Neonatal intensive care at borderline viability—is it worth it?
Introduction
Survival rates for very preterm infants at the borderline of viability, especially those <25 weeks of gestational age, have increased through the 1990s [1], [2] ranging up to 46% at 23 weeks [3] and 68% at 24 weeks [4]. However, most survival rates have been reported from single hospital studies, whereas survival rates from geographically defined regions are invariably lower [5], [6], [7] because they have few or no exclusions of infants who ultimately die, including those with lethal anomalies, those who never survive the delivery room, or those who are not transferred for intensive care.
As survival rates have improved, concern about the long-term outcome for very preterm survivors has risen. Infants <25 weeks have been highlighted as not worthy of intensive care [8] because either they are stated to have poor survival rates or quality of survival, or they are considered to be too expensive to treat. However, data on the long-term quality of their survival compared with not so preterm or even term controls, and on the costs of their treatment are sparse.
The aims of this study were to determine the changes in outcome to 2 years of age between two cohorts of very preterm infants born in Victoria in the 1990s, and the incremental costs of achieving that outcome.
Section snippets
Subjects
The study included infants born at 23–27 completed weeks of gestation in the state of Victoria in two distinct eras; the first comprised 401 consecutive livebirths born during the calendar years 1991–1992, and the second comprised 208 consecutive livebirths born during the calendar year 1997. The multiple data sources (the four level-III centres in the state, the Newborn Emergency Transport Service, and the Victorian Perinatal Data Collection Unit) were cross-checked to obtain the total number
Results
The proportion of very preterm infants offered intensive care was significantly higher at 23 weeks of gestation in 1997, and overall at 23–27 weeks, but not at other individual weeks, where in some cases it was already quite high in 1991–1992 (Table 1). The survival rate to 2 years of age was higher at each week of gestation in 1997 compared with 1991–1992 (Table 1), but was statistically significant only at 23 weeks and 26 weeks, and overall from 23–27 weeks. Of the NBW controls, two of the
Discussion
Survival rates and quality-adjusted survival rates for very preterm infants in Victoria increased through the 1990s. The incremental costs of these gains were not excessive, and were not substantially different for infants <25 weeks vs. 25–27 weeks. Certain assumptions were necessary in assigning utilities and the value of nonventilated hospital days relative to days of AV, which we have previously justified and shown that wide variations have little effect on the final calculations [13]. The
Acknowledgements
Supported in part by a grant from Health and Community Services, Victoria, and by the National Health and Medical Research Council, Australia.
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Participants: Convenor; Lex W Doyle, MD, FRACP.a,b* Collaborators (in alphabetical order); Ellen Bowman, FRACP,a,c Catherine Callanan, RN,a Elizabeth Carse, FRACP,d Dan Casalaz FRACP,e Margaret P Charlton, M Ed Psych,d Noni Davis, FRACP,a Geoffrey Ford, FRACP,a Simon Fraser, FRACP,e Jane Halliday, PhD,f Marie Hayes, RN,d Elaine Kelly, MA,a,e Anne Rickards, PhD,a Michael Stewart, FRACP,a,g Andrew Watkins, FRACP,e Heather Woods, RN,e Victor Yu. MD, FRACP.d