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National Guideline Alliance (UK). Developmental follow-up of children and young people born preterm. London: National Institute for Health and Care Excellence (NICE); 2017 Aug. (NICE Guideline, No. 72.)
Surveillance strategies are used in preterm children to identify any developmental problems and disorders that might arise. More intensive surveillance strategies enable problems and disorders to be identified earlier but an increase the frequency or number of surveillance strategies can have significant resource implications. Therefore, there is a need to balance the clear benefits of earlier detection against the costs of surveillance when deciding upon the optimal surveillance strategy.
I.1. Objective
The analysis aims to estimate the resource impact associated with an enhanced surveillance strategy for preterm children.
I.2. Review of the literature
A systematic review of the economic literature was conducted but no relevant studies were identified which investigated the resource implications of enhanced surveillance methods for preterm children.
I.3. Methods
A resource impact analysis was developed in Microsoft Excel®. The analysis was conducted from the perspective of the NHS and Personal Social Services (PSS) as outlined in the NICE Reference Case (The guidelines manual, NICE October 2014).
I.3.1. Surveillance strategies
The analysis focuses on the assessment at 4-years of age for children born before 28+0 weeks’ gestation. This was identified by the Committee as a time point where changes could be made to current practice to enhance the current surveillance strategy.
In current practice, it was assumed that assessments were not routinely undertaken at four years of age for children born before 28+0 weeks’ gestation. In the enhanced surveillance strategy, it was assumed that the strengths and difficulties questionnaire (SDQ) and the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) test would be used. The assessment would involve a clinical psychologist and a paediatrician.
Note that while current practice has been estimated for the purposes of the analysis, it is recognised that there is variation in practice and the most commonly used strategy is not definitively known. Therefore, this has been identified as an area of uncertainty and will be subject to changes in sensitivity analysis where alternative strategies will be used to represent current practice.
I.3.2. Population estimates
The number of preterm children that would be assessed at 4 years of age was estimated using data on the number of live births by gestational age in England and Wales in 2015 from the Office for National Statistics (ONS). To estimate the number of children that would be alive at the assessment time points, mortality rates were applied to the live birth data. Infant mortality rates were estimated from the total number of infant deaths (occurring up to one year after birth) in England and Wales in 2013 from the ONS (note that this was the most recent data available).
Mortality from other causes in years two, three and four was estimated using ONS life tables 2013-15, which give an estimate of the annual probability of death given a person’s age and gender.
Table 26 shows the estimated population that would be assessed at four years of age.
Table 26Estimated number of preterm children born before 28+0 weeks’ gestation assessed at 4-years of age
| Gestational age (weeks) | Total live births | Infant mortality rate | Estimated deaths in year 1 | Estimated deaths in year 2-4 | Estimated population in year 4 |
|---|---|---|---|---|---|
| ≤ 22 | 462 | 88% | 408 | 0 | 54 |
| 23 | 293 | 70% | 205 | 0 | 88 |
| 24 | 465 | 41% | 189 | 0 | 276 |
| 25 | 534 | 24% | 127 | 0 | 407 |
| 26 | 560 | 17% | 96 | 0 | 464 |
| 27 | 735 | 11% | 80 | 0 | 655 |
| Total | 3,049 | - | 1,105 | 1 | 1,943 |
I.4. Assessment costs
Reflecting the UK NHS perspective of the analysis, the costs associated with assessments were estimated using relevant staff costs from NHS Reference Costs 2014/15, which gives the average cost associated with each of the staff visits or assessments.
The cost of an assessment by a paediatrician was estimated to be £192.99 based on the outpatient cost associated with ‘Paediatrics’ from NHS reference costs 2014/15. The costs of an assessment by a clinical psychologist was estimated to be £201.38 based on the outpatient cost associated with ‘clinical psychology’ from NHS reference costs 2014/15.
Note that the associated average time for each of these visits or assessments is not known because this is not reported in NHS reference costs. However, given that the time taken to perform each assessment is likely to vary, using the average across the NHS seemed to be a reasonable approach. An alternative approach would be to base the costs on estimates from the Unit Costs of Health and Social Care 2015, which does report the time taken. This alternative was explored and it was found that the assessment costs would be lower with this approach. Therefore, the values from NHS reference costs were used as it was preferable to run the risk of overestimating costs rather than underestimating them.
The overall costs for the assessments at four years of age under current practice and enhanced surveillance scenarios are shown in the Error! Reference source not found..
Table 27Assessment costs of surveillance strategies at children born before 28+0 weeks’ gestation at 4-years of age
| Surveillance strategy and assessments | Estimated costs | Source |
|---|---|---|
| Current practice | ||
| No assessment | £0.00 | |
| Enhanced surveillance | ||
| Paediatrician | £192.99 | NHS reference costs 2014/15 - outpatient costs for ‘Neonatology’ and ‘Paediatrics’ |
| Clinical psychologist | £201.38 | NHS reference costs 2014/15 - outpatient costs for ‘Clinical psychology’ |
| Total cost for assessment | £394.36 | |
I.5. Results
I.5.1. Base case results
The estimated resource impact of the enhanced surveillance program at the assessment undertaken at 4 years of age is shown in the table below.
Table 28Estimated costs of enhanced surveillance for children born before 28+0 weeks’ gestation at 4-years of age
| Gestational age (weeks) | Estimated population at year 2 assessment | Estimated costs | ||
|---|---|---|---|---|
| Current practice | Enhanced surveillance | Difference | ||
| ≤ 22 | 54 | £0 | £21,296 | £21,296 |
| 23 | 88 | £0 | £34,529 | £34,529 |
| 24 | 276 | £0 | £108,784 | £108,784 |
| 25 | 407 | £0 | £160,433 | £160,433 |
| 26 | 464 | £0 | £182,998 | £182,998 |
| 27 | 655 | £0 | £258,387 | £258,387 |
| Total | 1,943 | £0 | £766,426 | £766,426 |
At the assessment at four years of age, it can be seen that total cost of the enhanced surveillance programme is estimated to be £766,426 whereas there is no cost associated with current practice (since assessments at four years are not currently undertaken as part of routine practice). Therefore, the additional cost of the enhanced surveillance programme at the four year assessment point is estimated to be £766,426.
I.5.2. Sensitivity analysis
Various deterministic sensitivity analyses were conducted to assess the areas of uncertainty. The results of the sensitivity analysis are shown in the tables below.
Particularly noteworthy are the alternative scenarios where changes are made to the surveillance scenario assumed to represent current practice. For instance, it can be seen that the cost difference decreases when it is assumed that a proportion of places are already following the enhanced surveillance programme.
Table 29Sensitivity analysis results for assessment of children born before 28+0 weeks’ gestation at age 4
| Modelled scenario | Estimated costs | ||
|---|---|---|---|
| Current practice | Enhanced surveillance | Difference | |
| Population increased by 25% | £0 | £958,032 | £958,032 |
| Population decreased by 25% | £0 | £574,819 | £574,819 |
| Clinical psychologists used in current practice | £391,362 | £766,426 | £375,064 |
| Paediatricians used in current practice | £375,064 | £766,426 | £391,362 |
| 25% of places already following enhanced surveillance strategy | £191,606 | £766,426 | £574,819 |
| 50% of places already following enhanced surveillance strategy | £383,213 | £766,426 | £383,213 |
| 75% of places already following enhanced surveillance strategy | £574,819 | £766,426 | £191,606 |
I.6. Discussion
The results of the analysis show that the enhanced surveillance programme is likely to lead to a cost increase for children born before 28+0 weeks gestation at 4 years of age (£766,426). The benefits of the changes to the assessment at 4 years of age should lead to an increased number of children identified with problems or disorders who could be referred for diagnosis and appropriate management.
I.7. Conclusion
The suggested changes to the surveillance programme at four years were estimated to cost an additional £766,426 per year. The additional resources = should achieve improvements in the detection of developmental problems and disorders in a cost-effective manner.
- Resource impact analysis of delivery of enhanced support and surveillance - Deve...Resource impact analysis of delivery of enhanced support and surveillance - Developmental follow-up of children and young people born preterm
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