Impact of Very Preterm Birth on Health Care Costs at
Five Years of Age
WHAT’S KNOWN ON THIS SUBJECT: The hospitalization costs for very preterm infants are high during the first year of life and have been shown to decrease markedly with age. Few studies, however, have evaluated other health care–related costs in children who were born very preterm.
WHAT THIS STUDY ADDS: This study demonstrates that although the costs of hospitalizations decrease with age in very preterm children, other health care–related costs, such as costs for social welfare services and therapies, increase and thereby become more considerable.
abstract
OBJECTIVE:We assessed the effects of very preterm birth (gestational age ⬍32 weeks or birth weight ⬍1501 g) and prematurity-related morbidities on health care costs during the fifth year of life.
METHODS:The study population consisted of 588 very preterm chil-dren and 176 term control subjects born in 2001–2002. Costs of hospi-talizations, visits to health care professionals and therapists, and the use of other social welfare services were assessed during the fifth year of life. Hospital visits were derived from register data and other health care contacts, and the use of social welfare services were derived from parental reports. The effects of 6 prematurity-related morbidities (ce-rebral palsy [CP], seizure disorder, obstructive airway disease, hear-ing loss, visual disturbances or blindness, and other ophthalmologic problems) on the costs of health care were studied.
RESULTS:The average health care costs during the fifth year of life were 749€in the term control subjects, 1023€in the very preterm children without morbidities, and 3265€in those with morbidities. The costs of social welfare services and therapies exceeded the hospital-ization costs in all groups. Among children who were born preterm, CP was associated with 5125€ higher costs, whereas later obstructive airway diseases increased the costs by 819€compared with individu-als without these morbidities.
CONCLUSIONS:The health care costs during the fifth year of life in very preterm children with morbidities were 4.4-fold and in those without morbidities 1.4-fold compared with those of term control subjects. This emphasizes the importance of prevention of morbidities, especially CP, to reduce the long-term costs of prematurity. Pediatrics 2010;125: e1109–e1114
AUTHORS:Emmi Korvenranta, MD, MSc,aLiisa Lehtonen,
MD, PhD,aLiisi Rautava, MD,aUnto Ha¨kkinen, PhD,bSture
Andersson, MD, PhD,cMika Gissler, PhD,bMikko Hallman,
MD, PhD,dJaana Leipa¨la¨, MD, PhD,bMikko Peltola, MSc,b
Outi Tammela, MD, PhD,eand Miika Linna, PhD,bfor the
PERFECT Preterm Infant Study Group
aDepartment of Pediatrics, Turku University Hospital, Turku,
Finland;bNational Institute for Health and Welfare, Helsinki,
Finland;cDepartment of Pediatrics, Hospital for Children and
Adolescents, Helsinki, Finland;dDepartment of Pediatrics, Oulu
University Hospital, Oulu, Finland; andeDepartment of
Pediatrics, Tampere University Hospital, Tampere, Finland
KEY WORDS
cost analysis, health service use, hospitalizations, preterm infants, very low birth weight
ABBREVIATIONS
GA— gestational age PT—physiotherapist OT— occupational therapist CP— cerebral palsy
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2882
doi:10.1542/peds.2009-2882
Accepted for publication Jan 6, 2010
Address correspondence to Emmi Korvenranta, MD, MSc, Turku University Hospital, Department of Pediatrics, Kiinamyllynkatu 4-8, 20520 Turku, Finland. E-mail: emmi.korvenranta@utu.fi
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE:The authors have indicated they have no financial relationships relevant to this article to disclose.
and the costs increase with decreas-ing gestational age (GA) and birth weight.2–5In addition, very preterm in-fants continue to need more health care services than term infants later in childhood.6–9During the first 3 years of life, the need for hospital care clearly decreases more in very preterm chil-dren without prematurity-related mor-bidities than in very preterm children with these morbidities.10
Only a few studies have explored the costs of hospitalizations of very pre-term children after the first year of life, and other health care costs have barely been evaluated. In the study by Petrou et al,8the hospitalization costs significantly decreased after the first year. The fifth-year costs amounted to 1% to 2% of the costs of the first year of life8; however, the costs at 11 years of age were still higher in extremely pre-term children compared with the con-trol children when including also edu-cational and social welfare costs.11Our study on the total hospitalization costs during the first 4 years of life for chil-dren who were born very preterm showed similar results: the initial hos-pital costs composed 79% of the total costs, and thereafter the costs de-creased each year.12In addition, indi-viduals with prematurity-associated morbidities used significantly more hospital resources during the first 4 years of life than those without these morbidities.
Mangham et al13recently modeled the costs of preterm birth to the public sector during the first 18 years of life and concluded that the initial hospital stay composes 92% of the incremental costs per preterm survivor. Because prematurity is associated with in-creased chronic morbidity and disabil-ity,14–16costs other than hospitalization should be taken into account. The aim of our study was to assess the costs of
and therapies during the fifth year of life for very preterm infants and com-pare them with the costs of healthy control subjects. We hypothesized that the need and costs for all health care resources are significantly higher for children who were born very preterm with prematurity-associated morbidi-ties compared with children without these morbidities.
METHODS
The study protocol was approved by the ethics committee of the National Institute for Health and Welfare.
Study Population
We included all surviving children who were born at ⬍32 weeks’ GA or had a birth weight⬍1501 g during 2001– 2002 in Finnish hospitals that have level 2 or 3 NICUs as defined by the American Academy of Pediatrics
Com-mittee on Fetus and Newborn.17
Healthy gender-matched term infants (GA 38 – 42 weeks) who were born next after every third study infant in the same delivery hospital were selected for control subjects. Those with incom-plete Medical Birth Register or Hospi-tal Discharge Register data (n⫽181) and those who were born at a hospital with ⬍3 very preterm deliveries in 2001–2002 (n⫽4) were excluded from the analysis. A total of 23 children who were born very preterm and 13 control subjects were excluded because they were living abroad or had a missing address. Infants who were admitted to the NICU during the first 7 days of life were excluded from the control group. The final study population consisted of 901 very preterm children and 368 con-trol subjects.
Data Collection
Register data used in this study were collected from the National Medical Birth Register and the Hospital
Dis-Welfare. The Hospital Discharge Regis-ter contains data on all inpatient and outpatient hospital visits in Finland. A parental questionnaire was sent 0.5 to 1.5 months before the child’s fifth birthday, and 2 reminders were sent 1.5 and 2.5 months thereafter if needed. The questionnaire enquired about any long-term diagnoses of the child, the number of visits to various health care professionals during the last 12 months, the family structure, and parental education and current employment. The parents of 588 (65% of all surviving) children who were born very preterm and 176 (46%) con-trol subjects returned the question-naire. A dropout analysis (Table 1) showed no systematic bias in the study population.18
The study individuals were defined as having a prematurity-related morbid-ity whenⱖ1 of the studied morbidities, which have been shown to be overrep-resented in preterm populations, were reported at least once to the Hospital Discharge Register by the end of 2006. The morbidities and theInternational Statistical Classification of Diseases and Related Health Problems, 10th Re-visioncodes of the morbidities are pre-sented in Table 2.
Diagnoses for both inpatient and out-patient visits in hospitals were re-corded. On the basis of the health care system in Finland, diagnoses of these disease groups can be reliably derived from hospital registers, because these diseases are diagnosed and treated in specialized care in public hospitals. There are no private children’s hospi-tals in Finland. The diagnoses from the register data were in accordance with the diagnoses reported by the parents, which support the validity of the regis-ter data.18
hospitaliza-tion were collected from 4 hospitals: 1 level 3 hospital and 3 level 2 hospitals. The costs for hospital stays were esti-mated for those with missing cost data on the basis of the type of visits (emer-gency outpatient visit, nonemer(emer-gency outpatient visit, and inpatient hospital visit) and the child’s age at the time of the visit. The costs for municipal health and social welfare services were cal-culated according to reference costs determined by the National Institute for Health and Welfare.19
Statistical Analyses
We analyzed the number of visits during the fifth year of life to a (1) physi-cian, (2) nurse practitioner, (3) phy-siotherapist (PT) or occupational ther-apist (OT), (4) psychologist, (5) speech therapist, (6) dietician, and (7) other services (family support clinic, family adaptation courses, training in sign
language, home visits, and use of com-munal transfer services) on the basis of the parental questionnaire re-sponses. The number of inpatient days was received from the register data, as well as the number of nonemer-gency and emernonemer-gency outpatient visits to specialized health care. The register data on hospital visits and the parental reports on the contacts with other health and social care professionals and use of other municipal resources were combined with the cost data to obtain a net cost per child during the fifth year of life. The patient-level data were linked by means of unique en-crypted identification codes.
We analyzed the costs and the number of visits according to GA groups (23 weeks, 24 –25 weeks, 26 –27 weeks, 28 –29 weeks, 30 –31 weeks, ⱖ32 weeks, or term) and according to the presence of the morbidities in the very preterm population (no morbidities,
ⱖ1 prematurity-related morbidity). Analysis of variance was used to de-tect cost differences between these groups.P⬍.05 was considered signif-icant. In addition, we used a general-ized linear model with␥distribution to analyze the effect of morbidities on the costs of health care use during the fifth year of life. The model was ad-justed for gender, GA at birth, intra-uterine growth (small, appropriate, or large for GA), and multiple pregnancy. The marginal effect describes how the presence of the studied morbidities
af-fects the costs during the fifth year of life. The costs are presented in 2008 prices, and the discount rate was 3% per year. The analyses were per-formed with SAS 9.1 (SAS Institute, Cary, NC) and Stata 9 (Stata Corp., Col-lege Station, TX).
RESULTS
Of the very preterm children, 68% did not have any of the studied morbidi-ties. The number of visits to health care specialists and the number of hospital days are presented in Table 3. The most common health care contact in all study individuals was with a phy-sician in either the public or the pri-vate sector. Very preterm children with prematurity-related morbidities had more contacts with all health care professionals except nurse practitio-ners compared with children without these morbidities.
The average total health care costs during the fifth year of life amounted to 749€in control subjects, 1023€in very preterm children without prematurity-related morbidities, and 3265€ in those with ⱖ1 of these morbidities (Table 4). Thus, the costs of preterm children without prematurity-related morbidities were 1.4-fold higher than the costs of term control subjects; however, the costs of the preterm chil-dren with morbidities were 4.4-fold higher compared with those of the term control subjects. They composed 61% of the total costs in the very pre-TABLE 1 Background Variables of Responders and Nonresponders in the Very Preterm Children
Variable Responders Nonresponders OR 95% CI
Maternal age, mean⫾SD, y 30.7⫾5.8 30.2⫾6.3 0.980 0.960 to 1.010
Maternal smoking during pregnancy (yes), % 14 24 1.930 1.310 to 2.830
Multiple birth, mean⫾SD, No. of children 1.3⫾0.5 1.4⫾0.6 2.100 1.530 to 2.820
Female gender, % 43 53 1.360 1.002 to 1.850
Birth weight, g (OR per increase of 100 g), mean⫾SD 1249⫾382 1307⫾403 1.050 0.997 to 1.110
GA, weeks and days (OR per increase of 1 wk), mean⫾SD 295⁄7
⫾23⁄7
296⁄7
⫾24⁄7
1.070 0.980 to 1.170
No. of emergency visits at special health care from birth to 5 y, mean⫾SD 2.4⫾3.0 3.1⫾4.3 1.040 0.991 to 1.090
No. of other visits at special health care from birth to 5 y, mean⫾SD 20.8⫾19.9 22.6⫾23.0 1.003 0.999 to 1.010
Hospitalized or institutionalized from birth to 5 y, days to 5 y, mean⫾SD 68.4⫾39.5 76.3⫾69.8 1.003 0.994 to 1.010
None of the studied morbidities, % 68 65 0.850 0.650 to 1.130
OR indicates odds ratio; CI, confidence interval.
TABLE 2 Prematurity-Related Morbidities and Their ICD-10 Codes
Morbidity ICD-10 Codes
CP G80–83
Seizure disorder G40–47
Later obstructive airway disease (including asthma and other obstructive airway diseases)
J44–J45
Hearing loss H90–91
Visual disturbances or blindness H53–54 Other ophthalmologic problems
(including disorders of ocular muscles, binocular movement, accommodation, and refraction)
H49–52
ICD-10 indicatesInternational Statistical Classification of Diseases and Related Health Problems, 10th Revision.
term population. The mean costs of all cost categories except the visits to the nurse practitioner were lower for very preterm children without prematurity-related morbidities compared with those with prematurity-related morbidities.
The costs of hospital care composed only 33% of the total costs in the very preterm population. The costs for ther-apies (PT/OT, psychologist, speech therapy) composed 44% of the total costs in the very preterm children with morbidities, 27% in those who were born very preterm without morbidi-ties, and 30% in the control subjects. The hospital inpatient and outpatient costs composed 37% of the total costs in very preterm infants with morbidi-ties, 34% in those without morbidimorbidi-ties, and 17% in the control subjects. The
costs decreased with increasing GA (Fig 1).
Among children who were born very preterm, cerebral palsy (CP) was asso-ciated with 5127€ higher costs; later obstructive airway diseases increased the costs by 819€compared with indi-viduals without these morbidities. The cost increases that were attributed to each disease group according to the generalized linear model are pre-sented in Table 5. In addition, the aver-age cost for boys was 450€higher than for girls (P⫽.019).
DISCUSSION
The two-thirds of very preterm infants who survive without prematurity-related long-term morbidities in-curred only a little more health care–
related cost than their term peers; however, prematurity-related morbid-ities were still associated with a signif-icant cost burden during the fifth year of life. These costs were created espe-cially by PT/OT visits, nonemergency outpatient hospital visits, and inpa-tient hospital care.
The yearly hospitalization costs, which were 623€per child for very preterm children, were lower during the fifth year of life compared with third and fourth years of life (1179€and 776€, respectively12); however, the costs for therapies, primary care, and visits to private practitioners during the fifth year of life exceeded the costs for hos-pitalizations in all of the 3 study groups. It seems, thus, that although the costs of hospitalizations decrease with age in children who are born very preterm, other health care–related costs, such as costs for social welfare services and therapies, increase and thereby become more considerable; therefore, measuring only hospitaliza-tion costs will significantly underesti-mate the later costs of prematurity.
Morbidities, especially CP, increased greatly the costs of the very preterm population during the fifth year of life. Parallel to our results, Stevenson et al20showed in a small regional cohort of low birth weight children that chil-dren with disabilities accounted for a disproportionately high amount of the
Parameter No. of Visits (*days), mean (median)
No Morbidities
(n⫽400)
ⱖ1 Morbidity (n⫽188)
GA Term
(n⫽176) 23
(n⫽5)
24–25 (n⫽57)
26–27 (n⫽73)
28–29 (n⫽149)
30–31 (n⫽231)
ⱖ32 (n⫽73)
Emergency outpatient 0.1 (0.0) 0.2 (0.0) 0.6 (0.0) 0.2 (0.0) 0.3 (0.0) 0.1 (0.0) 0.1 (0.0) 0.20 (0.00) 0.1 (0.0)
Nonemergency outpatient 0.6 (0.0) 3.1 (2.0) 4.2 (6.0) 3.0 (2.0) 3.1 (2.0) 1.5 (0.0) 0.8 (0.0) 0.50 (0.00) 0.3 (0.0)
Hospitalizations, d 0.2 (0.0) 0.3 (0.0) 3.0 (0.0) 0.3 (0.0) 0.4 (0.0) 0.1 (0.0) 0.2 (0.0) 0.01 (0.00) 0.1 (0.0)
Other physician visits (primary care and private)
3.3 (2.0) 4.4 (4.0) 3.0 (3.0) 4.0 (3.5) 4.3 (4.0) 3.9 (3.0) 3.5 (3.0) 3.00 (2.00) 3.6 (2.0)
PT/OT 1.1 (0.0) 18.1 (0.0) 9.8 (0.0) 12.8 (0.5) 16.2 (0.0) 8.5 (0.0) 3.5 (0.0) 0.10 (0.00) 0.7 (0.0)
Psychologist 0.2 (0.0) 0.5 (0.0) 0.2 (0.0) 0.3 (0.0) 0.4 (0.0) 0.4 (0.0) 0.3 (0.0) 0.10 (0.00) 0.2 (0.0)
Nurse practitioner 1.0 (1.0) 1.0 (1.0) 1.4 (1.0) 1.0 (1.0) 0.9 (1.0) 0.9 (1.0) 1.0 (1.0) 1.40 (1.00) 0.8 (1.0)
Speech therapist 1.7 (0.0) 3.0 (0.0) 27.2 (5.0) 3.5 (0.0) 3.0 (0.0) 2.1 (0.0) 1.2 (0.0) 0.90 (0.00) 1.6 (0.0)
TABLE 4 Costs of Visits to Hospitals and Health Care Professionals During the Fifth Year of Life According to Morbidities in the Very Preterm Population and the term Control Population
Parameter Costs, mean (median),€ P
No Morbidities (n⫽400)
ⱖ1 Morbidity (n⫽188)
Term (n⫽176)
ⱖ1 Morbidity Versus No Morbidities
No Morbidities Versus Controls
Emergency outpatient 18 (0) 48 (0) 12 (0) .0005 NS
Nonemergency outpatient 157 (0) 814 (524) 73 (0) ⬍.0001 ⬍.0001
Hospitalizations, d 170 (0) 356 (0) 41 (0) .0055 NS
Other physician (primary care and private)
332 (244) 443 (356) 296 (237) .0007 NS
PT/OT 103 (0) 1108 (0) 67 (0) ⬍.0001 .0063
Psychologist 46 (0) 109 (0) 40 (0) ⬍.0001 NS
Nurse 55 (54) 52 (54) 42 (54) NS NS
Speech therapist 124 (0) 233 (0) 117 (0) .0194 .0070
Other 18 (0) 103 (0) 62 (0) ⬍.0001 NS
Total 1023 (423) 3265 (1368) 749 (291) ⬍.0001 .0008
total expenditure (hospital inpatient and outpatient care, visits to general practi-tioner, special education services) up to age 8 to 9 years. Similarly, Petrou et al8 showed that several different morbidity groups were associated with higher costs during the first year of life, but the study focused merely on the costs of hos-pitalization. Thus, calculating the cost-effectiveness of care of all very preterm infants as 1 group can be misleading, be-cause there is now evidence that chil-dren who are born very preterm without prematurity-related morbidities do not cause significant additional costs for public services after the initial hospital-ization compared with infants who are born healthy at term. In contrast, individ-uals with prematurity-related morbidi-ties not only consume more health care resources but also induce more social and productivity costs. For example, in a recent Danish study21 on the lifetime
costs of CP, two-thirds of individuals with CP never entered the labor market, and the average lifetime cost of CP was cal-culated to be 860 000€ for men and 800 000€for women, the social costs ac-counting for the majority of the costs. These facts underline the importance of effective perinatal care to prevent CP in the preterm population. The cost-effectiveness of primary prevention of CP in perinatal care should be evaluated carefully to attain optimal use of re-sources.
The major strength of this study is the use of data on true hospital visits for the whole population, because all hospital care in Finland is comprehensively regis-tered in the national registers.22By using a national cohort of preterm infants as a study population, the selection bias in studies that are based on a smaller geo-graphic region or a single hospital is
avoided. We defined the 6 most common prematurity-related morbidity groups. Very preterm infants may also have other morbidities; however, because the costs in the very preterm group without morbidities were very similar to the costs in the term group, it can be as-sumed that these 6 groups include the diseases and conditions that entail the most resource use.
A limitation of this study could be that the data on the use of therapies and social welfare services obtained from the ques-tionnaires rely on parental recall; how-ever, because the study period was 1 year only, we assume that the parents remembered the health care and ther-apy contacts well, especially when there were only a few contacts in most cases. In addition, the morbidities documented by the parents were in accordance with the morbidities from the registers, which supports the validity of the data from the parental reports. Another po-tential limitation is that the hospitaliza-tion costs were calculated according to data from 4 hospitals, so we did not have actual cost data for all of the hospitaliza-tions; however, it is unlikely that the costs would differ significantly between hospitals because all hospitalizations oc-curred in the public sector, because there are no private children’s hospitals in Finland. Because Finnish children start school at 7 years of age, the special education costs do not exist yet at 5 years of age. Although all other early in-tervention is included, it is likely that spe-cial education will add the cost burden in later childhood.
Despite that costs for social welfare ser-vices and therapies exceeded the hospi-talization costs in our study, the total costs during the fifth year of life were still low compared with the initial hospi-talization costs, which were 54 000€in the same very preterm population.12This is in accordance with previous studies, which showed that the use of health care resources declines with in-FIGURE 1
Mean health care–related costs during the fifth year of life according to GA. (Those born at 23 weeks’ GA were excluded from the figure because of the small number [5] of individuals.)
TABLE 5 Generalized Linear Model on the Effect of Morbidities on the Total Costs of Care During the Fifth Year of Life in Very Preterm Infants (N⫽588)
Morbidity n Marginal
Effect,€
95% CI P
Other ophthalmologic problems 81 464 ⫺312 to 1241 0.187
Visual disturbances or blindness 26 1217 ⫺613 to 3047 0.079
Hearing loss 8 167 ⫺1785 to 2118 0.859
Later obstructive airway diseasea 115 819 148 to 1490 0.004
Seizure disorder 16 907 ⫺1125 to 2939 0.264
CPa 26 5127 711 to 9543 ⬍0.001
hospitalization costs and, in particu-lar, the initial hospital stay compose the great majority of the total costs of care of very preterm infants.
CONCLUSIONS
The health care–related costs during the fifth year of life in very preterm children
children who were born term; however, the costs of the very preterm children with morbidities, especially CP, were 4.4-fold higher compared with those of the very preterm children without prematurity-related morbidities. Addi-tional prevention of morbidities such as CP would thus significantly reduce the
mating the costs of prematurity after the first year of life, one should calculate not only the hospitalization costs but also other costs for social welfare services, primary care, and therapies, because these exceed the hospitalization costs in very preterm infants during the fifth year of life.
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DOI: 10.1542/peds.2009-2882 originally published online April 5, 2010;
2010;125;e1109
Pediatrics
Linna and for the PERFECT Preterm Infant Study Group
Mika Gissler, Mikko Hallman, Jaana Leipälä, Mikko Peltola, Outi Tammela, Miika
Emmi Korvenranta, Liisa Lehtonen, Liisi Rautava, Unto Häkkinen, Sture Andersson,
Impact of Very Preterm Birth on Health Care Costs at Five Years of Age
Services
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DOI: 10.1542/peds.2009-2882 originally published online April 5, 2010;
2010;125;e1109
Pediatrics
Linna and for the PERFECT Preterm Infant Study Group
Mika Gissler, Mikko Hallman, Jaana Leipälä, Mikko Peltola, Outi Tammela, Miika
http://pediatrics.aappublications.org/content/125/5/e1109
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![FIGURE 1Mean health care–related costs during the fifth year of life according to GA. (Those born at 23 weeks’GA were excluded from the figure because of the small number [5] of individuals.)](https://thumb-us.123doks.com/thumbv2/123dok_us/9453766.1473736/5.594.53.379.318.404/figure-health-related-fth-according-excluded-gure-individuals.webp)
