PhD student University of Southern California University of Southern California Los Angeles, California, United States
Background: Some infants with congenital diaphragmatic hernia (CDH) may need advanced life support such as extracorporeal membrane oxygenation (ECMO) for longer than two weeks, which is the time limit arbitrarily set by many centers, to improve survival. The cost-effectiveness of longer duration of extracorporeal membrane oxygenation for these infants is unknown.
Objective: To evaluate the cost-effectiveness of additional weeks on ECMO beyond 2 weeks for newborns with CDH who may have increased survival with longer duration of ECMO.
Design/Methods: A decision tree was used to model the lifetime outcomes from the US societal perspective. Inputs were sourced from literature, the Pediatric Health Information System, and expert opinions. Probability of long-term sequelae, direct medical costs attributable to ECMO use, and long-term comorbidities if survived, indirect costs for the time loss due to the impact of long-term sequelae, and quality-adjusted life years (QALY) were considered. Net monetary benefits were calculated as: (willingness-to-pay per QALY * QALY gain) minus costs. One-way analyses were conducted, and 1,000 Monte Carlo simulations were done in the probabilistic sensitivity analyses to assess the effects of uncertainty.
Results: The lifetime costs per infant with CDH generated from staying on ECMO for <2 weeks, 2-3 weeks, and > 3 weeks are $473,334, $654,771, $1,007,476, respectively (2018 US dollars), and the total QALY gained from each treatment arm are 1.83, 3.6, and 5.05. At the willingness-to-pay of $200,000 per QALY in the base case, the net monetary benefit is -$108,034 for duration < 2 weeks, $64,258 for duration of 2-3 weeks, and $2,955 for duration > 3 weeks. One-way sensitivity analyses showed that the probability of survival at discharge, followed by the initial encounter costs, had the greatest influence on the observed incremental net monetary benefit for all three comparisons in the model. In probabilistic simulations, a duration of <2 weeks is dominated by duration of 2-3 weeks in 65.3% of simulations and dominated by > 3 weeks in 60.2%. A duration of 2-3 weeks is more cost-effective than >3 weeks in 68.6% of simulations. Conclusion(s): 2-3 weeks of ECMO may be the most cost-effective option for CDH infants unable to wean off ECMO at 2weeks. Future research on long-term outcomes of CDH survivors must be conducted to better inform decision-making in the neonatal intensive care unit.
Authors/Institutions: Hanke Zheng, University of Southern California, Los Angeles, California, United States; Cynthia L. Gong, University of Southern California, South Pasadena, California, United States; Rachel L. Chapman, Children's Hospital Los Angeles, Los Angeles, California, United States; Leah Yieh, Children's Hospital Los Angeles, Los Angeles, California, United States; Philippe S. Friedlich, Children's Hospital Los Angeles, Los Angeles, California, United States; Joel Hay, University of Southern California, Los Angeles, California, United States