OBJECTIVES: Treating respiratory distress in newborn infants is expensive. This study aims to compare the cost-effectiveness of two common non-invasive therapies, nasal continuous positive airway pressure (CPAP) and nasal high-flow (nHF), for newborns cared for in non-tertiary special care nurseries.

METHODS: The economic evaluation was prospectively planned alongside a randomized control trial conducted in nine Australian non-tertiary special care nurseries all of whom are proficient at using CPAP. 754 newborn infants with respiratory distress, born ≥31 weeks’ gestation and with birth weight ≥1200 g, <24 hours old, requiring non-invasive respiratory support and/or supplemental oxygen for >1 hour were recruited during 2015-2017. Costs were considered from a healthcare sector perspective comprising costs of inpatient stay and inter-hospital transfers, and the time horizon was the first 12 months of age. Hospital inpatient cost records were obtained for 753 infants of whom 676 were included in the per-protocol analysis. Effectiveness outcomes included rate of endotracheal intubation and transfer to a tertiary-level neonatal intensive care unit. The cost-effectiveness of CPAP versus nHF was analyzed using patient-level data under two scenaris: (i) CPAP versus nHF with infants randomized to nHF having ‘rescue’ CPAP back-up available (trial scenario); (ii) CPAP versus nHF with CPAP and nHF as sole primary support (hypothetical scenario).

RESULTS: As sole primary support, CPAP is more effective and on average cheaper and thus is the superior strategy. However, nHF with back-up CPAP produced equivalent cost and effectiveness results, and there is no reason to make a decision between the two treatment algorithms based on the cost or effectiveness outcomes.

CONCLUSIONS: Based on cost-effectiveness evidence from this study, non-tertiary special care nurseries choosing to use only one of the modes as primary respiratory support should choose CPAP. Using nHF as first-line therapy may be acceptable for units with both devices available when nHF has back-up CPAP.