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Economic evaluation of enhanced staff contact for the promotion of breastfeeding for low birth weight infants |
Rice SJ, Craig D, McCormick F, Renfrew MJ, Williams AF |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness of the enhanced promotion of breastfeeding for infants who were in neonatal units and had low birth weights, defined as 500 to 2,500g. It reported the cost-effectiveness analysis from a health technology assessment (HTA). The authors concluded that the enhanced intervention was highly cost-effective, unless donor milk was exclusively given as a supplement to mothers’ milk. The study followed the recommended methods for HTAs and this should ensure the validity of the authors’ conclusions. Type of economic evaluation Study objective This study examined the cost-effectiveness of enhanced support to promote breastfeeding of infants who were in neonatal units and had low birth weights, defined as 500g to 2,500g. It was a report of the cost-effectiveness analysis from a health technology assessment (HTA) by Renfrew, et al. 2009 (see 'Other Publications of Related Interest' below for bibliographic details). Interventions The breastfeeding promotion consisted of more contact with specially trained staff, who provided individual education, support, and a care plan for mothers of infants in neonatal units. This was compared with the normal staff contact, without nurses who were specifically trained to support breastfeeding mothers. Location/setting UK/hospital (neonatal unit). Methods Analytical approach:The analysis was based on a decision tree with a lifetime horizon. The authors stated that the perspective was that of the UK National Health Service (NHS).
Effectiveness data:The clinical evidence came from a literature review of electronic databases and a manual search of the references of the identified papers. Where more than one study with appropriate data was retrieved, these data were pooled. For example, the distribution of milk consumption between formula, mothers’ milk plus formula or donor milk, and mostly mothers’ milk was from the pooled analysis of data, weighted by sample size, from two US before-and-after studies. Some data were from country-specific statistics. More information was reported in the HTA publication. The key model input was the effectiveness of breastfeeding in reducing the risk of diseases, especially medical necrotising enterocolitis.
Monetary benefit and utility valuations:The utility values were from a published study that was conducted in the Netherlands and used the European Quality of life (EQ-5D) questionnaire.
Measure of benefit:Quality-adjusted life-years (QALYs) were the benefit measure and were discounted at an annual rate of 3.5%.
Cost data:The economic analysis included the following cost categories: intervention, treatment of confirmed necrotising enterocolitis and sepsis, in-patient stay in various wards, and lifetime cost of disability. The resource use data were from published sources, which included studies conducted in the USA for the hospital length of stay for different clinical outcomes. The unit costs were from official price lists, such as the Unit Costs of Health and Social Care, and NHS Reference Costs. All costs were in UK pounds sterling (£) and the price year was 2006. A 3.5% annual discount rate was applied.
Analysis of uncertainty:A probabilistic analysis was undertaken, using pre-determined probability distributions for the model inputs, and cost-effectiveness acceptability curves were generated. Univariate sensitivity analyses were carried out on selected inputs, such as the efficacy of the interventions, use of a hospital midwife rather than a registered nurse, length of hospital stay for clinical outcomes, and the probability of severe disability in the 1,000 to 1,749g weight group compared with the 1,750 to 2,500g weight group. In an alternative scenario, the costs of formula milk, donor milk, and an expression kit were included and these were based on official data and expert communications. Results For the 500 to 999g weight group, the expected costs were £86,759 with enhanced staff contact and £87,345 with normal staff contact. The QALYs were 14.70 with enhanced contact and 14.45 with normal contact. For the 1,000 to 1,749g weight group, the costs were £56,947 with enhanced contact and £57,240 with normal contact. The QALYs were 21.05 with enhanced contact and 21.00 with normal contact. For the 1,750 to 2,500g weight group, the costs were £47,228 with enhanced contact and £47,294 with normal contact. The QALYs were 21.92 with enhanced contact and 21.91 with normal contact.
For all three weight groups, the enhanced intervention was dominant as it was more effective and cheaper.
In the donor milk model (where donor milk was only used as a supplement to mothers' milk), the enhanced intervention was dominant in the 500 to 999g weight group, but the incremental cost per QALY gained over the normal intervention was £34,905 for the 1,750 to 2,500g weight group.
The probabilistic analysis showed that the enhanced intervention was highly likely to be cost-effective at various thresholds. The univariate sensitivity analysis confirmed these base-case findings and the enhanced intervention was dominant in most scenarios. Authors' conclusions The authors concluded that the enhanced intervention was highly cost-effective, unless donor milk was given exclusively as a supplement to mothers’ milk. CRD commentary Interventions:The selection of the comparators was valid as the conventional pattern of care was compared with the enhanced intervention.
Effectiveness/benefits:: A systematic literature review was a valid approach to identify the relevant sources of data. Few details of the methods and conduct of the review were reported as the full HTA report had been published elsewhere. In general, the most appropriate sources of data were used. Multiple values for a single input were pooled, using weighted means, which was a valid method. The authors noted some potential limitations of their analysis and these mainly related to the use of non-UK data for some inputs. QALYs were an appropriate benefit measure, but the authors noted that the health states associated with the utility values did not perfectly match the model health states.
Costs:The categories of costs and the sources of economic data appear to have been consistent with the viewpoint. A list of the cost items was provided and some unit costs and quantities of resources were reported. The authors pointed out that there was a lack of cost estimates for the breast pumps per infant and other items, such as the length of stay and surgery costs. Some US studies had to be used for some resource use data and it is not clear whether these were relevant for the UK context, as acknowledged by the authors. The price year and the use of discounting were clearly reported.
Analysis and results:An incremental analysis was appropriately used to combine the costs and benefits of the two approaches. The results were clearly reported. Appropriate approaches were used to deal with the issue of uncertainty and the analysis of alternative scenarios made the results relevant for different settings. A description of the model was provided and the authors pointed out that it could not take into account the possibility of adverse events, such as the transmission of diseases and infection from expressing, storing, and delivering mothers' milk. Conventional discounting was applied to both costs and benefits.
Concluding remarks:The study followed the recommended methods for HTAs and this should ensure the validity of the authors’ conclusions. Funding Funded by the NIHR Health Technology Assessment programme. Bibliographic details Rice SJ, Craig D, McCormick F, Renfrew MJ, Williams AF. Economic evaluation of enhanced staff contact for the promotion of breastfeeding for low birth weight infants. International Journal of Technology Assessment in Health Care 2010; 26(2): 133-140 Other publications of related interest Renfrew M, Craig D, Dyson L, et al. Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technology Assessment 2009; 13: 1-146. Indexing Status Subject indexing assigned by NLM MeSH Breast Feeding; Cost-Benefit Analysis; Data Collection; Decision Trees; England /epidemiology; Health Care Costs; Humans; Infant; Infant Mortality; Infant, Low Birth Weight; Infant, Newborn; Medical Staff; Professional-Patient Relations; Quality-Adjusted Life Years; Review Literature as Topic; Wales /epidemiology AccessionNumber 22010000946 Date bibliographic record published 04/08/2010 Date abstract record published 29/09/2010 |
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