Cost effectiveness of zanamivir for the treatment of influenza in a high risk population in Australia.

OBJECTIVE: To use data from a clinical trial of zanamivir, a new antiviral drug, to estimate the costs and effectiveness of alternative treatment strategies for a high-risk population in Australia visiting a physician for treatment of influenza or influenza-like illness within 36 hours of symptom onset. DESIGN AND SETTING: This was a modelling study using data from a randomised, double-blind, placebo-controlled trial with centres in Australia, New Zealand and South Africa. Cost data were taken from standard Australian sources. METHODS: Efficacy data from the clinical trial were used to populate a computer model designed to estimate the costs and health outcomes associated with alternative treatments for influenza and influenza-like illness. Only patients who consulted the physician within 36 hours of symptom onset were included in this trial. Cost data were used to translate the clinical data into treatment cost estimates. RESULTS: Treatment with zanamivir for this high risk population results in an incremental cost of $A14.20 per day of symptoms avoided in the base case. The cost per quality-adjusted life-year (QALY) gained is $A11,715. The results are sensitive to several parameter values, including the influenza-positive rate and the impact of zanamivir on days to alleviate symptoms and hospitalisation. CONCLUSIONS: Influenza is costly for the high risk population who seek physician treatment. Treatment with zanamivir for this population is cost effective based on an $A78,000 per QALY benchmark. Zanamivir could be cost saving if it reduces the hospitalisation rate.

Potential savings in the cost of caring for Alzheimer's disease. Treatment with rivastigmine.

OBJECTIVE: To estimate savings in the cost of caring for patients with Alzheimer's disease (AD) during 6 months, 1 year and 2 years of treatment with rivastigmine. An intermediate objective was to estimate the relationship between disease progression and institutionalisation. DESIGN AND SETTING: We assessed the relationship between Mini-Mental State Examination (MMSE) score and institutionalisation using a piecewise Cox proportional hazard model. To estimate cost savings from treatments lasting 6 months, 1 year and 2 years, estimates of the probability of institutionalisation were integrated with data from two 6-month phase III clinical trials of rivastigmine and a hazard model of disease progression. MAIN OUTCOME MEASURES AND RESULTS: Our data suggest that savings in the overall cost of caring for patients with mild and moderate AD can be as high as $US4839 per patient after 2 years of treatment. Furthermore, the probability of institutionalisation increases steadily as MMSE score falls. Among our study individuals, age, race, level of education and marital status were significant predictors of institutionalisation, whereas gender had little effect. CONCLUSIONS: Using rivastigmine to treat AD results in a delay in disease progression for patients who begin treatment during the mild or moderate stages of the disease. By delaying the probability that a patient will be institutionalised, the cost of caring for AD patients can be significantly reduced.

Assessing the Saskatchewan database for outcomes research studies of depression and its treatment.

This study was conducted to evaluate the validity of using the Saskatchewan Health administrative claims databases for conducting depression research. To develop a claims-based definition of depression, we identified a cohort of individuals who began a "new" period of antidepressant use (no use 180 days prior) from which we selected a stratified random sample (n = 600) for medical record abstraction. The medical record diagnosis was used as the gold standard for judging our database definitions of depression. After defining a primary database definition of depression, we tried to refine it using medically probable scenarios and assessed refinement by agreement statistics. Defining depression with ICD9 codes 296 (affective disorders), 309 (adjustment reaction), and 311 (depressive disorders), the sensitivity (Se), specificity (Sp), positive (PV+) and negative predictive (PV-) values were: 71%, 85%, 86%, and 70%, respectively. Algorithms that limited the number of false-negatives resulted in: Se = 84% and PV- = 77% whereas those that limited false-positives resulted in: Sp = 90% and PV+ = 86%. Although our depression definition requires treatment with antidepressants, this definition will allow us to conduct future studies of depression and its treatment using the Saskatchewan Health databases.

Impact of zidovudine-based triple combination therapy on an AIDS drug assistance program.

A static deterministic model was used to estimate the effect of the shift to a triple combination therapeutic standard on the annual AIDS Drug Assistance Program (ADAP) budget, total medical care expenditures, and population health outcomes for New York (NY) state ADAP enrollees. The model used opportunistic disease incidence data from the Multicenter AIDS Cohort Study (MACS) and other studies. Costs of treating opportunistic infections (OIs) and other HIV complications with each type of therapy were derived from treatment algorithms and standard unit costs. CD4+ cell counts were used as an index of need for OI prophylaxis and for determining OI incidence. Treatment with zidovudine-based combination therapy has been shown to increase CD4+ cell counts and reduce OI incidence. The model estimated that a change from monotherapy to triple therapy would have increased NY ADAP budget expenditures per enrollee by 115%. However, total medical system costs per ADAP enrollee (including ADAP costs) would decrease by 0.4% in the base case as a result of reduction in OIs and other HIV sequelae and associated costs. Results are sensitive to the assumed percentage of people taking combination therapy as well as to the assumptions made about the impact of the combination therapy on CD4+ cell count. Total ADAP budget impacts will depend on the growth in ADAP enrollment as a result of the availability of more effective therapies. In conclusion, this model demonstrates how access to newer, more effective HIV drug treatments can reduce the costs of treating OIs and provide major health benefits for ADAP enrollees.

Savings in the cost of caring for patients with Alzheimer's disease in Canada: an analysis of treatment with rivastigmine.

OBJECTIVE: To estimate per-patient potential cost savings using rivastigmine in the treatment of Alzheimer's disease (AD) in Canada. BACKGROUND: In recent years, new members of a class of pharmaceuticals known as cholinesterase inhibitors have been introduced for the treatment of patients with AD. Two recent studies conducted in the United Kingdom and the United States estimated potential cost savings from the new cholinesterase inhibitor rivastigmine. The present study combined the disease-progression model used in those 2 studies with Canadian costs to estimate per-patient potential savings resulting from the treatment of AD in Canada. METHODS: Efficacy data from 2 pivotal, phase III clinical trials of rivastigmine were used in a hazard model of disease progression to estimate long-term differences in cognitive functioning between patients receiving rivastigmine and patients receiving no treatment. We used the Mini-Mental State Examination (MMSE) score as our measure of disease progression. We also used Canadian costs of AD care, estimated as a function of MMSE score, to estimate cost savings experienced by treated patients compared with patients receiving no treatment. All costs and cost savings are presented in 1997 Canadian dollars. We used a societal perspective in this analysis. RESULTS: Rivastigmine was estimated to delay the transition to more severe stages of AD by up to 188 days for patients with mild AD after 2 years of treatment. For patients with mild-to-moderate and moderate disease, this delay was estimated to be 106 and 44 days, respectively. For patients with the mild stage of AD, estimated average daily cost savings (excluding the cost of rivastigmine) ranged from Can $0.45 per patient per day at 6 months to Can $6.44 per patient per day after 2 years of treatment. For all patients, these estimated average daily cost savings ranged from a low of Can $0.71 per patient per day after 6 months of treatment to a high of Can $4.93 per patient per day after 2 years. CONCLUSION: On average, treatment with rivastigmine yields savings in the direct cost of caring for AD patients that exceed the cost of the drug after 2 years of treatment.

Cost-effectiveness model of cytomegalovirus management strategies in renal transplantation. Comparing valaciclovir prophylaxis with current practice.

BACKGROUND: Cytomegalovirus (CMV) disease may occur following renal transplantation and has been shown to have health and cost consequences in this setting. OBJECTIVE: To compare the cost effectiveness of different CMV management strategies for renal transplant patients: prophylaxis with (i) oral valaciclovir or (ii) intravenous ganciclovir; viral testing for CMV followed by (iii) pre-emptive therapy with intravenous ganciclovir or (iv) adjustment of immunosuppression and intensive monitoring; or (v) waiting to treat when CMV disease develops. METHODS: A decision-tree model was constructed that included the different management strategies for the donor seropositive/recipient seronegative (D+R-) population. Clinical outcomes for the D+R- population came from clinical trials. Treatment algorithms and costs for CMV syndrome and tissue invasive disease were developed from published literature and UK physician interviews. One- and 2-way sensitivity analyses were performed. STUDY PERSPECTIVE: UK National Health Service. RESULTS: Prophylaxis with either oral valaciclovir or intravenous ganciclovir dominated (lower costs and fewer cases of CMV disease) the pre-emptive treatment and wait-and-treat strategies. The cost per patient was from 157 Pounds to 438 Pounds higher with oral valaciclovir prophylaxis compared with intravenous ganciclovir prophylaxis and the incremental cost per case of CMV disease avoided with valaciclovir prophylaxis ranged from 2243 Pounds to 8111 Pounds (1996 values). These results are sensitive to the efficacy of intravenous ganciclovir prophylaxis and CMV management costs. CONCLUSIONS: For D+R- renal transplant patients, prophylaxis is the dominant (more effective and less costly) management strategy compared with pre-emptive and wait-and-treat strategies. The cost per patient with oral valaciclovir prophylaxis compared with intravenous ganciclovir prophylaxis is slightly higher in our base case scenario, but may be lower under reasonable alternative assumptions.

Annual health outcomes and treatment costs for schizophrenia populations.

This article describes a model that estimates annual patient health and cost outcomes for schizophrenia under alternative treatment scenarios. We estimate these outcomes for typical antipsychotics and show how treatment with atypical antipsychotics could have an impact on these outcomes. Patients are divided into 5 subcategories--newly diagnosed, no episode, acute episode(s), extended care, and institutionalized--and patient health and cost outcomes are estimated for each category. The proportion of people in each category is estimated for U.S. general, state mental hospital, and community mental health populations. Outcomes include extrapyramidal and moderate/severe schizophrenia symptom days, employed days, suicides, hospital days, and health costs. For patients treated with typical antipsychotics, annual per-patient symptom days ranged from 55 to 365 and costs ranged from $16,000 to $57,000, depending on disease severity. Atypical antipsychotics may reduce symptoms and costs through better efficacy for negative symptoms and better compliance.

Willingness to pay as a measure of health benefits.

In this paper, we discuss the use of cost-benefit analysis (CBA) for evaluating new healthcare interventions, present the theoretical basis for the use of willingness to pay as a method for valuing benefits in a CBA and describe how to obtain willingness-to-pay (WTP) measures of health benefits and how to use these values in a CBA. We review selected economic studies on consumer demand and consumer surplus and studies presenting WTP estimates for healthcare interventions. The theoretical foundations of willingness to pay as a measure of commodity value are rooted in consumer demand theory. The area under the fixed income consumer demand curve represents the consumer's maximum willingness to pay for the commodity. We identify 3 types of potential benefits from a new healthcare intervention, namely patient benefits, option value and altruistic value, and suggest WTP questions for valuing different combinations of these benefits. We demonstrate how responses to these questions can be adjusted for income effects and incorporated into economic evaluations. We suggest that the lack of popularity of CBAs in the health area is related to the perceived difficulty in valuing health benefits as well as concern over how CBA incorporates the distribution of income. We show that health benefits can be valued using simple survey techniques and that these values can be adjusted to any desired income distribution.

A pharmacoeconomic model for the treatment of influenza.

OBJECTIVE: The aim of this study was to develop a generic treatment algorithm for influenza and influenza-like illness (ILI) that could be used to estimate the costs and outcomes of current and new treatments for influenza in different countries for different patient subgroups. METHODS: A series of possible treatment pathways was identified and the probabilities of different patient subgroups following each pathway were estimated by using the published literature. The health outcomes and health service use and unit costs for each pathway were estimated from trial data and standard data sources. An interactive computer model was created, the base-case input parameter values were assigned, and estimates of the current costs of influenza and ILI in different population subgroups estimated. Sensitivity analyses were performed by changing input parameter values. RESULTS: The average healthcare cost of influenza and ILI per person in the US was $US72 for the general population and $US330 for a high risk population (1997 values). The average total cost per patient (healthcare cost plus productivity losses) was $US320 for the general population and $US546 for a high risk population. These costs are sensitive to changes in the proportion of patients visiting a physician and to the proportion of patients hospitalised with complications of the disease. Days to alleviate major symptoms and other health outcome measures are sensitive to the percentage of patients who receive antiviral therapy as well as to the efficacy of this therapy. CONCLUSIONS: The costs and health outcomes of influenza and ILI depend on the extent to which patients visit a physician, the use of antiviral drugs, and the incidence of complications requiring hospital care. The computer model will allow decision-makers to assess the cost effectiveness and the potential budget impact of new antivirals for treating influenza.

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy.

OBJECTIVE: To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients. BACKGROUND: Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs). METHODS: We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years. RESULTS AND CONCLUSIONS: The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.

The role of cost-consequence analysis in healthcare decision-making.

A greater understanding of value associated with new pharmaceutical products should lead to better decision-making. Most commonly cost-effectiveness ratios (CERs) are used to indicate value; however, researchers have recently shown that CER estimates are rarely used by decision-makers in making formulary decisions. In this article, a cost-consequence approach to estimating the value for money of a new treatment for a specific disease is described. Using a cost-consequence approach, the impact of the new treatment on lifetime resource use and costs (including specific healthcare service use and costs, and productivity losses) and health outcomes (including disease symptoms, life expectancy and quality of life) for an individual or group of individuals is estimated and presented in a tabular format. The cost-consequence format is more likely to be approachable, readily understandable and applied by healthcare decision-makers than a simple CER. The decision-maker may use selected items from the cost-consequence analysis to compute composite measures of drug value, such as cost per life-year gained or cost per quality-adjusted life-year (QALY) gained. In general, the cost-consequence approach, by making the impact of the new treatment as comprehensive and transparent as possible, will enable decision-makers to select the components most relevant to their perspective and will also give them confidence that the data are credible to use as the basis for resource allocation decisions.

Comparison of valaciclovir and acyclovir for the treatment of herpes zoster in immunocompetent patients over 50 years of age: a cost-consequence model.

A method was developed for modeling the costs and consequences of treating varicella zoster viral infections to clinical data generated in a pivotal phase III clinical trial of valaciclovir versus acyclovir for the treatment of acute herpes zoster in immunocompetent patients over 50 years of age. Direct medical costs and indirect costs (productivity losses) were modeled using unit costs applicable in the United States. Compared with acyclovir, valaciclovir reduced average direct medical costs per patient by 17% ($60.01) and indirect costs by an average of 25% ($46.54). Median duration of pain was reduced by 13 days for valaciclovir compared with acyclovir in the intent-to-treat population or by 19 days in patients with pain after rash healing. The cost variables described in the model (drug costs, cost of treating long-term pain, physician visits, hospitalization, treatment of severe ocular involvement, productivity losses) were tested by sensitivity analysis. Total costs associated with valaciclovir treatment remained lower than those with acyclovir over the range of the analysis.

Functional status in depressed patients: the relationship to disease severity and disease resolution.

BACKGROUND: We set out to measure the impact of depression and its clinical resolution on patients' functional status. METHOD: The Work and Social Disability Scale (WSDS), a five-category investigator-rated scale measuring patient functional status, was completed at baseline and study discontinuation in a 56-day, open, uncontrolled study evaluating the safety of a sustained release (SR) formulation of bupropion in 3167 patients at 105 sites. To be included in the study, patients had to be 18 years or older, have a diagnosis of depression, and be considered appropriate for treatment with bupropion SR. The proportion of patients in each WSDS category, for those patients taking more than 7 days of bupropion SR (N = 2915), was assessed at screen and study discontinuation. The percentage of patients with improved WSDS scores at 56 days was also measured for all patients and correlated with patient and treatment characteristics. RESULTS: Of the patients entering the trial, 61.8% were markedly or severely impaired in their work or social activities, and only 5.4% were mildly or not impaired. At study discontinuation, more than 54% of patients were judged by the investigator to have very much or much improvement in their clinical symptoms. Results on the WSDS correlated with the clinical improvements; only 22.3% were markedly or severely impaired; and 50.0% were mildly or not impaired at study discontinuation. In addition, 63.9% of patients had less work or social disability at the end of the trial than at study entry. Functional status improved more in patients who had not previously been treated for the episode, had more severe depression at study entry, and had a higher dose and duration of treatment with bupropion SR. CONCLUSION: The results show that depression results in significant impairment in patients' functional status. Functional status improved in patients treated with bupropion SR for up to 56 days. This improvement was highly correlated with improvement in clinical symptoms and was related to patient characteristics at study entry as well as to treatment patterns during the study.

Estimating the dollar value of health outcomes from drug-abuse interventions.

OBJECTIVES: People who abuse drugs suffer from a host of medical problems that impose costs on both the abusers and society as a whole. Drug-abuse treatment and other interventions can help alleviate these medical problems, leading to health status improvements for chronic drug users and reduced social costs. The authors' dual purpose here is to (1) propose a theoretically rigorous yet easy-to-apply methodology for estimating the health-related costs of drug abuse and (2) demonstrate the methodology by estimating the potential dollar value of avoiding adverse health consequences as a result of successful drug-abuse interventions. METHODS: The authors' proposed multiattribute quality-adjusted life year methodology for estimating the value of avoiding morbidity and mortality involves eight steps to be followed sequentially. The framework is based on developing a common unit of well-being (i.e., quality-adjusted life year) that can be applied to all types of health conditions. If all health states can be denominated in this common unit, then the process of valuation is straightforward and consistent across all types of illnesses and diseases. The methodology is relatively inexpensive to execute because the estimation procedures are not complicated technically and the data demands are modest. Also, this approach incorporates elements from several disciplines, including psychology, epidemiology, medicine, and economics. Finally, the proposed methodology is flexible enough to cover a wide range of illnesses and diseases so that consistent and comparable estimates can be generated. RESULTS: The authors estimate the dollar value of avoiding acute hepatitis B, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), hypertension, bacterial pneumonia, sexually transmitted diseases, and tuberculosis for a white male aged 32 years. The authors' results illustrate that estimated avoided morbidity values can vary significantly across the range of health consequences associated with drug abuse. At the upper end of the range, the value of avoiding only the morbidity associated with a single case of HIV/AIDS is approximately $157,811 for the period beginning with transmission of HIV, through late-stage HIV and AIDS, and ending just before death. CONCLUSIONS: People who abuse drugs suffer from many medical problems in addition to their addiction. The proposed approach for estimating the dollar value of avoiding adverse health consequences provides policy analysts, evaluators, and researchers a method to calculate theoretically based benefit estimates for use in a benefit-cost analysis of drug-abuse interventions.

Economic impact of treatment of HIV-positive pregnant women and their newborns with zidovudine. Implications for HIV screening.

OBJECTIVES: To estimate the economic impact of (1) treating pregnant women who are human immunodeficiency virus (HIV)-positive with zidovudine and (2) voluntary screening programs for pregnant women for HIV infection and offering treatment with zidovudine to those found to be HIV-positive. MAIN OUTCOME MEASURES: Number of cases of pediatric HIV infection and costs of screening, zidovudine treatment, and pediatric HIV infection treatment. DESIGN: Health care costs associated with treatment of HIV-positive pregnant women and their newborns are estimated as the costs of zidovudine and its administration and the reduction in costs of treating pediatric HIV infection. The lifetime costs of pediatric HIV infection are derived from the published literature. Estimates of the reduction in maternal-to-fetal transmission rates are taken from the AIDS [acquired immunodeficiency syndrome] Clinical Trials Group (ACTG) Protocol 076. Costs of a voluntary screening program include costs of screening tests and counseling. Sensitivity and threshold analyses are performed to determine the impact of changes in input parameter values including zidovudine treatment costs, efficacy of treatment, costs of pediatric HIV infection, prevalence of HIV infection in pregnant women, screening test sensitivity and specificity, and pregnancy termination rates on the results. RESULTS: Assuming transmission rates are reduced from 25.5% to 8.3% as found in the ACTG 076 trial, treatment costs of $104,502 for 100 HIV-positive pregnant women and their newborns are offset by the reduction of $1,701,333 associated with fewer cases of pediatric HIV infection for a net savings of $1,596,831. The sensitivity and threshold analyses show that overall cost savings from treatment of HIV-positive pregnant women and their newborns are achieved for a wide range of possible maternal treatment costs, efficacy rates, and lifetime pediatric HIV treatment costs. In the base-case analysis for the voluntary screening program, overall cost savings are seen when HIV prevalence rate among pregnant women is greater than 4.6 per 1000. However, this threshold prevalence rate is sensitive to changes In parameter value-especially pediatric HIV treatment costs, counselling costs, efficacy of treatment, and years of additional HIV treatment for the pregnant women. CONCLUSIONS: Offering zidovudine treatment to pregnant women known to be HIV-positive will decrease the number of cases of pediatric HIV infection and reduce health care costs. Voluntary screening programs for pregnant women will further decrease the number of cases of pediatric HIV infection. The effect of a screening program on health care costs varies according to HIV prevalence and the costs associated with the screening program.

Cost-consequence models for varicella-zoster virus infections.

Three cost-consequence models were developed for treatment of infections due to varicella-zoster virus (VZV) with acyclovir in immunocompetent patients--adult- and childhood-onset chickenpox, and herpes zoster (shingles) in adults. For chickenpox, separate models allow examination of differences in severity and impact of the disease for children and adults, as well as in the management of civilians and adults in military service. Each model includes direct medical costs, indirect costs and health-related productivity loss, symptom and quality of life impact, and model assumptions and conclusions. Alternatives of treatment and no treatment are addressed. Quality of life impact is conceptualized in terms of a quality-adjusted life-days decrement due to VZV symptoms of importance to the patient, such as pain, rash, and itching. As experience and data become available, alternative agents such as valacyclovir and famciclovir for the treatment of patients with herpes zoster should be included in the modeling process.

Estimating the value of a generic quality-of-life measure.

In this paper, data from a clinical trial of a new antiviral agent for treating patients with zoster are used to answer the following question: Does the Nottingham Health Profile (NHP) add to the information obtained from the clinical measures? Three ways in which the NHP could add information are measured. First, Cox's regression analysis is used to determine whether health-related quality-of-life scores obtained at diagnosis give information about disease prognosis. Second, changes in mean NHP scores in different dimensions are computed after pain resolution to determine whether NHP scores provide more sensitive indicators of disease resolution. Third, linear regression is used to determine whether the impacts of disease on quality of life are measured adequately by the clinical parameters. These analyses show that use of the physical mobility and energy dimensions of the NHP increases understanding of disease prognosis; demonstrates the continuing impact of zoster on patients' sleep patterns and energy levels, disease symptoms not included as clinical measures, that persist after the cessation of zoster-associated pain; and gives a measure of the impact of zoster on the patient, which includes unmeasured and measured levels of severity.

Synthetic surfactant for rescue treatment of respiratory distress syndrome in premature infants weighing from 700 to 1350 grams: impact on hospital resource use and charges.

To determine the impact of the use of synthetic surfactant on hospital resource use and charges, we analyzed the economic data from a multicenter, randomized, placebo-controlled clinical trial of synthetic surfactant in infants with neonatal respiratory distress syndrome and birth weights between 700 and 1350 gm. Two 5 ml/kg doses of a synthetic surfactant (Exosurf Neonatal) or air placebo were administered to 419 infants who were receiving mechanical ventilation and had an arterial/alveolar oxygen tension ratio < 0.22. In addition to the clinical endpoints for safety and efficacy, data were collected on length of hospital stay, days in the neonatal intensive care unit, days of mechanical ventilation, days of oxygen supplementation, and hospital charges until the infant reached 1 year adjusted age. Growth and development of infants who received synthetic surfactant therapy in the study and survived to 1 year adjusted age were equivalent to those of the survivors in the air placebo group. For 1-year survivors, synthetic surfactant reduced the average length of stay at the different levels of care needed during the hospitalization such as neonatal intensive care unit days, days of mechanical ventilation, and days of oxygen supplementation. For nonsurvivors, synthetic surfactant increased the average length of stay, especially at more intense levels of care. Total hospital charges for the initial hospitalization and through 1 year adjusted age for a hypothetic cohort of 100 infants treated with synthetic surfactant were, on average, the same as those for a comparable cohort of infants in the air placebo group. These results indicate that rescue therapy with synthetic surfactant in infants with respiratory distress syndrome and birth weights from 700 to 1350 gm can result in significantly improved survival without significant increases in hospital charges.