NeoNotes
Journal Club
Andrew B. Kairalla MD, Editor
7-035 | Additional Comments | Previous
Article | Next Article | Search
| List of Articles | Submit
Comments | Index | FSN Home Page | Subscribe
Now
Cost of Apnea Watches
Zupancic JAF, Richardson DK, O’Brien BJ, et al. Cost-Effectiveness Analysis of Predischarge Monitoring for Apnea of Prematurity. PEDIATRICS (Jan 2003); 111: 146-152. [Full Text]; [ (PDF)]
Objective.
It is standard practice to defer discharge of premature infants until
they have achieved a set number of days without experiencing apnea.
The duration of this period, however, is highly variable across
institutions, and there is scant literature on its effectiveness or
value-for-money. Our objective was to establish the economic impact
of varying durations of pre-discharge observation for apnea of
prematurity.
Methods. Using computer simulation, we compared the
alternatives of hospital monitoring for 1 to 10 days, after apparent
cessation of apnea, with no monitoring and with the next longest
period of monitoring. The daily probability of apnea requiring
stimulation after a given number of apnea-free days was obtained from
chart review of 216 infants, beginning on the day they attained both
full feeds and temperature stability in an open crib. Baseline
rates of survival or impairment, utilities for calculation of
quality-adjusted life years (QALYs), outcomes for respiratory arrest
at home, and long-run costs for neurodevelopmental impairment were
derived from the literature. Hospital expenditures were obtained from
itemized billing records for infants on each of the final 10 days of
hospitalization and converted to costs using Medicare cost-to-charge
ratios. Costs are reported in 2000 US dollars.
Results. For infants born at 24 to 26 weeks’ gestation,
each additional day of monitoring cost from $41000 per QALY
saved for the first day to >$130000 per additional QALY gained for
the tenth day. Cost-effectiveness was poorer for infants who were
born at gestational ages >30 weeks. Results were sensitive to the
proportion of charted apneas requiring stimulation that would
actually progress, without intervention, to respiratory arrest.
Conclusions. In this model, the cost-effectiveness of
pre-discharge monitoring for apnea of prematurity declined
significantly as the duration of monitoring was increased.
Consideration should be given to alternative uses for resources in
formulating neonatal discharge guidelines.
Comments:
Prolonged in-hospital
observation for apnea monitoring is extremely wasteful of healthcare dollars.
Neonatology groups should consider establishing practice guidelines concerning
the timing of caffeine discontinuation that are geared to the practice of the
most conservative practitioner in the group. Decisions about caffeine
discontinuation and home monitoring need to be made early enough that their
impact will not prolong the infant’s total length of stay. ABK
Date: 12 Oct 2006
Time: 01:43:13
Excellent article. In this day of Evidence Based Practice -could somebody please direct me to the Evidence for this "EMINENCE BASED" practice of Apnea Free Days prior to Discharge. Thanks
UserName: Ravi Agarwal, MD
Institution:
telephone: 908-531-1705
email:
neodoc1@yahoo.com
Date: 25 Nov 2006
Time: 17:56:08
The crux of the matter to me is how much apnea is tolerable and/or harmful to the baby? We really don't know the answer to this question, so monitoring and the other measures we take become anecdotal in effectiveness. I see frequently that a premature who is otherwise doing well has some desaturations with feeds or spontaneously and this is used to keep them in the hospital longer. It becomes a phenomena of because we were monitoring and documented it that we feel that we have to act upon it. If we are willing to send a child home on a monitor then we must think that they are at risk, so why would we then necessarily keep a child in for apnea watch? Also, what about sending a child home on caffeine? I have seen this done rarely, but it makes sense to me just as we send children home on diuretics and oxygen.
UserName: Mark Croley
Institution: Wilford Hall USAF Medical Center
telephone: 210-292-2883
email:
mark.croley@lackland.af.mil
Date: 27 Dec 2006
Time: 15:28:20
There is no consistency whatever about how long a baby should be apnea-free before discharge; but the problem is even more complex. Standard monitoring does NOT accurately reflect the presence of significant episodes. Twenty years ago Spitzer and Fox documented that a large percentage of babies thought to be apnea-free in fact had significant episodes on pneumocardiograms (Pediatric Clinics of North America 33:3, June 1986). Our experience with routine pneumocardiograms on all prematures is the same -- at least 25% of babies thought to be apnea-free in fact have significant cardio-respiratory events. What good is observing until "apnea-free" when "apnea-free" may not mean anything? Four-channel pneumocardiograms are far more indicative of actual apnea status than simple observation and should be used much more often. And when in doubt, a month or two at home on a monitor is a far safer (and cheaper) plan than a few more days in the hospital.
UserName: Paul Hinkes M. D.
Institution: Providence St. Joseph Medical Center
telephone: 818-847-6332
email:
preemys@msn.com
You may add your own comments to the discussion of this topic by selecting : Submit Comments.