RESUMO
OBJECTIVE: To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight. STUDY DESIGN: We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212. RESULTS: The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization. CONCLUSIONS: Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.
Assuntos
Parto Obstétrico/economia , Custos Hospitalares/estatística & dados numéricos , Hospitalização/economia , Assistência Perinatal/economia , California , Feminino , Humanos , Recém-Nascido , Tempo de Internação/economia , Mães , Alta do Paciente , Gravidez , Estudos RetrospectivosRESUMO
OBJECTIVE: In 1976, the Committee on Perinatal Health recommended that hospitals with no neonatal intensive care unit (NICU) or intermediate NICUs transfer high-risk mothers and infants that weigh <2000 g to a regional NICU. This standard was based on expert opinion and has not been validated carefully. This study evaluated the effect of NICU level and patient volume at the hospital of birth on neonatal mortality of infants with a birth weight (BW) of <2000 g. METHODS: Birth certificates of 16 732 singleton infants who had a BW of <2000 g and were born in nonfederal hospitals in California in 1992 and 1993 were linked to death certificates and to discharge abstracts. The hospitals were classified by the level of NICU: no NICU, no intensive care; intermediate NICU, intermediate intensive care; community NICU, expanded intermediate intensive care; and regional NICU, tertiary intensive care. A logistic regression model that controlled for demographic risks, diagnoses, transfer, average NICU census, and NICU level was estimated using death within the first 28 days or first year of life if continuously hospitalized as the main outcome measure. RESULTS: Compared with birth in a hospital with a regional NICU, risk-adjusted mortality of infants with BW of <2000 g was higher when birth occurred in hospitals with no NICU (odds ratio [OR]: 2.38; 95% confidence interval [CI]: 1.81-3.13), an intermediate NICU (OR: 1.92; 95% CI: 1.44-2.54), or a small (average census <15) community NICU (OR: 1.42; 95% CI: 1.14-1.76). Risk-adjusted mortality for infants who were born in hospitals with a large (average census > or =15) community NICU was not statistically different compared with those with a regional NICU (OR: 1.11; 95% CI: 0.87-1.43). Except for large community NICUs, all of these ORs are larger when the data are restricted to infants with BW of <1500 g or BW of <1250 g and smaller for BW between 1250 g and 1999 g and 1500 g and 1999 g. For large community NICUs, the results are similar for the smaller BW intervals and significant only for the larger BW interval. CONCLUSIONS: These results support the recommendation that hospitals with no NICU or intermediate NICUs transfer high-risk mothers with estimated fetal weight of <2000 g to a regional NICU. For infants with BW of <2000 g, birth at a hospital with a regional NICU is associated with a lower risk-adjusted mortality than birth at a hospital with no NICU, intermediate NICU of any size, or small community NICU. Subsequent neonatal transfer to a regional NICU only marginally decreases the disadvantage of birth at these hospitals. The evidence for the few hospitals with large community NICUs is mixed. Although the data point to higher mortality in large community NICUs, they are not conclusive and additional study is needed on the mortality effects of large community NICUs. Greater efforts should be made to deliver infants with expected BW of <2000 g at hospitals with regional NICUs.