COST-ANALYSIS OF REDUCING MORTALITY RATE FOR LBW BABIES AT FATMAWATI HOSPITAL'S NICU
Background: As a developing country that still struggles with infant mortality, Indonesia needs high-quality and efficient neonatal care. However, due to the complexity of neonatal care, the neonatal intensive care unit (NICU) still has a high cost, approximately USD 950 - 31,000, as the last line of care.
Aims: This study analyzes the cost incurred due to service improvement at Fatmawati General Hospital. The cost analysis may serve as useful evidence for other hospitals with NICUs that seek to improve their service.
Methods: We used cost analysis to examine pre-intervention costs in 2015 and post-intervention costs in 2021. Our data were gathered primarily in the NICU of Fatmawati General Hospital for three months in 2023.
Results: The results showed an increase in total cost of IDR 1,898,040,489 (55%). The largest cost increase was personnel and supplies costs, which accounted for 83.8% of the cost increase. However, this cost increase was also followed by a significant decrease in mortality rates, from 128 deaths per 1,000 births to 17 deaths per 1,000 births.
Conclusion: This study found a correlation between investment in service improvements and decreased infant mortality rates in the NICU of Fatmawati General Hospital. Although the 55% increase in total cost was associated with a significant decrease in infant mortality rates in the NICU of Fatmawati General Hospital, further studies are needed to determine the effectiveness of improvements in the NICU's services.
Keywords: cost, Indonesia, LBW, NICU
Introduction
Infant health and well-being issues are being addressed globally. Goal 3.2 of the United Nations Sustainable Development Goals (SDGs) states that one of its goals is to reduce preventable deaths of newborns to as low as 12 per 1,000 live births by 2030(Nations, 2023). As of 2021, Indonesia’s infant mortality rate remained at 19 per 1,000 live births, even after Indonesia regained its status as an upper middle-income country(Finance, 2023);(U.N.I.C.E.F., 2023).
According to data for three consecutive years from the Indonesian Ministry of Health, LBW/ prematurity was the main cause of infant mortality, and the figure was around 27% annuallyTable 1. Premature birth occurs when a baby is born before completing 37 weeks of gestation. The more premature a baby is, the greater the risk of mortality and morbidity. Premature babies may experience breathing difficulties, digestive problems, bleeding in the brain, and may have long- term effects such as stunted growth during
childhood(C.D.C., 2022).
Causes of Death | Incidence | ||
|---|---|---|---|
| 2019 | 2020 | 2021 | |
LBW | 27.33% | 27.76% | 27.60% |
Asphyxia | 20.42% | 21.63% | 22.19% |
| Congenital | 9.95% | 8.97% | 12.36% |
As the last line of neonatal care, where premature infants with complications are usually cared for, a neonatal intensive care unit (NICU) is one of the more expensive forms of care.(Sharma & Murki, 2021)made a summary of NICU costs from a literature study of various studies related to cost analysis in the NICU while(Karambelkar et al., 2016)examined 126 neonates in India who were treated in the NICU for various diseases. It is estimated that approximately USD 90.7 is spent every day for care in the NICU.(Narang et al., 2005)showed that the expenditure for each baby admitted to the NICU has several classifications. For extreme low birth weight (ELBW) babies, it is around 3,800 USD, for babies between 1,000g and 1,250g, it is approximately USD 2,000, and for babies between 1,250g and 1500g, it is around USD 950(Narang et al., 2005). Meanwhile,(Kirkby & , 2007)found that the average cost for each preterm infant admitted to the NICU is USD 31,000.
Although it is difficult to make a balanced comparison for each costing study of the NICU, it can be concluded that managing a neonatal unit has significant costs. The complexity of neonatal unit management can be attributed to the high nurse/patient ratio and high expertise needed to solve neonatal problems(Sharma & Murki, 2021). With all the complexities and difference, and costly NICU treatments in multiple countries, it is important for Indonesia to have publications on NICU costs. To the best of our knowledge, no literature has discussed the empirical cost of NICU in Indonesia.
In addition to infants’ early complications, their underdeveloped immune system makes them at greater risk of infection. Unfortunately, infection can sometimes occur during hospitalization, which is called healthcare associated infections (HAIs). The impact of HAIs can be morbidity, mortality, or financial burden to various stakeholders such as patients, their families, and the country's healthcare system(Sikora & Zahra, 2022). The US Center for Disease Control and Prevention states that, every year, nearly 1.7 million treated patients develop HAIs, and more than 98,000 of them die from HAIs. The prevalence of HAIs documented in the data shows that approximately 3.2% of all US patients and 6.5% of all patients in the European Union are affected by HAIs, and even higher rates worldwide(Allegranzi & , 2011);(Magill & , 2018);(Suetens & , 2018).
The occurrence rate of HAIs in the neonatal intensive care unit is around 30%, and 40% of neonatal deaths in developing countries are due to such infections(Pessoa"Silva & , 2004);(Zaidi & , 2005). There are several reasons why HAIs are increasingly dangerous, with hospitals hosting more patients with weakened immune systems. In addition, with the outpatient system, the risk for pathogen spread is higher. Sanitation protocols are lacking, and sterilization of equipment by medical staff is not strict. Widespread use of anti-microbial drugs also has a negative impact due to accumulation of anti- microbial resistance. Increased infections are associated with longer hospital length of stay, long-term disability, socioeconomic disruption, and increased mortality(Khan et al., 2017). In addition, newborns admitted to the NICU are at risk for HAIs due to their physiologic instability, exposure to invasive medical equipment, and broad-spectrum antibiotics(N.N.I.S., 2004);(Singh, 2004);(Sohn & , 2001). Infection rates in NICUs are also higher than those in well-baby nurseries, with infection rates in NICUs ranging from 6 to 40 per 100 admissions, while infection rates in well-baby nurseries range from 0.3 to 1.7 per 100 admissions(Scheckler & Peterson, 1986);(Welliver & Mclaughlin, 1984).
Neonatal care is a difficult and expensive domain to implement. If not managed properly, the effectiveness and efficiency of the NICU can be questioned and can place a significant financial burden on healthcare budgets. The high cost in NICUs also makes many hospitals management reluctant to invest in NICUs, especially in the treatment of LBW babies. Therefore, a cost analysis study is needed to provide evidence of the cost of improving NICU service and the extent to which infant mortality rates have changed. Furthermore, we aim to provide evidence for other hospitals with NICUs that also seek to
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