Elizabeth S Draper

The Cost of Preterm Birth Throughout Childhood in England and Wales

BACKGROUND. Infants born preterm are at increased risk of adverse health and developmental outcomes. Mortality and morbidity after preterm birth impose a burden on finite public sector resources. This study considers the economic consequences of preterm birth from birth to adult life and compares the costs accruing to those born preterm with those born at term. METHODS. A decision-analytic model was constructed to estimate the costs to the public sector over the first 18 years after birth, stratified by week of gestational age at birth. Costs were discounted and reported in UK pounds at 2006 prices. Probabilistic sensitivity analysis was used to examine uncertainty in the model parameters and generate confidence intervals surrounding the cost estimates. RESULTS. The model estimates the costs associated with a hypothetical cohort of 669601 children and is based on live birth and preterm birth data from England and Wales in 2006. The total cost of preterm birth to the public sector was estimated to be £2.946 billion (US

Differences in rates and short-term outcome of live births before 32 weeks of gestation in Europe in 2003: results from the MOSAIC cohort.

4.567 billion), and an inverse relationship was identified between gestational age at birth and the average public sector cost per surviving child. The incremental cost per preterm child surviving to 18 years compared with a term survivor was estimated at £22885 (US

Impact of Fetal Growth Restriction on Mortality and Morbidity in a Very Preterm Birth Cohort

35471). The corresponding estimates for a very and extremely preterm child were substantially higher at £61781 (US

Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study

95760) and £94740 (US

Gastroschisis: one year outcomes from national cohort study.

146847), respectively. CONCLUSIONS. Despite concerns about ongoing costs after discharge from perinatal services, the largest contribution to the economic implications of preterm birth are hospital inpatient costs after birth, which are responsible for 92.0% of the incremental costs per preterm survivor.

Rates of Bronchopulmonary Dysplasia in Very Preterm Neonates in Europe: Results from the MOSAIC Cohort

OBJECTIVES. Advances in perinatal medicine increased survival after very preterm birth in all countries, but comparative population-based data on these births are not readily available. This analysis contrasts the rates and short-term outcome of live births before 32 weeks of gestation in 10 European regions. METHODS. The Models of Organizing Access to Intensive Care for Very Preterm Births (MOSAIC) study collected prospective data on all very preterm births in 10 European regions covering 494463 total live births in 2003. The analysis sample was live births between 24 and 31 weeks of gestation without lethal congenital anomalies (N = 4908). Outcomes were rates of preterm birth, in-hospital mortality, intraventricular hemorrhage grades III and IV or cystic periventricular leukomalacia and bronchopulmonary dysplasia. Mortality and morbidity rates were standardized for gestational age and gender. RESULTS. Live births between 24 and 31 weeks of gestation were 9.9 per 1000 total live births with a range from 7.6 to 13.0 in the MOSAIC regions. Standardized mortality was doubled in high versus low mortality regions (18%–20% vs 7%–9%) and differed for infants ≤28 weeks of gestation as well as 28 to 31 weeks of gestation. Morbidity among survivors also varied (intraventricular hemorrhage/periventricular leukomalacia ranged from 2.6% to ≤10% and bronchopulmonary dysplasia from 10.5% to 21.5%) but differed from mortality rankings. A total of 85.2 very preterm infants per 10000 total live births were discharged from the hospital alive with a range from 64.1 to 117.1; the range was 10 to 31 per 10000 live births for infants discharged with a diagnosis of neurologic or respiratory morbidity. CONCLUSIONS. Very preterm mortality and morbidity differed between European regions, raising questions about variability in treatment provided to these infants. Comparative follow-up studies are necessary to evaluate the impact of these differences on rates of cerebral palsy and other disabilities associated with preterm birth.

Long term trends in prevalence of neural tube defects in Europe : population based study

OBJECTIVEnTo assess the impact of being small for gestational age (SGA) on very preterm mortality and morbidity rates by using different birthweight percentile thresholds and whether these effects differ by the cause of the preterm birth.nnnSTUDY DESIGNnThe study included singletons and twins alive at onset of labor between 24 and 31 weeks of gestation without congenital anomalies from the Models of Organising Access to Intensive Care for very preterm births very preterm cohort in 10 European regions in 2003 (n = 4525). Outcomes were mortality, intraventricular hemorrhage grade III and IV, cystic periventricular leukomalacia, and bronchopulmonary dysplasia (BPD). Birthweight percentiles in 6 classes were analyzed by pregnancy complication.nnnRESULTSnThe mortality rate was higher for infants with birthweights <25th percentile when compared with the 50th to 74th percentile (adjusted odds ratio, 3.98 [95% CI, 2.79-5.67] for <10th; adjusted odds ratio, 2.15 [95% CI, 1.54-3.00] for 10th-24th). BPD declined continuously with increasing birthweight. There was no association for periventricular leukomalacia or intraventricular hemorrhage. Seventy-five percent of infants with birthweights <10th percentile were from pregnancies complicated by hypertension or indicated deliveries associated with growth restriction. However, stratifying for pregnancy complications yielded similar risk patterns.nnnCONCLUSIONSnA 25th percentile cutoff point was a means of identifying infants at higher risk of death and a continuous measure better described risks of BPD. Lower birthweights were associated with poor outcomes regardless of pregnancy complications.

Epidemiology of congenital diaphragmatic hernia in Europe: a register-based study

BACKGROUNDnIntensive care services for children have undergone substantial centralisation in the UK. Along with the establishment of regional paediatric intensive care units (PICUs), specialist retrieval teams were set up to transport critically ill children from other hospitals. We studied the outcome of children transferred from local hospitals to PICUs.nnnMETHODSnWe analysed data that were gathered for a cohort of children (<or=16 years) admitted consecutively to 29 PICUs in England and Wales during 4 years (Jan 1, 2005, to Dec 31, 2008). We compared unplanned admissions from wards within the same hospital as the PICU and from other hospitals; interhospital transfers by non-specialist and specialist retrieval teams; and patients transferred to their nearest PICU and those who were not. Primary outcome measures were mortality rate in PICU and length of stay in PICU. We analysed data by use of logistic regression analysis.nnnFINDINGSnThere were 57 997 admissions to PICUs during the study. Nearly half of unplanned admissions (17 649 [53%] of 33 492) were from other hospitals. Although children admitted from other hospitals were younger (median 10 months [IQR 1-55] vs 18 months [3-85]), sicker at admission (median predicted risk of mortality 6% [4-10] vs 4% [2-7]), stayed longer in PICUs (75 h [33-153] vs 43 h [18-116]), and had higher crude mortality rates (1384 [8%] of 17 649 vs 996 [6%] of 15 843; odds ratio 1.27, 95% CI 1.16-1.38), the risk-adjusted mortality rate in PICUs was lower than among children admitted from within the same hospital (0.65, 0.53-0.80). In a multivariable analysis, use of a specialist retrieval team for transfer was associated with improved survival (0.58, 0.39-0.87).nnnINTERPRETATIONnThese findings support the policy of combining centralisation of intensive care services for children with transfer by specialist retrieval teams.nnnFUNDINGnNational Clinical Audit and Patient Outcomes Programme through Healthcare Quality Improvement Partnership, Health Commission Wales Specialised Services, National Health Service (NHS) Lothian and National Service Division NHS Scotland, the Royal Belfast Hospital for Sick Children, and the Pan Thames PICU Commissioning Consortium.

Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study

Objective To describe one year outcomes for a national cohort of infants with gastroschisis. Design Population based cohort study of all liveborn infants with gastroschisis born in the United Kingdom and Ireland from October 2006 to March 2008. Setting All 28 paediatric surgical centres in the UK and Ireland. Participants 301 infants (77%) from an original cohort of 393. Main outcome measures Duration of parenteral nutrition and stay in hospital; time to establish full enteral feeding; rates of intestinal failure, liver disease associated with intestinal failure, unplanned reoperation; case fatality. Results Compared with infants with simple gastroschisis (intact, uncompromised, continuous bowel), those with complex gastroschisis (bowel perforation, necrosis, or atresia) took longer to reach full enteral feeding (median difference 21 days, 95% confidence interval 9 to 39 days); required a longer duration of parenteral nutrition (median difference 25 days, 9 to 46 days) and a longer stay in hospital (median difference 57 days, 29 to 95 days); were more likely to develop intestinal failure (81% (25 infants) v 41% (102); relative risk 1.96, 1.56 to 2.46) and liver disease associated with intestinal failure (23% (7) v 4% (11); 5.13, 2.15 to 12.3); and were more likely to require unplanned reoperation (42% (13) v 10% (24); 4.39, 2.50 to 7.70). Compared with infants managed with primary fascial closure, those managed with preformed silos took longer to reach full enteral feeding (median difference 5 days, 1 to 9) and had an increased risk of intestinal failure (52% (50) v 32% (38); 1.61, 1.17 to 2.24). Event rates for the other outcomes were low, and there were no other significant differences between these management groups. Twelve infants died (4%). Conclusions This nationally representative study provides a benchmark against which individual centres can measure outcome and performance. Stratifying neonates with gastroschisis into simple and complex groups reliably predicts outcome at one year. There is sufficient clinical equipoise concerning the initial management strategy to embark on a multicentre randomised controlled trial comparing primary fascial closure with preformed silos in infants suitable at presentation for either treatment to determine the optimal initial management strategy and define algorithms of care.

Gastroschisis: a national cohort study to describe contemporary surgical strategies and outcomes

Background: A considerable local variability in the rate of bronchopulmonary dysplasia (BPD) has been recorded previously. Objectives: The objectives of the present study were to describe regional differences in the rate of BPD in very preterm neonates from a European population-based cohort and to further delineate risk factors. Methods: 4,185 survivors to 36 weeks’ postmenstrual age of 4,984 live-born infants born at 24+0–31+6 weeks’ gestation in 2003 (the MOSAIC cohort) in 10 European regions were enrolled using predefined structured questionnaires. Results: Overall median gestational age of preterms without BPD was 30 weeks (range 23–31), median birth weight 1,320 g (range 490–3,150) compared with 27 weeks (23–31) and 900 g (370–2,460) in those with BPD. The region-specific crude rate of BPD ranged from 10.2% (Italian region) to 24.8% (UK Northern region). Maternal hypertension, immaturity, male gender, small for gestational age, Apgar <7 and region of care were associated with an increased incidence of BPD on multivariate analysis. Conclusion: A wide variability of BPD between European regions may be explained by different local practices; the strongest association however was with degree of immaturity.