Cost-effectiveness of strategies that are intended to prevent kernicterus in newborn infants

Objective. There is concern about an increasing incidence of kernicterus in healthy term neonates in the United States. Although the incidence of kernicterus is unknown, several potential strategies that are intended to prevent kernicterus have been proposed by experts. It is necessary to assess the costs, benefits, and risks of such strategies before widespread policy changes are made. The objective of this study was to determine the direct costs to prevent a case of kernicterus with the following 3 strategies: ( 1) universal follow-up in the office or at home within 1 to 2 days of early newborn discharge, ( 2) routine predischarge serum bilirubin with selective follow-up and laboratory testing, and ( 3) routine predischarge transcutaneous bilirubin with selective follow-up and laboratory testing. Methods. We performed an incremental cost-effectiveness analysis of the 3 strategies compared with current practice. We used a decision analytic model and a spreadsheet to estimate the direct costs and outcomes, including the savings resulting from prevented kernicterus, for an annual cohort of 2 800 000 healthy term newborns who are eligible for early discharge. We used a modified societal perspective and 2002 US dollars. With each strategy, the test and treatment thresholds for hyperbilirubinemia are lowered compared with current practice. Results. With the base-case assumptions ( current incidence of kernicterus 1: 100 000 and a relative risk reduction [RRR] of 0.7 with each strategy), the cost to prevent 1 case of kernicterus was $10 321 463, $5 743 905, and $9 191 352 respectively for strategies 1, 2, and 3 listed above. The total annual incremental costs for the cohort were, respectively, $202 300 671, $112 580 535, and $180 150 494. Sensitivity analyses showed that the cost per case is highly dependent on the population incidence of kernicterus and the RRR with each strategy, both of which are currently unknown. In our model, annual cost savings of $46 179 465 for the cohort would result with strategy 2, if the incidence of kernicterus is high ( 1: 10 000 births or higher) and the RRR is high (greater than or equal to0.7). If the incidence is lower or the RRR is lower, then the cost per case prevented ranged from $4 145 676 to as high as $77 650 240. Conclusions. Widespread implementation of these strategies is likely to increase health care costs significantly with uncertain benefits. It is premature to implement routine predischarge serum or transcutaneous bilirubin screening on a large scale. However, universal follow-up may have benefits beyond kernicterus prevention, which we did not include in our model. Research is required to determine the epidemiology, risk factors, and causes of kernicterus; to evaluate the effectiveness of strategies intended to prevent kernicterus; and to determine the cost per quality-adjusted life year with any proposed preventive strategy.