In a recently released article in Pediatrics, Dr. Susan Trang and colleagues (10.1542/peds.2017-0737)Assistant Editor, Pediatrics ask an important question: is donor milk for premature
infants cost-effective? The cost of donor milk is high in comparison to preterm formula,
and hence the authors’ question is meaningful for both healthcare consumers and payers.
However, breast milk, including donor human milk, has been well shown to reduce the
risk of necrotizing enterocolitis (NEC), a disastrous, life-threatening complication
of prematurity.1 Certainly parents and physicians want the best for each infant regardless of cost,
but determining cost-effectiveness, or “bang for the buck” is an important transparency.
In this prospective randomized trial, 363 premature infants of mean gestational age
of 27.7 weeks and mean birthweight of 996 grams were enrolled and randomized to receive
either donor human milk or preterm formula if mother’s breastmilk was not sufficient
in supply. Results from this trial have previously been published related to neurodevelopmental
outcomes.2 The cost-effectiveness analysis described here by Dr. Trang and colleagues was pre-planned,
and was conducted in tandem with the feeding trial. The authors clearly explain how
costs associated with the study infants’ hospital care were calculated, primarily
with a standardized accounting system: these included hospital stay costs (for example
laboratory, medication and imaging costs), provider salaries, and indirect institutional
costs allocated by length of the infant’s hospital stay. Post-discharge health and
non-health costs were captured with a previously validated Family Health Economic
Questionnaire filled out monthly; this questionnaire included the cost of parental
missed work due to infant illness.
The cost of donor milk varies but is generally estimated as $3-5 per ounce, which
includes both direct costs such as screening of donors, and processing and pasteurizing
of breast milk, and indirect costs such as research and infrastructure. Both not-for
profit (HMBANA - the Human Milk Banking Association of North America) and for-profit
milk banks (Prolacta® Bioscience Inc.) supply donor human milk to hospitals. Dr. Trang
et al use a cost of $4.95 (Canadian dollars) per ounce for donor human milk (with
an additional $0.14 to fortify the donor milk so that protein, calories and micronutrients
are sufficient), versus $0.13 dollars for bovine-based preterm formula. The difference
in cost is striking. Many hospitals continue to receive preterm formula free from
vendors, but this practice is not permitted for Baby Friendly designated birthing
hospitals who must pay “fair market” price; including a cost for formula acknowledges
the societal cost (and actual cost for Baby Friendly designated hospitals) of formula.3
At the end of the day, mean total cost from birth through 18 months corrected age
was the same in both groups! However, the authors help us understand the difference
between cost and cost-effectiveness by explaining the cost-effectiveness acceptability
curve (CEAC) and the uncertainties associated with decision-making relative to cost
– how many dollars are decision-makers willing to spend to prevent one case of NEC?
For non-economists, this explanation is truly enlightening. And while total initial
hospitalization charges were the same for both groups, what do you predict for the
post-discharge period? Read on for this interesting result!