Elsevier

Early Human Development

Volume 80, Issue 2, November 2004, Pages 103-113
Early Human Development

Neonatal intensive care at borderline viability—is it worth it?

https://doi.org/10.1016/j.earlhumdev.2004.05.009Get rights and content

Background

Very preterm infants at the borderline of viability, especially those <25 weeks of gestational age, have survived in increasing numbers in recent years, but concerns persist about their long-term outcome and their consumption of scarce hospital resources.

Aims

To determine incremental changes in long-term outcome and consumption of resources by very preterm infants in the 1990s.

Patients

Consecutive livebirths with gestational ages 23–27 weeks born in the state of Victoria in two discrete eras, 1991–1992 (n=401) and 1997 (n=208), and randomly selected contemporaneous normal birthweight (NBW, birthweight >2499 g) controls (1991–1992 n=265, 1997 n=198).

Main Outcome Measures

Survival, and neurosensory impairments, disabilities and utilities, and consumption of hospital resources to 2 years of age.

Results

Compared with 1991–1992, in 1997 more infants were offered intensive care and the survival rate was higher at each week of gestation, and overall (absolute increase in survival 16%; 95% confidence interval, 8%, 24%). The largest increases in the survival and quality-adjusted survival rates were in infants at 23 weeks (31% and 20%, respectively). The incremental resource costs of improving survival and quality-adjusted survival were similar in infants of 23–24 weeks compared with those of 25–27 weeks (e.g., 112 vs. 105 days of assisted ventilation per additional survivor, or 167 vs. 180 days of assisted ventilation per additional quality-adjusted survivor, respectively).

Conclusions

Increased intensive care in the late 1990s for infants at the borderline of viability was associated with improved outcomes, at incremental costs that were not excessive compared with slightly more mature infants.

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.

References (23)

  • T. Sheldon

    Dutch doctors change policy on treating preterm babies

    Br. Med. J.

    (2001)
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