Author: William King
Objective To examine the effect of heart rate characteristics (HRC) monitoring on length of stay and cost among very low birth weight (VLBW; <1500 g birth weight) neonates in the HeRO Randomized Controlled Trial (RCT). Study design In one of the largest RCTs ever conducted among VLBW infants, Moorman and colleagues showed that HRC monitoring (HeRO®; MPSC, Charlottesville, VA) decreased all-cause mortality by 22%. In a subsequent retrospective analysis of the RCT, Fairchild et al determined that patients randomized to receive HRC monitoring experienced a 40% reduction in mortality after infection, and the one life was saved for every 16 infected VLBW patients. One of the other pre-specified outcomes of the RCT was length of stay, but there was no significant difference in length of stay between the control group and the HRC group. Length of stay, however, is a competing outcome with mortality. The fact that HRC monitoring saved the lives of VLBW infants intrinsically increased their length of stay. In this analysis, we examined whether length of stay was affected by HRC monitoring among survivors in each group as well as in a subgroup of survivors with blood or urinary infection. Results Among all patients, as well as survivors, there were non-significant trends toward an increase in the proportion of patients that were discharged before day 120 among the HRC-Display group compared with controls, although trends in median length of stay were not apparent. The analysis was subsequently focused by first selecting patients most likely to benefit from HRC monitoring: those with a positive blood or urine culture (where the timing of the diagnosis and effectiveness of the therapy could be positively impacted by HRC monitoring, approximately 31% of the patients). Second, the effects of differences in gestational ages between the HRC-display and non-display groups were controlled by examining the PMA at discharge. Among survivors with positive blood or urine cultures, there was a non-significant trend toward a greater proportion of patients discharged prior to day 120 (81.0% vs 76.3%, one-tailed p=0.040) among HRC monitored patients. The HRC-display group also trended toward a lower gestational age at birth as well as a shorter length of stay compared with controls, although neither approached statistical significance. However, when using PMA at discharge to control for the expected effect of gestational age on length of stay, a statistically significant 3.2 day improvement in length of stay was seen for patients that were randomized to HRC-display compared with controls (p=0.013). Implementation of HRC monitoring represents an opportunity to reduce costs (borne by hospitals and third party payers) by approximately $6,500 per bed per year. HRC monitoring by the HeRO System costs approximately $50,000 per life saved, and is 4 times more cost effective to save the life of a VLBW than the NICU itself. The return on investment (ROI) to society of HRC monitoring is 150 times, due largely to the substantial impact of reduced mortality. Conclusion HRC monitoring reduces hospital costs and improves mortality among VLBW patients.
Co Author/Co-Investigator Names/Professional Title: Reese H. Clark, MD. Mednax. Pediatrix Center for Research, Education, and Quality. Jonathon R. Swanson, MD. University of Virginia, Department of Neonatology. Douglas E. Lake, PhD. University of Virginia, Department of Statistics. Karen D. Fairchild, MD. University of Virginia, Department of Neonatology. Joseph Randall Moorman, MD. University of Virginia, Department of Cardiology. Waldemar A. Carlo, MD. University of Alabama, Birmingham, Department of Neonatology. John Kattwinkel, MD. University of Virginia, Department of Neonatology. Robert L. Schelonka, MD. Oregon Health Sciences University, Department of Neonatology. Peter J. Porcelli, MD. Wake Forest University, Department of Neonatology. Christina T. Navarrete, MD. University of Miami, Department of Neonatology. Eduardo Bancalari, MD. University of Miami, Department of Neonatology. Judy L. Aschner, MD. Albert Einstein College of Medicine of Montefiore Health, Department of Pediatrics. Jose A. Perez, MD. Winnie Palmer Children’s Hospital, Department of Neonatology. Charles Palmer, MD. Pennsylvania State University, Department of Neonatology. Thomas Michael O’Shea, MD. University of North Carolina, Department of Neonatology. Marshall Whit Walker, MD. Greenville Hospital System, Department of Neonatology.
Funding Acknowledgement (If Applicable): Conflicts of Interest: WEK is CEO of MPSC. DEL and JRM have been consultants to and are shareholders of MPSC. There are no other conflicts. No honorarium, grant, or other form of payment was given to anyone to produce the manuscript.