Cost-effectiveness assessment of a Human Milk Bank

Transcription

1 Cost-effectiveness assessment of a Human Milk Bank Israel Macedo, MD Human Milk Bank - Pediatric Department Maternity Dr Alfredo da Costa, CHLC - Lisbon Rising health care costs 1st Int. Congress EMBA - Lisbon

2 Public health care systems / debt 1st Int. Congress EMBA - Lisbon Portuguese 1st HMB - Lisbon Start, development of the project Start, contacts with Spanish, Brasilian MBN, UKMBA, HMBANA, Iowa HMB; Works, equipment; : OM Project / Procedures & safety check-lists; : OM 1st Edition; 08 / : First donors recruited / First pasteurizations; : First NICU premies received PHM: 1st Int. Congress EMBA - Lisbon

3 Portuguese 1st HMB - Lisbon - Facilities Breastfeeding Area & Doctor s s Office Donor candidates selection: Telephone screening (nurse); Personal interview (nurse, physician); Third trimester serologies HBV, HCV, HIV 1 & 2, Syphilis; Own baby feeding well, increasing weight; Information, support to breastfeeding mothers. Blood collection (after 3 months of donation): By PCR detection - HBV, HCV, HIV 1 & 2; By other techniques - HTLV 1 & 2, Syphilis, AST, ALT; 1st Int. Congress EMBA - Lisbon Portuguese 1st HMB - Lisbon - Facilities Storage & Technical Area Area 30 sq m, air conditioning; Freezers (2) 200 l each, Raw and pasteurized milk, Laminar air flow chamber, Pasteurizer - (8,75 l capacity, automatic), HM Homogeneiser; HM Analyser; Laptop computer, label printer; Containers, etc. 1st Int. Congress EMBA - Lisbon

4 First portuguese HMB - Donors -First year st Int. Congress EMBA - Lisbon First portuguese HMB - Receptors -First year Lisbon HMB: Receptors ( ) Nr Nov Dec Jan Feb Mar Apr Mai Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar st Int. Congress EMBA - Lisbon

5 NICUs in Lisbon area 1st HMB HGO 1st Int. Congress EMBA - Lisbon First portuguese HMB - First year costs: Maintenance 2% Other 9% Sterilization 19% Consumables 2% Staff salaries 11% Carrier 8% Analyzes 49% Total: 71,06 / L 70 donors / Y 1260 L / Y 1st Int. Congress EMBA - Lisbon

6 Rationalize: use reason to alocate resources Cut unnecessary costs: Adequately controlled generics; No routine diagnostic tests / medical investigations;... Keep useful costs: Organization / Safety based on risk assessment; Well proven prevention measures; Evidence based therapies; Savings (short & long term) 1st Int. Congress EMBA - Lisbon Rationalizing costs: Cut unnecessary costs: No need of a surgical instruments sterilization; Too many donors, a lot of them giving very few milk; Too many donors with blood screening / few milk; Many donors start at >4 monts after delivery; Staff may use automation to improve time use;... Keep useful costs: Keep useful costs: Priorize safety and traceability; Help other NICUs start DHM; 1st Int. Congress EMBA - Lisbon

7 Lisbon HMB - Rationalizing costs: Sterilization No need of surgical instruments sterilization & package 1st Int. Congress EMBA - Lisbon Rationalizing costs: Admit donors until 3 monts after delivery; Agree suspension of donation if < 130 ml / day after 2 weeks (with some exceptions); Adopt progessively NICE guidelines: Blood analysis (every 3 / 4 months); Discard batch pooled donor milk if samples exceed 10 5 CFU / ml for total viable microorganisms or 10 4 CFU / ml for Enterobacteriaceae or 10 4 CFU / ml for Staphylococcus aureus. Post pasteurization analysis (every cicle); 1st Int. Congress EMBA - Lisbon

8 First portuguese HMB - Donor nr Donors Nr Jul Set Nov Jan Mar Mai Jul Set Nov Jan Months/Years Mar Mai Jul Set Nov Jan Mar Mai Jul Set Admitted Active 1st Int. Congress EMBA - Lisbon Lisbon HMB - Rationalizing costs: Few milk / Nr of donors Liters Liters of milk / donor - Nr donors 4,0 44 3,8 45 Nr 3,5 3,0 3,0 35 2,5 2,0 1,5 1,0 0,5 24 1,6 0,7 0,8 11 1,8 16 1,2 1,2 0,9 3 1, Q3 Median Q1 Nr of donors 0,0 0,1 0,2 0,0 0,0 0, S S S S S S1-5 1st Int. Congress EMBA - Lisbon

9 First portuguese HMB - 2 nd / 3 rd year costs: Maintenance 2% Other 10% Sterilization 17% Consumables 2% Staff salaries 8% Carrier 7% Analyzes 54% Total: 65 / L 20 donors / Y 445 L / Y 1st Int. Congress EMBA - Lisbon Preterm Human Milk versus PT Formula Premature (VL-ELBW): Comparator: PT Formula Evidence level NEC 34% 1b GI Intolerance 20% 1b Nosocomial sepsis 3% 2a Catherine AB. Meta-analysis 2007 Quigley M.Cochrane Syst. Ver Schanler RJ. RCT (n=273) 2005 McGuire. Systematic review st Int. Congress EMBA - Lisbon

10 Evidence ence: Pasteurized ed PT Formula (1) (very preterm NB) PTF: Increased risk of NEC RR 2,5 [IC 95% 1,2-5,1] Mortality of NEC ± 22 % PTF: Better growth in short term, No difference at m and 7-8 y, No difference in neurodevelopment. (Cochrane 2008: 8 RCT) 1st Int. Congress EMBA - Lisbon Evidence ence: Pasteurized ed PT Formula (2) (very preterm NB) PHM as trophic feeding: Better tolerance. PHM as MM supplement: Protection from NEC and sepsis. (Ziegler E. 2008) More studies needed: Better PHM Fortification vs PTF ( growth and sepsis). 1st Int. Congress EMBA - Lisbon

11 Lisbon HMB (VLBW population) Comparison before (2y) / after (2y) HMB Surgical NEC and Nosocomial sepsis % Before HMB NEC (surgical) p=0,118 2 After HMB (3y) % Before HMB Sepsis, late p=0,78 35 After HMB (3y) 1st Int. Congress EMBA - Lisbon Impact in our NICU (VLBW infants) Median Nr of VLBW infants / year: 150 to 160 Cases of Surgical NEC (Nr/y): Before HMB: After HMB: Mortality from Surgical NEC (Nr/y): Before HMB: 2 10,5 3 to 5 After HMB: 0,6 to 1,5 Surgery (Nr/y): Before HMB: After HMB: Short gut (Nr/y): Before HMB: After HMB: 5,3 2,5 0,5 0,23 1st Int. Congress EMBA - Lisbon

12 Estimation of impact in our NICU (VLBW infants) Impact of NEC reduction: Increase in LOS (total days/year): Before HMB: After HMB: Gain in LOS (days/year): QALY lost (Death and short gut): Before HMB: 188 to 435 After HMB: 62 to 130 Gain in Quality Adjusted Life Years: 126 to 305 1st Int. Congress EMBA - Lisbon Estimation of impact in our NICU (VLBW infants) Assumptions - Average preterm: Costs: Has a median BW of (g): Has a median LOS (days): Has a median discharge weight (g): Starts EF on day 2 with (ml/day): On discharge is fed with (ml/day): Milk is fortified when > 100 ml/kg/day Total amount of milk / baby (ml): 8120 Donor milk is used in 50% of LOS days / babies Amount of DHM / year (liters): ,00 Cost of fortifier in DHM fed infants: Total cost of DHM fed infants: , ,00 1st Int. Congress EMBA - Lisbon

13 Estimation of impact in our NICU (VLBW infants) Cost of the "gains": Cost of each day of stay (LOS) gained: 549,00 Cost of each QALY gained: 492,00 to 203,00 1st Int. Congress EMBA - Lisbon Conclusions: In a 3 years period, there was a decrease in the incidence of NEC, but p > 0,05; Assuming a tendency, The DHM cost of the gained LOS is lower than the real LOS daily cost; The gained QALY costs 203 to 492 ; The use of DHM seems very cost-efective. 1st Int. Congress EMBA - Lisbon

14 Thank you for your attention! 1st Int. Congress EMBA - Lisbon