Abstract

Preterm babies are at increased risk of mortality and morbidity. While current medical practice supports extending their hospital stay for further observation, even when they have achieved the physiological requirements for discharge, it is unclear whether prolonging the hospital stay would improve clinical outcomes and be cost-saving in the long term. This study examined the difference in post-discharge costs and outcomes for preterm babies discharged at different days following birth. Finding suggests that once a baby has reached physiological maturity, staying longer (for no other reason than to become more mature) is neither cost-saving in the long term nor does it improve post-discharge clinical outcomes. Background: Once preterm babies have achieved the physiological requirements for discharge, staying longer in hospital solely for the purpose of physical maturation does not save money after discharge nor improve post-discharge outcomes. Babies who are born preterm or small for their gestational age (SGA) are at increased risk of mortality and morbidity. In 2006-2007, over 54,000 lives births in Canadian hospitals involved preterm birth, accounting for approximately 8% of all live births combined. According to a recent report by the Canadian Institute for Health Information (CIHI), the average in-hospital cost associated with preterm babies (<37 weeks) was approximately $9,000 CDN - almost nine times higher than for the average cost for full-term babies, $1,050 CDN. The average in-hospital cost for babies born extremely preterm (<28 weeks) is $85,103 CDN, and can be as high as $109,286 CDN if they are also SGA. Current medical practice supports extending hospital stay for preterm babies, even when they have achieved the physiological requirements for discharge - leading to excess hospital costs. However, it is unclear whether prolonging the hospital stay of physiologically competent preterm babies will actually improve clinical outcomes and be cost-saving in the long term. This study examined the difference in post-discharge costs and outcomes for preterm babies discharged at different days following birth.

Methods: 701 early discharge infants ("early babies") were matched to 701 infants who were discharged 2 to 7 days later ("late babies"). Financial outcomes consisted of in-hospital costs and cost of out-patient medical services following discharge (e.g. diagnostic tests, drugs and medical supplies used, as well as care personnel and room costs for additional days spent in a hospital). Clinical outcomes were based on coherence rank scores, comparing each of the 1,402 babies to all others in terms of physiological maturity (e.g. use of respirator/incubator, body temperature, incidences of apnea and bradycardia, weight, feeding method, and requirements for intravenous fluids). In addition to the level of physical maturity upon discharge, babies were also matched on the length of time required to reach physical maturity. Clinical outcomes of the matched pairs were regressed on matched pair differences in covariates.

Findings: Late babies were physiologically comparable to early babies and there was no difference in formal discharge requirements at the different hospitals. On average, total cost was higher in babies who stayed longer in the hospitals, by approximately $7,624.27 CDN (converted to 2001 Canadian dollars). However, subsequent differences in post-discharge costs (up to 180 days) were not significant, and averaged around $18.24 CDN. There were no significant differences in clinical outcomes between early and late babies; although late babies were ranked slightly, but not significantly, worse than early babies.

Conclusions: Once a preterm baby has achieved the physiological maturity for discharge, staying longer (for no other reason than to become more mature) is not cost-saving in the long term nor does it improve post-discharge clinical outcomes. Since the cost of extended hospital stay does not seem to provide significant benefits, one policy implication for improving neonatal care while reducing health care costs associated with preterm births is to establish uniform guidelines for determining when preterm babies should be discharged.

References

Silber JH, Lorch SA, Rosenbaum PR, Medoff-Cooper B, Bakewell-Sachs S, Millman A, Mi L, Even-Shoshan O, Escobar GJ. Time to send the preemie home? Additional maturity at discharge and subsequent health care cost and outcomes. Health Services Research, 2009.

Canadian Institute for Health Information (CIHI). Too Early, Too Small: A profile of small babies across Canada. Ottawa, ON: CIHI, 2009.