Marten J. Poley - Erasmus Universiteit Rotterdam

Cost-Effectiveness of Treatment for Congenital Diaphragmatic Hernia 453.4 DISCUSSIONThe cost-effectiveness ratio amounts to € 2,434 (costs per QALY), which indicatesgood cost-effectiveness. We conclude that, although CDH patients might fall intothe costliest category of all hospitalized patients, the effects of treatment areworth the costs. Only minor social and demographic differences were foundbetween CDH survivors and the general population. The costs of treatment aresubstantial (€ 42,658), mainly consisting of costs of the initial hospitalization. Tothe best of our knowledge, complete direct medical costs of treatment for CDH(i.e., not only those of ECMO), including all presenting patients, have not beencalculated previously. For example, some studies did not include the full range ofcosts, 20,21 because the research questions made it unnecessary to include, forexample, costs of surgeries and hospital overhead costs. The methods of the fewother studies reported in the literature are either not sufficiently refined forcalculating real economic costs 22,23 or unclear. 24 With the exception of theresearch of Waitzman et al., 22 no attempts have been made to consider other costcategories that should also be taken into account from a societal perspective. Upto adulthood, CDH patients to some degree, suffer from disease-specificsymptoms such as pulmonary problems and stomach aches. Previous studieshave suggested that this is the case. 8-11,25 Taking medical consumption as anindication of quality of life, the quality of life of CDH patients seems lower thanthat of the general population. Despite these findings, the EQ-5D shows that theoverall quality of life of CDH patients does not differ from the general population.This outcome is in line with our introductory remark that, in general, CDHsurvivors can expect good survival.Direct medical costs could be calculated only for 38 patients born in a rather shortperiod (between 1993 and 1996). No conclusions are drawn on patients born inother periods. Our results are likely to be representative for most patients born inthat era. Of course, we cannot be sure that the same results apply to previous orfuture patients. For example, treatment patterns may change in the future.However, some parts of the calculations, such as the large share of the costs ofhospital days in the total direct medical costs, are likely to show similar results.Many of the reflections on the cost calculations in our study in ARM patients 4 alsoapply to the current study. For example, we chose solutions that were more likelyto overestimate the costs of treatment. We therefore consider it unlikely that wehave presented a too favorable picture of cost-effectiveness. One particularcaveat should be made, however, on the cost calculations in this study, i.e., thecosts of ECMO were taken from a large Dutch survey on ECMO in neonates. 14 It isunlikely, however, that this would lead to substantial bias, because both ourstudy and the ECMO survey were performed in patients at the Sophia Children'sHospital, and in both studies the cost calculations were largely based on the samefinancial accounts. Moreover, only 21% of the patients in this study underwentECMO treatment, and the costs of ECMO comprised only 6% of all direct medicalcosts.