Page 199 - 16Neonatal Jaundice_compressed

Neonatal jaundice

Analysis 1 – varying clinical parameters
In this analysis it was assumed that the mortality rate for an exchange transfusion was 3 per
1000. 243 Furthermore, we took the upper limit of the 95% confidence intervals for the NNT. In
this analysis the ICER for Rhesus haemolytic disease was £34,379. For ABO haemolytic disease
the ICER was £243,381.
Analysis 2 – varying treatment costs
In this sensitivity analysis the clinical parameters were maintained at their base-case value. The
costs of IVIG were then increased to determine the value at which IVIG treatment would no
longer be cost-effective. For ABO haemolytic disease IVIG treatment remained cost-effective for
all IVIG treatment costs less than £2,421. For Rhesus haemolytic disease IVIG treatment would
have to exceed £6,054 for it to no longer be considered cost-effective.

D.6 Discussion

This analysis strongly suggests that IVIG is a cost-effective treatment in babies with Rhesus
haemolytic disease as an adjunct to phototherapy where bilirubin levels are still rising. This
finding seems reasonably robust with respect to uncertainty in model inputs. Even when the
NNT was taken from the upper limit of the 95% confidence interval and much lower exchange
transfusion mortality than the base case was assumed, the ICER was only just outside what
would be considered cost-effective by NICE criteria. Also, with base-case clinical inputs the
cost-effectiveness of IVIG in Rhesus disease babies was not sensitive to the costs of IVIG.

For patients with ABO haemolytic disease the cost-effectiveness of IVIG is less certain because
of the higher NNT. The cost-effectiveness in this group is very sensitive to exchange transfusion
mortality and the NNT within plausible ranges. While cost-effective in the base-case analysis,
the ICER in the ‘worst-case’ scenario would not be considered to be a cost-effective use of
scarce NHS resources.
While the sensitivity analysis did not suggest that the results were particularly sensitive to
changes in IVIG cost, it should be remembered that if the true clinical inputs conferred a lower
benefit with IVIG treatment then the importance of treatment costs as a determinant of cost-
effectiveness would increase.

D.7 Conclusion

The model seems to provide good evidence that IVIG treatment in babies with Rhesus
haemolytic disease can be considered cost-effective and it therefore supports the GDG
recommendation. IVIG treatment in babies with ABO haemolytic disease may also be cost-
effective, as indicated by the base-case results. However, sensitivity analysis suggested this
finding is subject to considerable uncertainty. Nevertheless, IVIG treatment in this group of
patients is consistent with recent Department of Health guidance and is also likely to have a
relatively small cost impact given the number of babies affected and therefore the GDG
recommendation seems reasonable. Research to ascertain the cost-effectiveness of IVIG,
especially in babies with ABO haemolytic disease, could be useful given the current evidence
base.

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