cost-effectiveness assessmentofa humanmilk bank · 2016-11-16 · cost-effectiveness assessmentofa...

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Cost-effectiveness

assessment of a

Human Milk Bank

Israel Macedo, MD

Human Milk Bank - Pediatric Department

Maternity Dr Alfredo da Costa, CHLC - Lisbon

1st Int. Congress EMBA - Lisbon 2012 2

Cost-effectiveness of a HMB

Rising health care costsRising health care costs

2



Public health care systems / debtPublic health care systems / debt


Portuguese 1st HMB - Lisbon

StartStart, , developmentdevelopment ofof thethe projectproject

• 2008 - Start, contacts with Spanish, Brasilian MBN,

UKMBA, HMBANA, Iowa HMB;

• Works, equipment;

• 02-2009: OM Project / Procedures & safety check-lists;

• 11-2009: OM 1st Edition;

• 08 / 09-2009: First donors recruited / First pasteurizations;

• 11-2009: First NICU premies received PHM:

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Portuguese 1st HMB - Lisbon - Facilities

Breastfeeding Area & DoctorBreastfeeding Area & Doctor’’s Offices Office

Donor candidates’ selection:�Telephone screening (nurse);

�Personal interview (nurse, physician);

�Third trimester serologies – HBV, HCV, HIV 1 & 2, Syphilis;

�Own baby feeding well, increasing weight;

Information, support to breastfeeding mothers.

Blood collection (after 3 months of donation):�By PCR detection - HBV, HCV, HIV 1 & 2;

�By other techniques - HTLV 1 & 2, Syphilis, AST, ALT;


Portuguese 1st HMB - Lisbon - Facilities

Storage & Technical Area

�Area 30 sq m, air conditioning;

�Freezers (2) 200 l each,

– Raw and pasteurized milk,

�Laminar air flow chamber,

�Pasteurizer

- (8,75 l capacity, automatic),

�HM Homogeneiser;

�HM Analyser;

�Laptop computer, label printer;

�Containers, etc.

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First portuguese HMB First portuguese HMB -- Donors Donors --First yearFirst year

20092009 20102010 20112011


Lisbon HMB: Receptors (2009-11)

3

1716

28

1718

24

19

24

18

10

17

12

19

15

11

14

0

5

10

15

20

25

30

Nov Dec Jan Feb Mar Apr Mai Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Nr

2009 2010 2011


First portuguese HMB First portuguese HMB -- Receptors Receptors --First yearFirst year

5


HGO


NICUs in Lisbon area

1st HMB1st HMB



First portuguese HMB First portuguese HMB -- First year costs:First year costs:

Analyzes

49%

Carrier

8%

Staff salaries

11%

Consumables

2%

Sterilization

19%

Maintenance

2%

Other

9%

Total: 71,06€ / LTotal: 71,06€ / L

70 donors / Y

1260 L / Y

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Rationalize: use reason to alocate resourcesRationalize: use reason to alocate resources

•• Cut unnecessary costs:Cut unnecessary costs:– Adequately controlled generics;

– No “routine” diagnostic tests / medical investigations;

– ....

•• Keep useful costs:Keep useful costs:– Organization / Safety based on risk assessment;

– Well proven prevention measures;

– Evidence based therapies;

Savings (short & long term)Savings (short & long term)



Rationalizing costs:Rationalizing costs:

•• Cut unnecessary costs:Cut unnecessary costs:– No need of a “surgical instruments” sterilization;

– Too many donors, a lot of them giving very few milk;

– Too many donors with blood screening / few milk;

– Many donors start at >4 monts after delivery;

– Staff may use automation to improve time use;

– ....

•• Keep useful costs:Keep useful costs:– Priorize safety and traceability;

– Help other NICUs start DHM;

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Cost-effectiveness of a HMB Lisbon HMB Lisbon HMB -- Rationalizing costs:Rationalizing costs: SterilizationSterilization

No need of “surgical instruments” sterilization & package



Rationalizing costs:Rationalizing costs:

• Admit donors until 3 monts after delivery;

• Agree suspension of donation if < 130 ml / day after 2 weeks (with some exceptions);

• Adopt progessively NICE guidelines:

– Blood analysis (every 3 / 4 months);

– Discard batch pooled donor milk if samples exceed• 105 CFU / ml for total viable microorganisms or

• 104 CFU / ml for Enterobacteriaceae or

• 104 CFU / ml for Staphylococcus aureus.

– Post pasteurization analysis (every cicle);

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Donors

2

85

24 3 2 3

5

1214

8

0 0 0

74

0

42

6

2 20 1 0

20 0 1 2 1 0 0

20 1

36

2

912

14 1517 17

1922

32

4143 43

41 41

45

15

710 11

13 1412

9 8

3 2 1 0 0 1 2 20 1 1 2 2

8

0

10

20

30

40

50

Jul

Set

Nov Ja

nMar

Mai Ju

lSet

Nov Ja

nMar

Mai Ju

lSet

Nov Ja

nMar

Mai Ju

lSet

Months/Years

Nr

Admitted Active

20092009 20102010 20112011 20122012


First portuguese HMB First portuguese HMB -- Donor nrDonor nr


Liters of milk / donor - Nr donors

1,6

0,8

0,0

1,8

1,2

3,8

0,7

0,20,0

1,2

0,9

3,0

0,10,0 0,0 0,0

0,9

1,3

24

44

11

16

3

5

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

2009-S2 2010-S1 2010-S2 2011-S1 2011-S2 2012-S1

Liters

-5

5

15

25

35

45 Nr

Q3

Median

Q1

Nr of donors

Cost-effectiveness of a HMBLisbonLisbon HMB HMB -- Rationalizing costs:Rationalizing costs:

Few milk / Nr of donorsFew milk / Nr of donors

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Analyzes

54%

Carrier

7%

Staff salaries

8%

Consumables

2%

Sterilization

17%

Maintenance

2%

Other

10%


First portuguese HMB First portuguese HMB -- 22ndnd / 3/ 3rdrd year costs:year costs:

Total: 65€ / LTotal: 65€ / L

20 donors / Y

445 L / Y



Preterm Human MilkPreterm Human Milk versusversus PT FormulaPT Formula

• Premature (VL-ELBW):

Comparator: PT Formula Evidence level

– NEC ↓ 34% 1b

– GI Intolerance ↓ 20% 1b

– Nosocomial sepsis ↓ 3% 2a

Catherine AB. Meta-analysis 2007Quigley M.Cochrane Syst. Ver. 2007

Schanler RJ. RCT (n=273) 2005McGuire. Systematic review 2003

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EvidEvidenceence: : PasteurizPasteurizeded –– PT FormulaPT Formula (1)

(very preterm NB)

• PTF: Increased risk of NEC

RR 2,5 [IC 95% 1,2 - 5,1]

Mortality of NEC ± 22 %

• PTF: Better growth in short term,

No difference at 18-24 m and 7-8 y,

No difference in neurodevelopment.

(Cochrane 2008: 8 RCT)


• PHM as trophic feeding:

Better tolerance.

• PHM as MM supplement:

Protection from NEC and sepsis.

(Ziegler E. 2008)• More studies needed:

– Better PHM Fortification vs PTF

(↑ growth and ↓ sepsis).


EvidEvidenceence: : PasteurizPasteurizeded –– PT FormulaPT Formula (2)

(very preterm NB)

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7

2

0

1

2

3

4

5

6

7

%

Before HMB After HMB (3y)

NEC (surgical)

p=0,118

Lisbon HMB (VLBW population)

Comparison before (2y) / after (2y) HMB

Surgical NEC and Nosocomial sepsisSurgical NEC and Nosocomial sepsis

38

35

33

34

35

36

37

38

%

Before HMB After HMB (3y)

Sepsis, late

p=0,78



Impact in our NICU Impact in our NICU (VLBW infants)

Median Nr of VLBW infants / year: 150 to 160

Cases of Surgical NEC (Nr/y):

Before HMB:

After HMB:

Mortality from Surgical NEC (Nr/y):

Before HMB: 2 to 5

After HMB: 0,6 to 1,5

Surgery (Nr/y):

Before HMB:

After HMB:

Short gut (Nr/y):

Before HMB:

After HMB:

0,5

0,23

10,5

3

5,3

2,5

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Estimation of impact in our NICUEstimation of impact in our NICU

(VLBW infants)

Increase in LOS (total days/year):

Before HMB:

After HMB:

Gain in LOS (days/year):

QALY lost (Death and short gut):

Before HMB: 188 to 435

After HMB: 62 to 130

Gain in Quality Adjusted Life Years: 126 to 305

Impact of NEC reduction:

158

45

113


Costs:

Has a median BW of (g):

Has a median LOS (days):

Has a median discharge weight (g):

Starts EF on day 2 with (ml/day):

On discharge is fed with (ml/day):

Total amount of milk / baby (ml):

Amount of DHM / year (liters): 39.585,00 €

22.500,00 €

62.085,00 €Total cost of DHM fed infants:

609

Donor milk is used in 50% of LOS days / babies

8120

Cost of fortifier in DHM fed infants:

8

1100

288

Milk is fortified when > 100 ml/kg/day

Assumptions - Average preterm:

60

1800



(VLBW infants)

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549,00 €

Cost of each QALY gained: 492,00 € to 203,00 €

Cost of the "gains":

Cost of each day of stay (LOS) gained:



(VLBW infants)


• In a 3 years period, there was a decrease in

the incidence of NEC, but p > 0,05;

• Assuming a tendency,

• The “DHM cost” of the gained LOS is lower

than the real LOS daily cost;

• The gained QALY costs 203 € to 492 €;

• The use of DHM seems very cost-efective.


Conclusions:Conclusions:

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Thank you for your attentionThank you for your attention !!

cost-effectiveness assessmentofa humanmilk bank · 2016-11-16 · cost-effectiveness assessmentofa...

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