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Neonatal jaundice

more reliable strategy for the detection of babies who require treatment with phototherapy may
be required if it is cost-effective.
The cost of the care of a person with kernicterus throughout their life runs to millions of pounds.
If resources were invested in a testing strategy that is effective in reducing the number of cases
of kernicterus annually by one case per year, it would be cost saving if the total annual cost of
the strategy were less than the discounted lifetime cost of caring for one individual with the
disease. Since kernicterus is a lifetime condition with poor quality of life, the value that the NHS
places on preventing a case of kernicterus is not only calculated as the cost saved by preventing
the downstream costs but also the £20,000 per quality-adjusted life year (QALY) over the
lifetime of the condition. Clearly, if the intervention were more successful in preventing
kernicterus, then more NHS resources could be used to identify hyperbilirubinaemia and still be
cost-effective.
It seems plausible that a more intensive testing strategy could be clinically effective if it
overcomes the limitations of visual examination alone, thereby leading to better detection and
treatment. Currently, there are two methods of testing: a TSB and a transcutaneous
bilirubinometer (TCB), which is a non-invasive test on the surface of the skin. TCB is probably
not accurate above a threshold level of 250 micromol/litre of bilirubin so that TSB testing is
required in babies whose TCB is above this threshold level. Hence a strategy involving more
bilirubin measurements could be based on TSB alone or TCB with TSB only required for those
babies whose TCB level was higher than the threshold value. Current evidence does not favour
one strategy over the other for the detection of babies with bilirubin levels under
250 micromols/litre. That is, even though TSB is the gold standard test, both strategies, when
used correctly as part of an assessment and management process to test babies who are visibly
jaundiced, would be equally effective at detecting hyperbilirubinaemia and preventing
kernicterus. Both methods are in use in the NHS. The TSB can be analysed in hospital
laboratories without the need for additional equipment. The TCB requires the purchase of hand-
held devices, sufficient for one to be available for each community midwife undertaking
postnatal visits on any particular day.
The economic evaluation was undertaken to determine the conditions under which increased
testing would be cost-effective, and to explore which testing strategy would be cost-effective
under different circumstances.

C.4 Method

In this analysis we evaluate the cost-effectiveness of moving from current practice to a more
intensive test strategy in England and Wales subject to the limitations of the published evidence.

The following strategies are compared:
1. ‘Current practice’ – a visual examination followed by TSB in 10% of visually jaundiced
babies
2. TSB – a TSB on all babies with a positive visual examination
3. TCB followed by TSB if positive TCB – a TCB on all babies with a positive visual
examination, with a TSB on those babies with a positive TCB.

Visual examination has a high negative predictive value, which means that babies who do not
appear visually jaundiced are very unlikely to have clinically significant jaundice. However,
visual examination has been shown to be unreliable in detecting the severity of
hyperbilirubinaemia. Therefore, visual examination alone as a basis for detecting jaundice
requiring phototherapy has poor sensitivity, which may put jaundiced babies at a higher risk of
developing kernicterus.
Detection of hyperbilirubinaemia requiring treatment or further monitoring can be better
assessed using a TCB or a blood test to measure the TSB. The TCB is done with a hand-held
device (such as the Minolta JM-103 or the BiliChek) that is simple to use and is placed on the
baby’s skin. The TSB is the gold standard test but is more invasive and distressing to the baby
since it requires a blood sample. Both tests can be carried out by the midwife during the home
visit or in hospital if the baby has not been discharged.

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