Monthly Archives: April 2018

Each baby counts 

Last month, the Royal College of Obstetricians and Gynaecologist (RCOG) published a summary report showing the findings of their each baby counts project.

The report found that in 2015, 1136 babies met the eligibility criteria (term babies who either died or suffered severe brain damage). The work did not involve new investigations into any of these tragic cases, but rather reviewed the local investigations that had already taken place.

One of the most unacceptable findings of the work was that in 25% of these cases, the investigation that had taken place was of such poor quality that it was not possible for the review team to fully establish what happened and whether the outcome might have been preventable.

Of the remaining 727 cases,  in 76% it was judged that the outcome could have been avoided with different care.

The work identified that in 2015, there were 282 babies that died and 854 babies that suffered severe brain damage. Taking the 76% figure and extrapolating suggests that around 215 babies died and around 650 babies suffered brain damage that could have been avoided.

The aspiration of the each baby counts project is that no term baby should suffer death or disability as a consequence of events in labour. In other words, to reduce these numbers to zero.

But how much investment should an ethical healthcare system devote to achieving this aim?

Before going further, it is important to say that the impact of each and every one of these cases is beyond any economic measure. For a family, it’s hard to imagine anything more devastating than the loss of, or serious harm to a child. The repercussions of these events are felt across whole communities. No one would dispute the importance of working to reduce the number of these events, but the question of how much effort and resources we should invest in doing so is less  clear.

Purely for illustration, I thought it was worth looking at how interventions in healthcare to save or enhance lives are usually economically evaluated.

Health economists have invented the concept of a quality-adjusted life-year (QALY). The concept is fairly simple. A scale of 0-1.0 is used, 1 representing perfect health and 0 representing death. Different values are used to represent degrees of morbidity in between. For example, if you have diabetes and a foot amputation due to diabetic complications, your quality of life might be assessed as being reduced by 35%. In other words, your quality-adjusted life-year (for each year you remained alive with this condition) would be only 0.65.

This concept is used by NICE to evaluate the cost effectiveness of new treatment options as a key aspect of their approval process. As a hypothetical example, a new drug to treat a specific type of cancer might be subject to a clinical trial and shown to add an average of 2 QALYs for each person treated. If the total treatment cost was £50,000, the cost effectiveness ratio of this treatment option would be £25,000. In other words, the cost of each QALY gained for the individual patient would be £25,000.

The graph below shows the decisions NICE took from 2007 -2013 against the cost effectiveness ratio (the cost of each QALY gained). As you can see, around £30,000 seems to be used by NICE as the cut-off point for economic evaluation.

Taking the each baby counts report, it is fairly easy to come up with a ballpark approximation for the total QALY impact of the cases of harm where it was judged different care could have altered the outcome.

215 babies died. Assuming that on average, people born in 2015 could be expected to live 60 years in good health, we can approximate that if these deaths were avoided, 215 * 60 = 12,900 QALYs would have been gained.

650 babies suffered avoidable brain damage. Again, and only as a very approximate estimation, if we assume that for each child a figure of 0.5 is used for each year of their life to reflect the reduction to  quality of life due to severe brain damage, we can approximate that 650 * .5 * 60 = 19,500 QALYs would have been gained if these cases of severe brain damage were avoided.

This of course is very imprecise estimate only to illustrate a point. However, if all of the cases highlighted as being potentially avoidable in the each baby counts report had been prevented, a gain of around 32,400 QALYs (12,900 + 19,500) seems like a reasonable ballpark estimate.

Knowing that NICE generally approve interventions that cost up to £30,000 per QALY gained, this gives us a useful frame of reference to think about what would be a reasonable sum to spend on effective interventions to prevent these tragic cases (assuming that the lives of babies are treated with the same value as all human life).

32,400 QALYs * £30,000 = £972m

Currently, 25% of these cases are not even subject to adequate investigation.