PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.
"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."
Dr. Brendan T. Campbell
The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).
In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.
A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.
Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).
Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.
Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.
Limitations of the study included its retrospective design and the potential for coding errors and missing data.
Dr. Campbell said that he had no relevant financial conflicts to disclose.
The meeting was supported by a grant from Elsevier, which owns this news organization.