1. Is Neonatal Intensive Care Expensive? Liisa Lehtonen, MD Head of Division of Neonatology, Turku University Hospital Estonian Perinatal Association 10.-11.12.2010 Tarto, Estonia Liisa Lehtonen, MD Head of Division of Neonatology, Turku University Hospital Estonian Perinatal Association 10.-11.12.2010 Tarto, Estonia

2. Content Expenses are affected by prevalence of prematurity –Preterm infants as a part of other neonatal intensive care –European perspective Expenses are affected by e.g. –The length of hospital stay –Longterm outcome New knowledge about cost-effectiveness of the care of VLGA/VLBW infants from PERFECT Preterm InfantsStudy Theses by Liisi Rautava, MD Emmi Korvenranta MD, MSc Expenses are affected by prevalence of prematurity –Preterm infants as a part of other neonatal intensive care –European perspective Expenses are affected by e.g. –The length of hospital stay –Longterm outcome New knowledge about cost-effectiveness of the care of VLGA/VLBW infants from PERFECT Preterm InfantsStudy Theses by Liisi Rautava, MD Emmi Korvenranta MD, MSc

3. Prevalence of prematurity in Europe www.europeristat.com

4. Prevalence of prematurity in Europe

5. Multiple births www.europeristat.com 20.4/1000 17.8/1000 18.2/1000 17.4/1000 15.2/1000

6. Newborns in Finland n=60.577 live born in 2009 9.6% admitted to neonatal ward 7.6% in hospital at 1 week of age

7. Neonatal intensive care TYKS 2009 Heterogenic patient population Majority of patient are fullterm infants

8. Preterm infants n= 3473 (5.7%) live born below 37 weeks v 2009 Preterm infants are one significant patient group of those needing neonatal intensive care

9. VLGA/VLBW infants n=644 (1.0 %) liveborn <1500 g or <32 weeks v 2009 VLGA/VLBW infants need a long initial hospital care

10. The quality of care affects mortality length of stay longterm outcome costs  the quality of the initial care has large and longterm consequences affects mortality length of stay longterm outcome costs  the quality of the initial care has large and longterm consequences

12. Perfect = PERFormance, Effectiveness and Cost of Treatment episodes To develop measures for cost-effectiveness based on the existing registers –VLGA/VLBW infants included To develop an online database to follow the changes in cost-effectiveness www.thl.fi/ search: PERFECT  keskoset  perusraporttiwww.thl.fi/ –Last update includes years 2004-2007 The Institute of Health and Welfare and hospital districts in collaboration To develop measures for cost-effectiveness based on the existing registers –VLGA/VLBW infants included To develop an online database to follow the changes in cost-effectiveness www.thl.fi/ search: PERFECT  keskoset  perusraporttiwww.thl.fi/ –Last update includes years 2004-2007 The Institute of Health and Welfare and hospital districts in collaboration

14. PERFECT Keskoset Perusraportit

15. The Effect of the Birth Hospital and the Time of Birth on the Outcome of Finnish Very Preterm Infants Thesis by Liisi Rautava, MD To study the effects of the organisation of the initial care on –mortality, –diagnoses (hospital discharge register) –child development –quality bof life by 5 years of life Thesis by Liisi Rautava, MD To study the effects of the organisation of the initial care on –mortality, –diagnoses (hospital discharge register) –child development –quality bof life by 5 years of life

16. Very Preterm Infants in Finland – Use of Health Care Services and Econimic Consequences During the First Five Years of Life Thesis by Emmi Korvenranta, MD The factors affecting the length of stay, the costs of care and the cost of a quality adjusted life year (QALY) by 4 yr of life Thesis by Emmi Korvenranta, MD The factors affecting the length of stay, the costs of care and the cost of a quality adjusted life year (QALY) by 4 yr of life

17. The length of stay

18. Gestational age at discharge by gest age at birth Alue<28 wk28-32 wk>32 wk A39+637+238+1 B38+036+438+0 C38+437+438+6 D39+237+639+3 E41+638+338+6 Korvenranta E, Linna M, Häkkinen U et al for the PERFECT Preterm Infant Study Group: The differences in the length of stay in very preterm infants. Acta Paediatrica 2007;96:1416-1420.

19. The factors affecting LOS [days (95% CI)] Previous c/s –1.9 (–3.7; –0.7) Previous pregnancies –1.1 (–1.9; –0.2) C/S 2.9 (2.1; 3.6) Gest age (1 additional day)–1.07 (–1.10; –1.05) Apgar 1 min (1 additional point) –0.7 (–0.9; –0.5) Male1.7 (1.0; 2.4) Multiple2.6 (1.8; 3.4) Ventilator care during the first week 5.0 (4.3; 5.8) SGA 13.7 (12.7; 14.6) LGA –7.6 (–9.5; –5.6) Death–35. 8 (–36.9; –34.6) Backtransfer to other hospital1.7 (0.7; 2.7) Discharge from univ ersity hospital 1.3 (0.4; 2.3) Distance to home (per 100 km) 1.8 (1.1; 2.4) Rehospitalization4.1 (3.3; 4.8) Previous c/s –1.9 (–3.7; –0.7) Previous pregnancies –1.1 (–1.9; –0.2) C/S 2.9 (2.1; 3.6) Gest age (1 additional day)–1.07 (–1.10; –1.05) Apgar 1 min (1 additional point) –0.7 (–0.9; –0.5) Male1.7 (1.0; 2.4) Multiple2.6 (1.8; 3.4) Ventilator care during the first week 5.0 (4.3; 5.8) SGA 13.7 (12.7; 14.6) LGA –7.6 (–9.5; –5.6) Death–35. 8 (–36.9; –34.6) Backtransfer to other hospital1.7 (0.7; 2.7) Discharge from univ ersity hospital 1.3 (0.4; 2.3) Distance to home (per 100 km) 1.8 (1.1; 2.4) Rehospitalization4.1 (3.3; 4.8) Continues…

20. Independent effect of the university district on adjusted LOS, days (95% CI) 10,5d –4.6 (–5.6;–3.5) –10.5 (-11.5;–9.3) –4.7 (–5.8;–3.5) –2.3 (–3.6;–1.1) 0 Korvenranta E, Linna M, Häkkinen U et al for the PERFECT Preterm Infant Study Group. Acta Paediatrica 2007;96:1416-1420.

21. Adjusted LOS according to the birth hospital

22. Absolute LOS by districts

23. Care days in survivors by 1 year of age

24. The LOS in VLGA/VLBW infants Decreased by 4 days –58 days in 2000-2003 –53 days in 2004-2006 5 days x 520 = 2600 days –The workload is decreased by in overcrowded units –Resources to be used in more critical work Decreased by 4 days –58 days in 2000-2003 –53 days in 2004-2006 5 days x 520 = 2600 days –The workload is decreased by in overcrowded units –Resources to be used in more critical work

25. Quality of Life (17D) Rautava L et al for the PERFECT Preterm Infant Study Group. J Pediatr 2009

26. The total cost of hospital care by 4 years of age The total cost of hospital care by 4 years of age Korvenranta E et al for PERFECT Preterm Infant Study Group Arch Pediatr Adolesc Med 2010;164:657-663.

27. The costs during the fifth year of life Korvenranta E, Lehtonen L, Rautava L, et al. Pediatrics 2010;125;e1109-e1114.

28. The costs during the fifth year of life Korvenranta E, Lehtonen L, Rautava L, et al. Pediatrics 2010;125;e1109-e1114.

29. The cost of a QALY average 19,245€ by 4 years of age None of diagnoses 14,066€ Seizures 22,516€ Cerebral Palsy 21,165€ Other ophthalmologic problems 20,472€ Visual disorder 20,371€ Hearing loss 26,563€ Obstructive airway disease 21,682€ 2 or more of the above diagnoses 31,991€ None of diagnoses 14,066€ Seizures 22,516€ Cerebral Palsy 21,165€ Other ophthalmologic problems 20,472€ Visual disorder 20,371€ Hearing loss 26,563€ Obstructive airway disease 21,682€ 2 or more of the above diagnoses 31,991€ Korvenranta E et al for PERFECT Preterm Infant Study Group Arch Pediatr Adolesc Med 2010;164:657-663.

30. The total costs of preterm infant care in Finland 560 VLGA/VLBW infants survive per year x 65,000 € (4 year total hospital costs) = 36 milj €/year Compare to the costs of ambulances/taxi drives for patients more than 200 milj € 560 VLGA/VLBW infants survive per year x 65,000 € (4 year total hospital costs) = 36 milj €/year Compare to the costs of ambulances/taxi drives for patients more than 200 milj €

31. Mercedes Benz

33. Summary Preterm infants comprise one important patient group in neonatal intensive care Good quality of care requires resources Good quality of initial care saves later costs The goal of treatment is a healthy child  quality measure which is mandatory to follow Preterm infants comprise one important patient group in neonatal intensive care Good quality of care requires resources Good quality of initial care saves later costs The goal of treatment is a healthy child  quality measure which is mandatory to follow

34. How runs on a road?

36. Preterm infant care is a good investment Cost-effectiveness can be improved by improving longterm outcome of preterm infats Quality improvement based on longterm outcomes should be the mission of all neonatologists Cost-effectiveness can be improved by improving longterm outcome of preterm infats Quality improvement based on longterm outcomes should be the mission of all neonatologists

37. CP diagnosis in VLBW infants 2001-2007 (n=14/204). PIPARI Study % p=0.04

38. PIPARI Study: Cognitive level in VLBW infants at 2 yr of corrected age has improved dramatically

39. Cognitive outcome at 5 years of age (WPPSI-R) / PIPARI (Munck et al, unpublished) VLBW (n=89) ka (SD) Verrokit (n=152) ka (SD) p FSIQ101.9 (15.0)112.0 (14.6)<0.001 VIQ104.8 (14.6)108.2 (13.9)ns PIQ99.0 (15.6)111.7 (13.4)<0.001

40. Is neonatal intensive care expensive? No! Preterm infant care is cost-effective already at 4 years of age The investment on initial care will be even more beneficial with more follow-up years –The cost of the gained life years decreases as the divider increases –The costs of later years are small Preterm infant care is cost-effective already at 4 years of age The investment on initial care will be even more beneficial with more follow-up years –The cost of the gained life years decreases as the divider increases –The costs of later years are small

41. PERFECT Preterm Infant Study Rautava L, Lehtonen L, Peltola M, Korvenranta E, Korvenranta H, Linna M, Hallman M, Andersson S, Gissler M, Leipälä J, Tammela O, Häkkinen U, for the PERFECT Preterm Infant Study Group. The Effect of Birth in Secondary or Tertiary Level Hospitals in Finland on Mortality in Very Preterm Infants: A Birth Register Study. Pediatrics 2007;119:257-263. Korvenranta E, Linna M, Häkkinen U, Peltola M, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Rautava L, Tammela O, Lehtonen L for the PERFECT Preterm Infant Study Group: Differences in the LOS in very preterm infants. Acta Paediatrica 2007;96:1416-1420. Korvenranta E, Lehtonen L, Peltola M, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Rautava L, Tammela O, Linna M. Morbidities and hospital resource use during the first 3 years of life among very preterm infants. Pediatrics 2009;124:128-34. Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Linna M, Peltola M, Tammela O, Lehtonen L. Health-related quality of life in 5-year-old VLBW infants. J Pediatr 2009;155:338-43. Korvenranta E, Linna M, Rautava L, Andersson S, Gissler M, Hallman M, Häkkinen U, Leipälä J, Peltola M, Tammela O and Lehtonen L for PERFECT Preterm Infant Study Group. The economic impact of a very preterm birth during the first 4 yr of life in Finland. Arch Pediatr Adolesc Med 2010;164:657-663. Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H,Leipälä J, Peltola M, Tammela O, and Lehtonen L for PERFECT Preterm Infant Study. Health and the Use of Health Care Services in 5-yr-old VLBW Infants. Acta Paediatrica 2010;99:1073-1079. Korvenranta E, Lehtonen L, Rautava L, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Peltola M, Tammela O, and Linna M. The Impact of Very Preterm Birth on Health Care Costs at Five Years of Age. Pediatrics 2010;125;e1109-e1114. Rautava L, Andersson S, Gissler, M, Hallman M, Häkkinen U, Korvenranta E, Korvenranta H, Leipälä J, Tammela O, Lehtonen L for PERFECT Preterm Infant Study Group: Development and Behavior of Five-Year-Old VLBW Infants. Eur Child&Adolescent Psychiatr 2010;19:669-677. Rautava L, Lehtonen L, Peltola M, Korvenranta E, Korvenranta H, Linna M, Hallman M, Andersson S, Gissler M, Leipälä J, Tammela O, Häkkinen U, for the PERFECT Preterm Infant Study Group. The Effect of Birth in Secondary or Tertiary Level Hospitals in Finland on Mortality in Very Preterm Infants: A Birth Register Study. Pediatrics 2007;119:257-263. Korvenranta E, Linna M, Häkkinen U, Peltola M, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Rautava L, Tammela O, Lehtonen L for the PERFECT Preterm Infant Study Group: Differences in the LOS in very preterm infants. Acta Paediatrica 2007;96:1416-1420. Korvenranta E, Lehtonen L, Peltola M, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Rautava L, Tammela O, Linna M. Morbidities and hospital resource use during the first 3 years of life among very preterm infants. Pediatrics 2009;124:128-34. Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H, Leipälä J, Linna M, Peltola M, Tammela O, Lehtonen L. Health-related quality of life in 5-year-old VLBW infants. J Pediatr 2009;155:338-43. Korvenranta E, Linna M, Rautava L, Andersson S, Gissler M, Hallman M, Häkkinen U, Leipälä J, Peltola M, Tammela O and Lehtonen L for PERFECT Preterm Infant Study Group. The economic impact of a very preterm birth during the first 4 yr of life in Finland. Arch Pediatr Adolesc Med 2010;164:657-663. Rautava L, Häkkinen U, Korvenranta E, Andersson S, Gissler M, Hallman M, Korvenranta H,Leipälä J, Peltola M, Tammela O, and Lehtonen L for PERFECT Preterm Infant Study. Health and the Use of Health Care Services in 5-yr-old VLBW Infants. Acta Paediatrica 2010;99:1073-1079. Korvenranta E, Lehtonen L, Rautava L, Häkkinen U, Andersson S, Gissler M, Hallman M, Leipälä J, Peltola M, Tammela O, and Linna M. The Impact of Very Preterm Birth on Health Care Costs at Five Years of Age. Pediatrics 2010;125;e1109-e1114. Rautava L, Andersson S, Gissler, M, Hallman M, Häkkinen U, Korvenranta E, Korvenranta H, Leipälä J, Tammela O, Lehtonen L for PERFECT Preterm Infant Study Group: Development and Behavior of Five-Year-Old VLBW Infants. Eur Child&Adolescent Psychiatr 2010;19:669-677.

42. The PERFECT Preterm Infant Study Group The National Institute of Health and Welfare Unto Häkkinen, Professor Miika Linna, Docent Mika Gissler, Professor Mikko Peltola, Researcher Merja Juntunen, Researcher Antti Malmivaara, Professor Clinical experts Liisa Lehtonen, MD, Docent, TYKS, the Principal Investigator Sture Andersson, MD, Docent, HYKS Mikko Hallman, MD, Professor, OYS Heikki Korvenranta, MD, Docent, TYKS Ulla Sankilampi, MD, KYS Jaana Leipälä, MD, Docent, THL Outi Tammela, MD, Docent, TAYS PhD Emmi Korvenranta, Economist, MD, Turku University Liisi Rautava, MD, Turku University

43. Quality of Life (17D) Rautava L et al for the PERFECT Preterm Infant Study Group. J Pediatr 2009

44. ICD-10 dg:t 5 v ikään mennessä Pikkukeskoset (%) Täysiaikaiset (%) P-value CP4.000.004 Karsastus8.80.6<0.001 Taittovika6.71.10.002 Korvatulehdus (nonsupp)13.85.10.001 Märkäinen korvatulehdus32.010.2<0.001 Ylähengitystieinfektio24.15.7<0.001 Pneumonia8.41.70.001 Akuutti bronkiitti4.8 0<0.001 Bronkioliitti24.48.0<0.001 Astma18.94.6<0.001 Atooppinen ihottuma3.89.70.005

45. Adjusted mortality by 1 year of age in live born VLGA/VLBW infants by birth hospital level Rautava L, Lehtonen L, Peltola M, et al for the PERFECT Preterm Infant Study Group. Pediatrics 2007;119:257-263.

46. Mortality in live born VLGA/VLBW infants according to the birth hospital level and time of birth in 2000-05(n=3070)

47. The proportion of VLGA/VLBW infants born in university hospitals by districts

48. Live born VLBW/VLGA inafnts by hospitals (15 hospitals excluded with ≤2/yr)

49. Outcome of VLBW infants at 2 years of corrected age PIPARI Study Munck P et al: Acta Paediatrica 2010;99:359-366 GA23242526272829303132333435 n3101819142924261210863 MDI7392981009510410510910510110210696 Delay % 331005734000000 Disabi lity(% ) 672017514 4001013033