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Original Investigation
March 11, 2019

Cost-effectiveness of Antenatal Corticosteroid Therapy vs No Therapy in Women at Risk of Late Preterm Delivery: A Secondary Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, New York
  • 2Department of Neonatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
  • 3George Washington University Biostatistics Center, Washington, DC
  • 4Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
  • 5Department of Obstetrics and Gynecology, University of Texas Health Science Center at Children’s Memorial Hermann Hospital, Houston
  • 6Department of Obstetrics and Gynecology, University of Alabama, Birmingham
  • 7Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
  • 8Department of Obstetrics and Gynecology, Emory University, Atlanta, Georgia
  • 9Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston
  • 10Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
  • 11Department of Obstetrics and Gynecology, Ohio State University, Columbus
  • 12Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City
  • 13Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill
  • 14MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
  • 15Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
  • 16Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
  • 17Department of Obstetrics and Gynecology, Stanford University, Stanford, California
  • 18Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
  • 19Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 20Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland
  • 21Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
  • 22Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston
JAMA Pediatr. 2019;173(5):462-468. doi:10.1001/jamapediatrics.2019.0032
Key Points

Question  Is administration of antenatal corticosteroids to women at risk for late preterm delivery a cost-effective strategy?

Findings  In this secondary analysis of a randomized clinical trial, treatment with betamethasone was associated with a total mean woman-infant–pair cost that was significantly less than that for women and infants in the placebo group.

Meaning  The findings suggest that antenatal betamethasone treatment is associated with a statistically significant decrease in health care costs and with improved outcomes; thus, the treatment may be an economically desirable strategy.

Abstract

Importance  Administration of corticosteroids to women at high risk for delivery in the late preterm period (34-36 weeks’ gestation) improves short-term neonatal outcomes. The cost implications of this intervention are not known.

Objective  To compare the cost-effectiveness of treatment with antenatal corticosteroids with no treatment for women at risk for late preterm delivery.

Design, Setting, and Participants  This secondary analysis of the Antenatal Late Preterm Steroids trial, a multicenter randomized clinical trial of antenatal corticosteroids vs placebo in women at risk for late preterm delivery conducted from October 30, 2010, to February 27, 2015. took a third-party payer perspective. Maternal costs were based on Medicaid rates and included those of betamethasone, as well as the outpatient visits or inpatient stay required to administer betamethasone. All direct medical costs for newborn care were included. For infants admitted to the neonatal intensive care unit, comprehensive daily costs were stratified by the acuity of respiratory illness. For infants admitted to the regular newborn nursery, nationally representative cost estimates from the literature were used. Effectiveness was measured as the proportion of infants without the primary outcome of the study: a composite of treatment in the first 72 hours of continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, supplemental oxygen with a fraction of inspired oxygen of 30% or more for 4 hours or more, and extracorporeal membrane oxygenation or mechanical ventilation. This secondary analysis was initially started in June 2016 and revision of the analysis began in May 2017.

Exposures  Betamethasone treatment.

Main Outcomes and Measures  Incremental cost-effectiveness ratio.

Results  Costs were determined for 1426 mother-infant pairs in the betamethasone group (mean [SD] maternal age, 28.6 [6.3] years; 827 [58.0%] white) and 1395 mother-infant pairs in the placebo group (mean [SD] maternal age, 27.9 [6.2] years; 794 [56.9%] white). Treatment with betamethasone was associated with a total mean (SD) woman-infant–pair cost of $4681 ($5798), which was significantly less than the mean (SD) amount of $5379 ($8422) for women and infants in the placebo group (difference, $698; 95% CI, $186-$1257; P = .02). The Antenatal Late Preterm Steroids trial determined that betamethasone use is effective: respiratory morbidity decreased by 2.9% (95% CI, −0.5% to −5.4%). Thus, the cost-effectiveness ratio was −$23 986 per case of respiratory morbidity averted. Inspection of the bootstrap replications confirmed that treatment was the dominant strategy in 5000 samples (98.8%). Sensitivity analyses showed that these results held under most assumptions.

Conclusions and Relevance  The findings suggest that antenatal betamethasone treatment is associated with a statistically significant decrease in health care costs and with improved outcomes; thus, this treatment may be an economically desirable strategy.

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