Kramer’s rule with or without transcutaneous bilirubin screening for neonatal jaundice in primary healthcare clinics: a cost-minimization analysis

Neonatal jaundice (NNJ) is a prevalent condition requiring timely detection and management to prevent severe hyperbilirubinemia and its long-term sequelae. In Malaysia, NNJ screening in primary care predominantly relies on Kramer’s Rule (KR), followed by total serum bilirubin (TSB) testing if it is necessary. Given the similar safety outcome incorporating transcutaneous bilirubin (TcB) screening with KR versus KR-TSB strategy, this study aimed to compare the cost implication between two different screening strategies: KR-TcB-TSB versus the conventional KR-TSB. A retrospective cost-minimization analysis was conducted using data from the TRANDLAB study, involving 765 neonates screened for NNJ across six Malaysian government-run primary care clinics, using two different strategies: KR-TcB-TSB ( n = 384) and KR-TSB ( n = 381). Direct medical costs over a 10-day neonatal monitoring period were analyzed via decision-tree models that captured all potential clinical pathways. Probabilities were derived from TRANDLAB study data, and costs incorporated personnel time, consumables, equipment acquisition, calibration, and maintenance for both TSB and TcB testing. Sensitivity analyses included variations in TcB per-measurement costs and comparing with KR-TcB-TSB using American Academy of Pediatrics (AAP) screening threshold. Decision-tree modelling revealed significantly lower mean (SD) costs per neonate in the KR-TcB-TSB cohort [USD 4.15 (SD 2.33)] versus the KR-TSB cohort [USD 5.41 (SD 2.75)]. The KR-TcB-TSB cohort yielded significant cost savings of USD 1.25 per neonate compared to the KR-TSB cohort ( P < 0.001). Threshold analysis indicated cost savings were maintained unless TcB per-measurement costs exceeded USD 1.17. The AAP-guided KR–TcB–TSB strategy reduced mean cost per neonate by 6.4% and decreased blood draw requirements by 20.2% compared with local guidelines, without compromising detection of severe hyperbilirubinaemia. Integrating TcB screening with KR enables targeted TSB use, maintaining clinical safety while significantly reducing the mean cost per neonate. These findings offer robust evidence to inform health policymakers in optimizing resource allocation and enhancing the efficiency and quality of neonatal care delivery.