Adding a Skin Bilirubin Scan to Visual Jaundice Checks Cuts Costs in Clinics

A cost-minimization analysis from Malaysia suggests that adding transcutaneous bilirubin screening to the conventional visual assessment of newborn jaundice could lower the cost of care in primary healthcare clinics without compromising clinical safety. The study, published in BMC Health Services Research, compared two screening strategies for neonatal jaundice across six Malaysian government-run primary care clinics.

Neonatal jaundice is a prevalent condition that requires timely detection and management to prevent severe hyperbilirubinemia and its long-term sequelae. In Malaysia, screening in primary care has predominantly relied on Kramer’s Rule, a visual scoring method based on the extent of yellow discoloration of the skin, followed by total serum bilirubin testing when necessary. The research team asked whether incorporating transcutaneous bilirubin measurement, a non-invasive device-based reading, into this pathway would change the cost profile, given that earlier work reported similar safety outcomes between the two approaches.

The retrospective cost-minimization analysis drew on data from the TRANDLAB study, in which 765 neonates were screened using two different strategies: a combined pathway of Kramer’s Rule, transcutaneous bilirubin screening and serum testing, involving 384 neonates, and the conventional Kramer’s Rule plus serum testing pathway, involving 381 neonates. Direct medical costs over a 10-day neonatal monitoring period were analyzed using decision-tree models that captured all potential clinical pathways.

The probabilities used in the models were derived from the TRANDLAB study data, while the cost estimates incorporated personnel time, consumables, equipment acquisition, calibration and maintenance for both serum and transcutaneous testing. This structure allowed the researchers to compare the full economic footprint of each screening strategy rather than the price of any single test.

The decision-tree modelling revealed significantly lower mean costs per neonate in the combined screening cohort, at USD 4.15 with a standard deviation of 2.33, compared with USD 5.41, standard deviation 2.75, in the conventional cohort. That translated into a significant saving of USD 1.25 per neonate for the transcutaneous screening strategy, with a P value below 0.001.

Sensitivity analyses tested how robust these savings were. A threshold analysis indicated that the cost advantage was maintained unless the per-measurement cost of transcutaneous bilirubin testing exceeded USD 1.17. The analyses also compared the combined strategy using American Academy of Pediatrics screening thresholds against the local guideline-based approach.

Under the American Academy of Pediatrics-guided version of the combined strategy, the mean cost per neonate fell by 6.4% and blood draw requirements decreased by 20.2% compared with local guidelines, without compromising detection of severe hyperbilirubinemia.

The authors conclude that integrating transcutaneous bilirubin screening with Kramer’s Rule enables targeted use of serum testing, maintaining clinical safety while significantly reducing the mean cost per neonate. They position these findings as evidence to inform health policymakers in optimizing resource allocation and enhancing the efficiency and quality of neonatal care delivery in primary care settings.

As a cost-minimization analysis grounded in one screening study across six clinics, the analysis reflects the costs and clinical pathways of the Malaysian primary care context, and the reported savings depend on local equipment, personnel and consumable prices. Within those bounds, the study provides a quantitative estimate of what a non-invasive screening step could add, economically, to a widely used visual assessment rule for newborn jaundice.

Subject of Research: Cost comparison of neonatal jaundice screening strategies with and without transcutaneous bilirubin measurement in Malaysian primary care clinics

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

Article References: Lim, X.-J., Hing, N. Y. L., Leong, E.-L., Ambigapathy, S., Mior Azmi, N. I., Annamalai, M. S., Nandi Mithra, S. M., Lee, L.-Y., Abu Bakar, M. Z., Kaur, P., Devesahayam, P. R., Khoo, Y. Y., Mustapha, F. I., & Nachiappan, J. P. (2026). Kramer’s rule with or without transcutaneous bilirubin screening for neonatal jaundice in primary healthcare clinics: a cost-minimization analysis. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15508-9

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15508-9

Keywords: neonatal jaundice, transcutaneous bilirubin, Kramer's Rule, cost-minimization analysis, primary healthcare, Malaysia, screening, total serum bilirubin, decision-tree model, health economics, TRANDLAB study, hyperbilirubinemia