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PEDIATRICS Vol. 112 No. 6 December 2003, pp. 1422-1423

COMMENTARY

Cost-Effectiveness of Inhaled Nitric Oxide in the Treatment of Neonatal Respiratory Failure in the US

David Field, DM, FRCPCH

Division of Child Health
Leicester University Medical School
Leicester LE1 5WW, United Kingdom

Charles Normand, DPhil, FFPM

Department of Health Economics
London School of Hygiene and Tropical Medicine
London WC1E 7HT, United Kingdom

Diana Elbourne, MSc, PhD

Medical Statistics Unit
London School of Hygiene and Tropical Medicine
London WC1E 7HT, United Kingdom

Abbreviations: iNO, inhaled nitric oxide • ECMO, extracorporeal membrane oxygenation

Nitric oxide is probably unique in terms of the course of events leading to its designation as a "drug." After the identification of endothelium-derived relaxing factor as nitric oxide, there was much excitement about the therapeutic potential of this simple molecule across a whole range of medical specialties. Cost was certainly not an issue. However, after little more than 10 years, much of the therapeutic promise has not (yet) occurred, but cost certainly is now an issue.

The article by Angus et al¹ in this issue looks specifically at the cost effectiveness of a policy of using nitric oxide in mature infants with severe respiratory failure. This study was conducted carefully, taking account of current guidance on such exercises. However, there remain reasons why it is perhaps unwise to draw the conclusion that "iNO [inhaled nitric oxide] has a favorable cost-effectiveness profile... " The study relies heavily on certain assumptions that are not entirely sound:

1. It is appropriate to seek to avoid extracorporeal membrane oxygenation (ECMO): In reality, the only issues are what ECMO costs and what it achieves.
   
2. ECMO (per se) is associated with a high long-term morbidity: There are very few data comparing late outcome of children treated with ECMO to a control group, of similar disease severity, treated with other therapies including nitric oxide but avoiding ECMO. The data that are available demonstrate that those treated without ECMO have a worse long-term prognosis.^2,3
   
3. Cost effectiveness of NO can be meaningfully discussed without reference to any adverse outcome after the age of 1 year: This issue is possibly the most important, because costs in the first year can easily be dwarfed by differences in long-term costs, and if iNO achieves some improved survival, some of this is likely to be with very high-cost care needs. The question is if the overall cost of caring in the long run goes up or down as a result of a policy of using iNO.
   

In addition, some estimates made in this study should be treated with caution. For example, the quality-of-life weighting for respiratory and neurologic morbidity may be low given the severity of such morbidities. Costs here have been assessed as charges, which is in line with US guidelines but does introduce some potential biases. For example, charges for non-ECMO care in ECMO centers is estimated to be higher than in other hospitals, but there is no a priori reason why this should be the case. Savings on ECMO may also be exaggerated given the different thresholds for use of this technology.

Although this is generally a well-constructed article and goes some way to justifying the use of nitric oxide at its present price, that is not the central issue for the families of infants eligible for this treatment. For them, knowing when (in terms of the clinical course) is the optimal time that nitric oxide should be started, when it has failed, and when ECMO cannot safely be avoided remains much more important.

	FOOTNOTES

 
Received for publication Sep 8, 2003; Accepted Sep 8, 2003.

Address correspondence to David Field, DM, FRCPCH, Neonatal Unit, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, United Kingdom. E-mail: david.field{at}uhl-tr.nhs.uk

During the last 3 years, Dr Field has received funding to attend educational meetings and honoraria for speaking on the subject of nitric oxide from the following companies: British Oxygen, AGA, and Inomax.

	REFERENCES

TOP REFERENCES

 

1. Angus DC, Clermont G, Watson RS, Linde-Zwirble WT, Clark RH, Roberts MS. Cost-effectiveness of inhaled nitric oxide in the treatment of neonatal respiratory failure in the united states. Pediatrics.2003; 112 :1351 –1360[Abstract/Free Full Text]
2. UK Collaborative ECMO Group. The collaborative UK ECMO trial: follow-up to 1 year of age. Pediatrics.1998; 101(4). Available at: http://www.pediatrics.org/cgi/content/full/101/4/e1
3. Bennett CC, Johnson A, Field DJ, Elbourne D. UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation: follow-up to age 4 years. Lancet.2001; 357 :1094 –1096.[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics

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This article has been cited by other articles:

				T. W. R. Hansen, D. Field, C. Normand, D. Elbourne, D. C. Angus, G. Clermont, R. S. Watson, and W. T. Linde-Zwirble Inhaled Nitric Oxide and the Societal Perspective Pediatrics, June 1, 2004; 113(6): 1849 - 1851. [Full Text]

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