Infant CCHD deaths cut by 33% after mandatory pulse oximetry testing

Infant deaths from critical congenital heart disease (CCHD) declined by 33.4 percent in eight states that mandated pulse oximetry screening for newborns, according to a study published online Dec. 5 in JAMA.

“Critical congenital heart disease, a subset of 12 phenotypes or defects with a high likelihood of presenting with low blood oxygen saturation (hypoxemia), occurs in 200 per 100,000 births,” wrote lead author Rahi Abouk, PhD, and colleagues. “The rationale for screening is that timely detection can reduce the risk of an apparently healthy infant with critical congenital heart disease being discharged home and experiencing a potentially fatal crisis. If not diagnosed in a timely manner, particularly before the patent ductus arteriosus closes at a few days of life, infants with these defects often die.”

In 2011, critical congenital heart disease was added to the U.S. Recommended Uniform Screening Panel for newborns. Abouk and colleagues used National Center for Health Statistics data from approximately 26.5 million births from 2007-2013 to assess whether state-mandated, pulse oximetry screening was associated with a reduction in early infant deaths coded for CCHD or other/unspecified cardiac causes. They compared post-implementation data from the eight states which had adopted these policies by June 1, 2013, to previous data from those states and other states that had not yet adopted mandatory screening policies.

In addition to a one-third reduction in CCHD deaths, the researchers found early infant deaths (between 24 hours and six months after birth) for other cardiac causes declined by 21.4 percent in states with mandatory screening policies. The absolute declines were 3.9 deaths per 100,000 births for CCHD and 3.5 deaths per 100,000 births for other cardiac causes. No significant decreases were detected for either cause of death in states without mandatory screening.

“A one-third reduction from the baseline of 350 to 380 critical congenital heart disease infant deaths per year would imply 120 fewer deaths per year if mandatory screening were implemented nationwide,” Abouk and colleagues wrote. “A previous cost-effectiveness analysis that assumed that 20 deaths would be averted each year by universal critical congenital heart disease screening in the United States calculated an incremental cost-effectiveness ratio of $40,385 per life-year gained (in 2011 U.S. dollars). The present results suggest a lower cost per life-year gained.”

Presently, only two states, Idaho and Wyoming, do not have mandatory screening policies, according to the authors of a related editorial. Because of this, the findings of the JAMA study aren’t intended to inform future policy in the U.S., but rather evaluate the policy’s impact. In addition, the results could be helpful to other countries considering routine CCHD screening, Abouk et al. wrote.

Due to the small number of deaths in states with fully implemented mandatory screening policies by June 1, 2013, the Abouk and colleagues cautioned the differential estimates could be imprecise. They said replicating their results with additional years of data is needed to substantiate their findings.

In addition, some hospitals may have screened for critical congenital heart disease without state-mandated policies, but that would only lessen the comparative effectiveness observed in screening policies.

“The evidence is now sufficient to declare newborn screening for critical congenital heart disease a successful public health intervention,” wrote Alex R. Kemper, MD, MPH, MS; Wendy K. K. Lam, PhD; and Joseph A. Bocchini Jr., MD, in the accompanying editorial. “Additional data are needed to provide more specific information about what aspects of the critical congenital heart disease newborn screening requirements are most effective in improving health outcomes.

“The specific remaining issues require careful research, such as the comparative effectiveness of different screening algorithms, how screening should be modified for newborn nurseries at high altitude, and the categorization and management of the other cardiac and noncardiac conditions identified by screening for critical congenital heart disease.”