Economic Evaluation Of Interventions To Reduce Preterm Birth And Its Consequences

Economic evaluation of interventions that can be used to reduce the rates of preterm birth and its adverse consequences can aid in decision making regarding the development and integration of new technologies and programs. The techniques for such an evaluation take on several different forms. Cost identification assesses the burden of illness and the features of its distribution in economic terms, as with the estimates provided above. Such estimates can form part of the foundation for the comparison of the cost with the outcome. Identified costs that are averted from primary or secondary prevention of preterm birth, for example, can be treated as benefits in benefit-cost or cost-reduction analysis.

Cost-effectiveness analysis is distinct from benefit-cost analysis, in that outcomes are expressed in some unit of health improvement, such as a reduction in the numbers of cases of a health-limiting condition or the numbers of lives or years of life saved rather than in strict monetary terms. The cost per unit of gain, or effectiveness, among interventions can be compared, as long as the health improvements are expressed in a single metric. The fact that most interventions have diverse health consequences means that such comparisons are often limited. Cost-utility analysis is a form of cost-effectiveness analysis in which health outcomes are expressed in a single metric, such as quality-adjusted life years (QALYs), to afford the assessment of the relative effectiveness of programs with diverse health consequences (Drummond et al., 2003; Gold et al., 1996). The conversion of QALYs into monetary units permits the translation of cost-effectiveness into a cost-benefit, but such a conversion is controversial largely because the tradeoffs that are used to elicit preferences over health states in developing QALYs, as opposed to so-called "willingness-to-pay" preference measures, are too constrained to comport with the theoretical foundations of valuation in welfare economics. A recent expert panel therefore recommended against the use of this practice (IOM, 2006).

It should be emphasized, as well, that although the average performance of an intervention or program may prove to be of net benefit, the incremental expansion of such efforts may not prove to be of net benefit. Appropriate economic evaluation in decision making often requires the assessment of a marginal net benefit rather than an average net benefit.

To date, there have been limited analyses of the cost-benefit or the cost-effectiveness associated with interventions for preterm birth. One global cost-benefit analysis of the reduction in mortality and morbidity associated with LBW due to advances in neonatal intensive care technology between 1950 and 1990 found that the net societal return was not only high but also outweighed that of several other widely used technologies in health care (Cutler and Meara, 2000). Although the historical advances in neonatal intensive care technology have been vast, as have the increases in the associated costs, the analysis was based on limited available data on the extent of and the quality of life associated with the developmental disabilities associated with LBW. It also ignored the effects of LBW on the quality of life of the family and caregivers and implicitly assumed a zero replacement rate; that is, that no subsequent births were tied to infant deaths associated with LBW. It also converted QALYs to dollars, which, as noted above, runs contrary to the recommendations of a recent expert panel on health valuation (IOM, 2006). Notwithstanding these limitations, the analysis provides a provocative case for the fact that cost-increasing neonatal technologies generate a net societal value. Because the results are tabulated as an average return over an historical period, however, they could not serve as the basis for the incremental evaluation of new technologies or programs for the prevention or treatment of LBW, as the authors noted (Cutler and Meara, 2000).

One recent study of the initial hospitalization cost by week of gestational age for the cohort born in California between 1998 and 2000 demonstrated that substantial reductions in such costs, on average, could be garnered by extending gestation by an additional week, particularly among those infants born at less than 32 weeks of gestation (Phibbs and Schmitt, 2006). The large interquartile variance in cost among those born at each week of gestational age, however, even after accounting for infant mortality, reinforced the high degree of uncertainty over the extent of the savings that would actually be reaped through selective extensions of gestation rather than through general extensions of gestation. In a similar approach applied to LBW, another study found that even small increases in BW could generate significant savings in medical care costs in the first year of life, although such an incremental weight gain among those infants born with a birth weight below a threshold of 750 grams might generate increases in medical costs (Rogowski, 1998). These analyses represent a solid methodological foundation for a more refined economic evaluation of the interventions and programs aimed at the prevention of preterm birth that include longer-term and broader categories of outcomes and associated costs.

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