title: Resuscitation of neonates at 23 weeks' gestational age: a cost-effectiveness analysis.
abstract: OBJECTIVE
  Resuscitation of infants at 23 weeks' gestation remains controversial; clinical practices vary. We sought to investigate the cost effectiveness of resuscitation of infants born 23 0/7-23 6/7 weeks' gestation.
  
  
  METHODS
  Decision-analytic modeling comparing universal and selective resuscitation to non-resuscitation for 5176 live births at 23 weeks in a theoretic U.S. cohort. Estimates of death (77%) and disability (64-86%) were taken from the literature. Maternal and combined maternal-neonatal utilities were applied to discounted life expectancy to generate QALYs. Incremental cost-effectiveness ratios were calculated, discounting costs and QALYs. Main outcomes included number of survivors, their outcome status and incremental cost-effectiveness ratios for the three strategies. A cost-effectiveness threshold of $100 000/QALY was utilized.
  
  
  RESULTS
  Universal resuscitation would save 1059 infants: 138 severely disabled, 413 moderately impaired and 508 without significant sequelae. Selective resuscitation would save 717 infants: 93 severely disabled, 279 moderately impaired and 343 without significant sequelae. For mothers, non-resuscitation is less expensive ($19.9 million) and more effective (127 844 mQALYs) than universal resuscitation ($1.2 billion; 126 574 mQALYs) or selective resuscitation ($845 million; 125 966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22 256 and 15 134 nQALYS, respectively, versus 247 nQALYs for non-resuscitation. In sensitivity analyses, universal resuscitation was cost-effective from a maternal perspective only at utilities for neonatal death <0.42. When analyzed from a maternal-neonatal perspective, universal resuscitation was cost-effective when the probability of neonatal death was <0.95.
  
  
  CONCLUSIONS
  Over wide ranges of probabilities for survival and disability, universal and selective resuscitation strategies were not cost-effective from a maternal perspective. Both strategies were cost-effective from a maternal-neonatal perspective. This study offers a metric for counseling and decision-making for extreme prematurity. Our results could support a more permissive response to parental requests for aggressive intervention at 23 weeks' gestation.
authors.affiliation: Department of Pediatrics, Center for Clinical and Policy Perinatal Research, University of California San Francisco , San Francisco, CA , USA .
authors.forename: J Colin
authors.initials: JC
authors.lastname: Partridge
authors.forename: Kathryn R
authors.initials: KR
authors.lastname: Robertson
authors.forename: Elizabeth E
authors.initials: EE
authors.lastname: Rogers
authors.forename: Geri Ottaviano
authors.initials: GO
authors.lastname: Landman
authors.forename: Allison J
authors.initials: AJ
authors.lastname: Allen
authors.forename: Aaron B
authors.initials: AB
authors.lastname: Caughey
mesh_terms: D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005865:Gestational Age; D006801:Humans; D052577:Infant, Extremely Low Birth Weight; D062071:Infant, Extremely Premature; D007231:Infant, Newborn; D015931:Intensive Care, Neonatal / Q000191:economics; D018579:Patient Selection; D011788:Quality of Life; D012151:Resuscitation / Q000191:economics / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014481:United States
keywords: Cost-effectiveness; death and dying; decision-making; ethics; extreme prematurity; health policy; perinatal care; resuscitation