Friday, March 10, 2006

Dollars

I hadn't intended to write about 23 weekers again so soon after my previous posting, but the comments to that post raised a couple of issues I can't resist addressing. The first issue is about the "cost effectiveness" of care for extremely premature babies. Cost effectiveness studies are inherently a little distasteful, trying to put a dollar value on a human life. Roughly speaking, they are usually done by looking at the cost of certain interventions - such as NICU care or angioplasty - and comparing the ratios of the cost of the treatment to the amount of money generated by the survivors of that treatment in the productive years of life they live following the treatment. The good news, at least for us neonatologists, and a surprise to most people is that in such studies NICU care is usually more cost effective than many other common treatments, such as coronary artery bypass graft surgery and dialysis for kidney failure. Although sometimes you might hear someone complain about the high cost of NICU's, when's the last time you heard anyone say we shouldn't do heart bypasses because they're not cost effective? You won't hear anyone say it, because people the age of bypass patients have a pretty good political voice - unlike premature neonates.

It's only fair that I insert a disclaimer here. The cost effectiveness studies I've seen have not usually gone down to 23 weekers but have included slightly more mature babies. If anyone knows of cost effectiveness studies encompassing 23 weekers, I'd love to see them.

The second issue raised in the comments was the idea that, instead of spending money on NICU costs, we should spend more money on prenatal care so we can prevent premature births and NICU costs. This is a very appealing idea and a darling of the public health community. Unfortunately, though, it's probably not true. The data supporting the notion that prenatal care saves subsequent postnatal dollars is pretty scant. It makes sense, too, that it is not true. We don't know how to prevent preterm birth. If we did, the rate of preterm birth in the U.S. would be falling, but in fact it is rising. More than 10% of births are preterm now. Don't get me wrong: I think it's good to provide prenatal care, but let's not subscribe to the too-good-to-be-true idea that every dollar spent on prenatal care will save five dollars in NICU costs. (For reasons not clear, that concept always reminds me of Wimpy in the Popeye cartoon: "I'd gladly give you a nickel on Tuesday for a hamburger today.")

If you want to think about whether NICU dollars are justified, here's some food for thought. What if we took money spent on NICU care - about $2,ooo per day per baby - and spent it on food, clean water, immunizations, and medicine for kids in the developing world? There, the money probably could save more lives. But that's another big subject in itself, so I'll stop here.

P.S. If we're going to send NICU dollars to developing countries, we'd better send dialysis and coronary bypass dollars there too.

15 Comments:

Anonymous maribeth, CNM said...

Thanks for commenting on this further Doc. $2000 a day – you do live in the Midwest! My referral NICU is $5000 per day in stay and nursing care alone – never mind meds, procedures, surgeries, physician fees, etc. And we’re even pretty rural. Presently, one out of eight babies is born prematurely. Once preterm labor has begun, it’s well demonstrated that medical intervention won’t change an inevitable outcome (but may buy an important few more days). It’s true we don’t know what causes it – any more than we know what causes labor at term – but I strongly disagree that there is not much to be done about it.

I do agree that “routine” prenatal care won’t make a flip of a difference. But addressing socioeconomic, nutritional, and other health issues through public health programs would likely decrease the risk of preterm birth. First off Doc, don’t you think the rate of preterm birth is rising because of increased fertility drugs and multiple births? There’s an easy way to reduce the rate, no? Preventative health (often such a dirty word for specialists!) to reduce the incidence of disease that can lead to preterm birth (HTN, diabetes, etc) would help. The things that are associated with higher risk for preterm birth mean something, after all – poverty, poor nutritional status, smoking, periodontal disease, etc. For example, we know that teens have a higher risk of preterm birth. This opens a can of worms, but free contraceptive or sexual health clinics in schools or at malls or wherever, may trickle down to reduce the number of premature babies. We know that illicit drug abuse can induce PTB – outreach RVs providing specialized prenatal care, maybe even with methadone clinics, may decrease the risk. A real program to counter the devastation of methamphetamines would likely make a difference. We know that pregnant women are abused (and murdered) more than any other group – programs to address this may cause that trickle down. Progesterone supplementation, screening for STIs and infections in the women who don’t receive prenatal care, free dental care for all!, each one could reduce the incidence of PTB. Heck, simple social programs to give poor, black women a better quality of life – having not a thing to do with health care – would likely reduce the rate of PTB.

But my point is not by any means to rip these dollars out of the hands of desperately tiny babies, or to squash the hopes of loving parents like La Labu. It’s just to ask everyone to look at the big picture, as we continue down the slope of lower and lower gestational ages of viability. It’s a symptom of the hugely problematic medical philosophy in America – let us fix bad things after they happen - oooh aren’t we so good at it, smart smart us! - rather than trying to prevent them from happening in the first place. Doc, with upmost respect (I love my neonatologists) you dismissed the idea of primary prevention pretty easily. To me, that’s the very problem.

And, do forgive me for writing comments longer than the post. Pith my middle name is not :(

12:38 PM  
Anonymous armchair ethicist said...

Some things can't be prevented, ever. Throwing dollars at March of Dimes will never prevent Down syndrome, or much else, really. (I am all for throwing dollars at March of Dimes, don't get me wrong).

Can we just accept that some of us need more basic interventions to live? Is that "unacceptable"?

As a healthcare consumer (well, aren't we all?), I'm less concerned about who is getting service - let's err on the side of life, every life is precious. But I am concerned about healthcare costs in terms of waste, redundancy, etc.

Why did my tylenol cost $20? If someone could show me that it cost $20 in the hospital because some of it was to offset the costs of keeping a 23 weeker alive, I wouldn't complain. I'm just not convinced it is.

1:54 PM  
Blogger clara said...

If we could then convince every single preemie mom to breastfeed for a year that would be a big savings too, and help the babies get out sooner and be seen less for illnesses in the early years. If every NICU mom was provided a place to stay and take care of her baby,I think that would also help get them home sooner.

Having had 3 boys in the NICU`s of 3 different hospitals, I have to say my dream NICU would be double beds so mom could sleep next to baby (of course it would be safe & monitors would all be hooked up) and nurse or at least have her body next to a tube fed baby.

All the basic human needs for closeness go a long way towards healing, much more than these moms who show up once a week to check on baby. Who knows why, it may be that they live too far & have other children, but for a NICU baby, all the chaos needs to be cut through with the most familiar thing, MOM.

3:17 PM  
Anonymous Anonymous said...

I would simply like to ask that people stop using "Down syndrome" as an example of a dirty word. What I mean by that is that I'm tired of seeing it lumped in with highly disabling or medically disastrous conditions, when most people with "Down syndrome" don't usually suffer much or any, even if their level of functioning is not what most consider ideal and many consider acceptable or even worthy of being allowed to exist. (witness the termination rate). Yes, I understand possible dire outcomes and possible complications connected to the syndrome. I'm not discounting those realities. But they are by no means universal. People with trisomy 21 are, in my view, a not-uncommon variety of human being. (We all have differences somewhere in our physical makeup, genetic variations if not extra whole chromosomes, that make us "different" from the next person.) By the way, they are not necessarily "delightful" and "happy" but have a full range of emotions and unique characteristics just like everyone else, even if they draw from a common pool characteristics seen more often in their diagnosis than within the general population. Thank you.

But in reference to the context in which the phrase was used, yes, I agree - the March of Dimes cannot prevent trisomy 21; only preventing the birth of those with trisomy 21 (destruction of those individuals prenatally) will reduce the incidence of trisomy 21. And I'm sure y'all can guess that I take a dim view on that practice. Maybe convincing people to have their children only whilst spring chickens would have some effect, but since we're talking about a (relatively) uncommon occurrence anyway, it would only make a relatively small change - mothers age 16, 19, 21 and all other ages have children with trisomy 21.

The March of Dimes has made headway in preventing some spinal cord defects. I guess that is the feather in their cap. I do wish they'd stop including what I obviously feel is a legitimate and not "defective" population in their group of to-be-prevented conditions. I guess I wonder where the line would be drawn. Dwarfism - no one requests it - but should such embryos and fetuses be "reduced," "terminated," or whatever terminology is most comfy? (I know that they already are, at parents' discretion). Diabetes? Tendency toward coronary disease, if said genetic tendency is uncovered prenatally? Susceptibility to mental illness? Sorry, I've turned a whole ball of wax into a can of worms, and I realize I've tangentialized from the original topic.

4:33 PM  
Anonymous armchair ethicist said...

I used Down syndrome because it's not "preventable" (which was the point) and because, unlike most other trisomy syndromes, many people would understand why we would spend dollars preventing the death of a child with Down syndrome. If there were not a history of questioning the value of allowing a child with trisomy 18 to live, here (and to be fair, elsewhere), I would have used that as an example instead.

I most certainly do not use down syndrome as a dirty word.

4:59 PM  
Anonymous Anonymous said...

eh... pardon me for taking out my irkedness with the usage of others on your usage. I did wind up basically agreeing with you - sorry I just keyed into that word (as you had used it) on my unrelated rant jumping-off-point.

I guess I have a little beef with the March of Dimes and don't know if I endorse throwing dollars at them, but I certainly won't get into that here. Some other day, some other place.

Excuse me! Remainder of rant (and entire rant, not directed at previous poster but at those out there on the internet who may or may not read here) still stands.

5:12 PM  
Blogger La Lubu said...

Here's a question---are prematurity rates rising for those who don't have any of the commonly-known risk factors?

9:20 AM  
Blogger neonataldoc said...

Thanks all - the comments here are always so interesting!

Maribeth, I'm very much in favor of an ounce of prevention preventing a pound of cure, and I agree that the interventions you suggest might decrease the rate of prematurity. But in these days of limited healthcare and social intervention dollars, we need to put those dollars towards proven solutions, towards evidenced based interventions. I don't think we know what those are yet; maybe we just need to do the things you suggest in bigger and better ways, but maybe we need a whole new paradigm. What we're doing now isn't working.

I'm a big fan of breastfeeding. It's hard, though, for mothers of small premies to keep pumping for weeks on end before their baby can actually suckle from the breast.

La luba, I don't know the answer to your question, but if I find it I'll let you know.

1:54 PM  
Anonymous maribeth, CNM said...

There is progress being made!

http://www.marchofdimes.com/files/MP_SupplementalProgesterone041904.pdf

La Labu, I am not 100%, but I don't think rates are increasing in women not at risk. I think the increasing rate of PTB is directly related to the increased use of fertility drugs and multiple pregnancies.

5:40 PM  
Anonymous maribeth, CNM said...

Try again...

http://www.marchofdimes.com/files/
MP_SupplementalProgesterone041904.
pdf

5:47 PM  
Blogger Flea said...

I'm not convinced cost-effectiveness is a metric that even applies to neonatology.

A former premie could grow up to be Donald Trump or a crack whore.

IMHO, it's pointless at best, and pernicious at worst to estimate the value of a premie's life.

best,

Flea

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