Partridge J Colin, Robertson Kathryn R, Rogers Elizabeth E, Landman Geri Ottaviano, Allen Allison J, Caughey Aaron B
Department of Pediatrics, Center for Clinical and Policy Perinatal Research, University of California San Francisco , San Francisco, CA , USA .
J Matern Fetal Neonatal Med. 2015 Jan;28(2):121-30. doi: 10.3109/14767058.2014.909803. Epub 2014 Jul 24.
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.
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.
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.
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.
对妊娠23周的婴儿进行复苏仍存在争议；临床实践各不相同。我们试图研究对妊娠23⁰/₇ - 23⁶/₇周出生的婴儿进行复苏的成本效益。
采用决策分析模型，将理论上美国队列中23周出生的5176例活产婴儿的普遍复苏、选择性复苏与不复苏进行比较。死亡（77%）和残疾（64 - 86%）的估计数据来自文献。将母亲及母亲与新生儿合并的效用值应用于贴现预期寿命以生成质量调整生命年（QALYs）。计算增量成本效益比，对成本和QALYs进行贴现。主要结果包括幸存者数量、他们的结局状况以及三种策略的增量成本效益比。采用100,000美元/QALY的成本效益阈值。
普遍复苏可挽救1059名婴儿：138名严重残疾，413名中度受损，508名无明显后遗症。选择性复苏可挽救717名婴儿：93名严重残疾，279名中度受损，343名无明显后遗症。对于母亲而言，不复苏比普遍复苏（12亿美元；126,574 mQALYs）或选择性复苏（8.45亿美元；125,966 mQALYs）成本更低（1990万美元）且更有效（127,844 mQALYs）。对于新生儿，普遍复苏和选择性复苏均具有成本效益，分别产生22,256和15,134 nQALYs，而不复苏为247 nQALYs。在敏感性分析中，仅当新生儿死亡的效用值<0.42时，从母亲角度看普遍复苏才具有成本效益。从母亲与新生儿角度分析时，当新生儿死亡概率<0.95时，普遍复苏具有成本效益。
在广泛的生存和残疾概率范围内，从母亲角度看，普遍复苏和选择性复苏策略均不具有成本效益。从母亲与新生儿角度看，两种策略均具有成本效益。本研究为极早产儿的咨询和决策提供了一个衡量标准。我们的结果可能支持对父母在妊娠23周时要求积极干预的请求做出更宽松的回应。
