributable neonatal costs in the US represent almost $367 million in 1996 dollars; these costs vary from less than a million in smaller states to over $35 million in California. These costs are highly preventable since the adverse effects of maternal smoking occur in the short-run and can be avoided by even a temporary cessation of maternal smoking. These cost estimates can be used by managed care plans, state and local public health officials and others to evaluate alternative smoking cessation programs.

How fetal cocaine exposure increases neonatal hospital costs.

OBJECTIVE: Our goals were to document hospital costs associated with prenatal cocaine exposure in an understudied population-women using rural county public health units who had minimal access to drug rehabilitation and whose cocaine of choice was crack with little other illicit drug use- and to explore why increased costs occur in an effort to identify cost-reduction strategies. METHODS: We identified a sample of cocaine-exposed infants who were computer-matched to a control group with no history or evidence of cocaine exposure. Matching was performed one-to-one on the variables of maternal race, age, parity, time of entry into prenatal care, and alcohol and nicotine use. There were 327 live births, for whom 311 were correctly classified as to their prenatal cocaine use and had billing and medical records available for review (156 exposed, 155 nonexposed). RESULTS: Hospital charges were positively correlated with length of stay. Cocaine-exposed infants had an across-the-board increase in utilization of hospital resources as well as higher hospital charges and longer lengths of stay. Cocaine-exposed infants were significantly younger in gestational age and lower in birth weight. Significantly more cocaine-exposed infants were admitted to the neonatal intensive care unit, had more social and family problems delaying discharge, and received more septic work-ups. In addition, of those infants urine-screened for cocaine at delivery, 92% were screened secondary to a maternal history of prenatal use. CONCLUSIONS: Cost-reduction strategies should be aimed at measures that reduce length of stay by addressing problems identified prenatally as an outpatient before delivery and by influencing objective decision-making regarding the need for medical interventions with the infant after birth.

The impact of prenatal exposure to cocaine on newborn costs and length of stay.

OBJECTIVE: Our intention is to determine newborn costs and lengths of stay attributable to prenatal exposure to cocaine and other illicit drugs. DATA SOURCES AND STUDY SETTING: All parturients who delivered at a large municipal hospital in New York City between November 18, 1991 and April 11, 1992. STUDY DESIGN: A cross-sectional analysis used multivariate, loglinear regressions to analyze differences in costs and length of stay between infants exposed and unexposed prenatally to cocaine and other illicit drugs, adjusting for maternal race, age, prenatal care, tobacco, parity, type of delivery, birth weight, prematurity, and newborn infection. DATA COLLECTION/EXTRACTION METHODS: Urine specimens, with linked obstetric sheets and discharge abstracts, provided information on exposure, prenatal behaviors, costs, length of stay, and discharge disposition. PRINCIPAL FINDINGS: Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed. Approximately 60 percent of these costs are indirect, the result of adverse birth outcomes and newborn infection. Hospital screening as recorded on discharge abstracts substantially underestimates prevalence at delivery, but overestimates its impact on costs.

Hospital costs for cocaine-exposed infants.

A retrospective study was done at University Medical Center at Jacksonville for the period November 1988 through October 1989 to estimate the cost of treatment for 207 infants from cocaine-exposed pregnancies, 151 (76%) black and 56 (24%) white. The mean age of the mothers was 26. Twenty-five (12%) infants were admitted into the neonatal intensive care nursery (NICU) and 82 (88%) into the normal nursery where 45% of total days was due to "social hold" pending clearance for discharge by the Florida Department of Health and Rehabilitative Services. Average stay was 21.5 days in the NICU and 6.7 days in the normal nursery. Average costs varied from $36,481 for NICU to $801 for normal nursery in excess of the usual charge for a normal full-term infant. Laboratory fees accounted for the largest percentage (41.5%) of the total cost of hospitalization in the NICU, while rooming charges are the major factor (50.8%) in the normal nursery. Total charges in the 12-month period amounted to $1,057,921 or $5,110 per patient and for a control group $520,251 or $2,513 per patient. A major concern above the cost of treatment is the special education needs when these children enter the school system.