Evaluation of neonatal intensive care for extremely-low-birth-weight infants

doi:10.1016/j.siny.2005.11.009

Seminars in Fetal and Neonatal Medicine

Volume 11, Issue 2, April 2006, Pages 139-145

https://doi.org/10.1016/j.siny.2005.11.009 Get rights and content

Summary

Neonatal intensive care for extremely-low-birth-weight (ELBW, 500–999 g) infants must be evaluated to determine that it is effective, efficient, and available to those who need it. From the late 1970s until the late 1990s in the state of Victoria, Australia, neonatal intensive care has been increasingly effective, with large increases in the long-term survival rate from 25% in 1979–1980 to 73% in 1997, and in the quality-adjusted survival rate from 19% to 59% over the same time. Its efficiency has been relatively high and stable over time, comparing favourably with many other health-care programmes. It is increasingly available, with fewer than 10% of ELBW infants born outside level III perinatal centres in the latest era, and proportionally more ELBW infants being offered intensive care over time. Neonatal intensive care should be re-evaluated at intervals in the future to ensure that its effectiveness, efficiency and availability are maintained.

Introduction

Neonatal intensive care is expensive, especially in developed countries. The cost is measured not only in financial terms, but also by the burden of illness caused by the inability to fund alternative health-care programmes that have to be foregone to finance neonatal intensive care. For those responsible within the health-care system, including those who treat the babies directly, it is obviously vital to evaluate neonatal intensive care thoroughly.

Sinclair et al.¹ in their landmark paper on the evaluation of neonatal intensive care programmes, wrote in 1981 ‘…the overall effectiveness of these programs has not been tested experimentally’, and ‘We conclude that neonatal intensive care programs require further evaluation with rigorous scientific methods’. In the 25 years since their comments, the need for evaluation of neonatal intensive care programmes has not diminished but instead has increased, especially since intensive care has been offered to more very tiny or preterm infants, at considerable cost to health-care systems.

Sinclair et al.¹ described the four steps required to evaluate neonatal intensive care programmes: efficacy, effectiveness, efficiency and availability. Efficacy asks if a programme works under ideal conditions, in contrast with effectiveness, which investigates whether a programme works under normal or ‘field’ conditions. Efficiency assesses whether the programme is worth implementing, and availability examines whether the programme is reaching those who need it. Effectiveness, efficiency and availability ideally should all be evaluated within the geographically defined regions that are served by the programmes.¹

Although there have been reports on individual components necessary for a full evaluation within a geographical region, there is only one group that has evaluated and re-evaluated neonatal intensive care within the same geographical region over several decades.2, 3, 4 The extremely-low-birth-weight (ELBW, 500–999 g) infants in these studies comprised consecutive ELBW live births born in the state of Victoria during four distinct eras, 1979–1980, 1985–1987, 1991–1992 and 1997. The state of Victoria comprises approximately one-quarter of the population of Australia and has had approximately 60,000 births annually over this time.⁵

Section snippets

Efficacy of neonatal intensive care

Sinclair et al.¹ outlined some components of neonatal intensive care that had proven efficacy up to 1981. Since then there have been major advances in the perinatal care of extremely tiny or very preterm infants. An example of a known efficacious therapy since 1981 is exogenous surfactant to prevent or treat respiratory distress syndrome.⁶

Effectiveness of neonatal intensive care

As distinct from individual therapies or interventions, Kitchen and Campbell,⁷ prior to 1981, assessed the effectiveness of a neonatal intensive care ‘package’ in a clinical trial in infants of birth-weight 1000–1500 g cared for within an individual hospital in the late 1960s. In this study a reduction in mortality with intensive care (18% intensive versus 35% non-intensive)⁷ was offset to some extent by an increased rate of ‘handicap’ in survivors (40% intensive versus 29% non-intensive).⁸

Efficiency of neonatal intensive care

There is a paucity of data on the efficiency, or the relationship between the costs and the consequences, of neonatal intensive care.²³ There is even less information on how the relationship between costs and consequences is changing over time, or how it might alter with birth-weight.

For ELBW infants in Victoria costs were expressed as equivalent days of assisted ventilation (AV), which included not only consumption of ventilator resources, but also non-ventilated time in the nursery, as well

Availability of neonatal intensive care

Having established effectiveness and efficiency, the final step in fully evaluating neonatal intensive care is to determine whether it is reaching those who might need it, i.e., is it available to them? For the Victorian ELBW infants availability of neonatal intensive care was determined, firstly, by the proportions offered intensive care, and, secondly, by the proportion of ELBW infants born outside level III (high-risk) perinatal centres (outborn).

The proportions offered intensive care rose

Conclusions

In their article on the evaluation of neonatal intensive care programmes in 1981, Sinclair et al.¹ indicated there was no firm evidence that the use of neonatal intensive care reflected the need for those services; they even suggested that the supply of neonatal intensive care might determine its use, rather than the need. The dramatically improving survival and quality-adjusted survival rates for ELBW infants in Victoria over two decades argue strongly the case for an increasing need for

Acknowledgements

This work was supported in part by a grant from Health and Community Services, Victoria, and the National Health and Medical Research Council (Project grant 108702), Australia

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L.W. Doyle