A Public Health Economic Assessment of Hospitals' Cost to Screen Newborns for Critical Congenital Heart Disease

Objective

Critical congenital heart disease (CCHD) was recently added to the U.S. Recommended Uniform Screening Panel for newborns. This evaluation aimed to estimate screening time and hospital cost per newborn screened for CCHD using pulse oximetry as part of a public health economic assessment of CCHD screening.

Methods

A cost survey and time and motion study were conducted in well-newborn and special/intensive care nurseries in a random sample of seven birthing hospitals in New Jersey, where the state legislature mandated CCHD screening in 2011. The sample was stratified by hospital facility level, hospital birth census, and geographic location. At the time of the evaluation, all hospitals had conducted CCHD screening for at least four months.

Results

Mean screening time per newborn was 9.1 (standard deviation = 3.4) minutes. Hospitals'' total mean estimated cost per newborn screened was $14.19 (in 2011 U.S. dollars), consisting of $7.36 in labor costs and $6.83 in equipment and supply costs.

Conclusions

This federal agency-state health department collaborative assessment is the first state-level analysis of time and hospital costs for CCHD screening using pulse oximetry conducted in the U.S. Hospitals'' cost per newborn screened for CCHD with pulse oximetry is comparable with cost estimates of existing newborn screening tests. Hospitals'' equipment costs varied substantially based on the pulse oximetry technology employed, with lower costs among hospitals that used reusable screening sensors. In combination with estimates of screening accuracy, effectiveness, and avoided costs, information from this evaluation suggests that CCHD screening is cost-effective.In September 2011, the U.S. Secretary of Health and Human Services approved the addition of critical congenital heart disease (CCHD) to the Recommended Uniform Screening Panel for newborns.¹ Just before that approval, New Jersey became the first state to implement mandatory pulse oximetry screening in all licensed birthing facilities to improve detection and early intervention for newborns with CCHD.² Similar legislation has since been introduced or enacted in many other states. Though clinical evidence supports routine CCHD screening,^3,4 at least one earlier attempt at passing state legislation was stymied by reservations that included cost concerns.⁵Congenital heart disease affects an estimated nine per 1,000 live births in the United States; approximately one-quarter of those children have critical conditions requiring surgery or catheter intervention during infancy.^3,6 Newborns with untreated CCHD are at risk for cardiovascular collapse within the first days of life,³ although some newborns do not present obvious physical signs of their condition before birth hospital discharge. Newborns with CCHD not detected during prenatal screening or postnatal examinations may benefit from routine screening at birth hospitals.

Previous estimates of screening time and cost

Estimates of the time and cost of pulse oximetry screening have appeared in the recent literature. Two studies—both from the United Kingdom—reported observations of the time spent by staff engaged in the screening process. One study reported a mean screening time of 2.0 minutes per newborn, where screening included one pulse oximetry reading conducted by a doctor during a clinical examination.^7,8 The second study reported a mean screening time per newborn of 6.9 minutes, based on a survey completed by midwives who conducted the screening.^9,10 The two studies reported an estimated cost per newborn screened—including labor and equipment—of $6.13 and $9.97, respectively (both estimates expressed as 2011 U.S. dollars^11,12). Recent U.S. studies provided estimates of mean screening times per newborn ranging from 45 seconds to 3.5 minutes (where screening usually included one pulse oximetry reading), and estimates of equipment-only screening costs per newborn ranging from “negligible” to $11.00.^{3,5,6,13–15} No previous estimates were based on reported systematic studies in which observers objectively recorded screening times.Robust estimates of hospitals'' costs to conduct routine newborn screening for CCHD using pulse oximetry may inform hospitals'' and states'' decisions on such screening. We aimed to estimate the screening time and cost—including labor and equipment—for hospitals to screen newborns for CCHD using pulse oximetry. This information was collected as part of a broader public health economic assessment of CCHD screening, which is summarized hereafter.