OBJECTIVES: Inhaled nitric oxide (iNO) improves oxygenation in term or near-term neonates with hypoxic respiratory failure. Early initiation of iNO at an oxygenation index (OI) of 15-19 is cost-effective compared to delayed initiation at an OI ≥25; however, early initiation is often not possible because iNO is not available in all US hospitals. The objective of this model was to compare the cost-effectiveness of early administration of iNO at the birth hospital vs. delayed initiation after transfer to an iNO hospital via helicopter emergency services (HES).

METHODS: The decision analytic model evaluated the costs and effectiveness of early initiation of iNO at the birth hospital vs. transfer to an iNO hospital via HES over a 12-month time horizon from the hospital perspective. Costs included iNO administration, hospital days (neonatal intensive care unit [NICU] and non-NICU), mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and hospital transfer via HES. The primary clinical endpoint was ECMO-free survival to hospital discharge (89.8% for early iNO; 82.6% for delayed iNO). The primary outcome was incremental cost-effectiveness ratio, calculated as the difference in total costs divided by the difference in ECMO-free survival. Costs are reported in 2017 US dollars.

RESULTS: Compared to early initiation of iNO at the birth hospital, HES transfer with delayed initiation was associated with lower iNO costs but higher hospitalization, ECMO, and transport costs. Early initiation of iNO at the birth hospital resulted in a cost savings of $2,607 compared to late initiation of iNO after HES transfer ($146,997 vs $149,604), with an increase in probability of ECMO-free survival of 0.072, and thus was economically dominant.

CONCLUSIONS: Assuming that HES transfer for iNO administration results in delayed initiation, availability of iNO at the hospital of birth is associated with lower costs and improved ECMO-free survival compared to HES transfer for iNO administration.