Cost-Effectiveness of Intensive and Local Neonatal Care Units in England: A Real-World Evidence Analysis of a National Birth Cohort

OBJECTIVES: To compare the costs and effects of care provided to very preterm babies born 27 to 31 weeks gestation in neonatal intensive care units (NICU) with care provided to those born in local neonatal units (LNU).

METHODS: The analysis used data from the National Neonatal Research Database (NNRD) on 18,612 babies admitted to neonatal units in England between 2014 and 2018. Data on the daily levels of neonatal care provided to each baby and on key health care interventions were costed using unit costs from established sources. Survival status at neonatal unit discharge was the measure of health outcome. To facilitate the comparison of NICU and LNU settings, an instrumental variable approach to account for unmeasured confounders with adjustment for measured confounders was estimated. Excess travel time defined as the difference in the distances between the mother’s residential postcode and her nearest NICU postcode, and the mother’s residential postcode and her nearest LNU postcode was used as the instrument. Linear two-stage least squares for costs and seemingly unrelated bivariate probit regression for mortality were employed.

RESULTS: No difference in mortality was observed between settings, however the mean cost of babies managed in NICU (£45,860 SE=£313) was lower than the cost of babies managed in LNU (£48,393, SE=£386) (mean cost difference -£2,534; 99% CI: -£4,096 to -£971). Costs were only significantly lower for babies born in NICU at later gestations (30 and 31 weeks) and were driven by shorter duration of higher level of care.

CONCLUSIONS: Shifting the care of less sick preterm babies to NICU beds to save costs is likely to be logistically difficult and controversial. Instead, research should focus on the reasons for the differences in the durations of intensive care observed between settings with a view to better aligning practices and safely reducing costs.