The selection of infants for surfactant replacement therapy under conditions of limited financial resources.

The cost of surfactant replacement therapy (SRT) will restrict its use under conditions of limited health resources. Before the local advent of SRT, infants ventilated for hyaline membrane disease (HMD) had an overall survival rate of 87% and an incidence of bronchopulmonary dysplasia of 6.4%. This, together with the cost of SRT, prompted a study to identify those infants who would benefit the most from SRT. Twenty-two infants assessed as having severe HMD were randomised to receive SRT at 3 - 4 hours (9) or at 6 - 8 hours (13) after birth. Two infants (15%) in the latter group did not require SRT. The outcome of these two groups was the same. Of 56 infants assessed as having moderate HMD, only 24 (43%) qualified for SRT from 6 hours of age. The outcome of the SRT and non-SRT infants was comparable. The group of infants with moderate HMD had a significantly better outcome than those with severe HMD. A limited period of observation to assess the severity of illness did not compromise outcome in this group of 78 infants with moderate to severe HMD.

The cost and effectiveness of surfactant replacement therapy at Johannesburg Hospital, November 1991-December 1992.

OBJECTIVE: To assess the impact of surfactant replacement therapy (SRT) on the outcome of hyaline membrane disease (HMD) and to assess the cost implications of a policy of selective administration of artificial surfactant. DESIGN: The short-term outcome of 103 newborns ventilated for HMD (61 selected for SRT according to initial and/or ongoing oxygen requirements) was compared with that of a historical control group of 173 infants ventilated for HMD before the introduction of SRT. MAIN OUTCOME MEASURES: Mortality and morbidity of HMD including death, bronchopulmonary dysplasia, pneumothorax, pulmonary haemorrhage, patent ductus arteriosus and intraventricular haemorrhage. RESULTS: There were significant demographic differences between the treatment and control groups (black patients 74% v. 28%, P < 0.0001; unbooked mothers 72% v. 15%, P < 0.0001) as well as evidence of more severe lung disease in the treatment group (pressor support 44% v. 27%, P < 0.005; and paralysis during ventilation 38% v. 25%, P < 0.005). Pneumothorax was reduced in the SRT group (7% v. 17%, P < 0.01). There were no significant differences between the two groups in the incidence of BPD or mortality. The use of SRT added to the total cost of treating a patient ventilated for HMD. CONCLUSION: The selective use of SRT had the effect of converting severe disease into moderate disease rather than achieving maximal benefit in all cases of HMD through routine use of the product. A policy of restricting use may result in cost savings where resources are limited.

Surfactant replacement therapy in neonates less than 32 weeks gestation: effect on neonatal intensive care resource utilization.

The effect of synthetic surfactant (Exosurf) replacement on complications from hyaline membrane disease (HMD) in infants < 32 weeks gestation and their resource utilization within a neonatal intensive care unit was studied in 1991-92. A control group was selected from infants admitted to the same unit during the preceding 3 years when Exosurf was not available. The infants were controlled for gestation, weight and severity of HMD. Infants given Exosurf had a significant reduction in the incidence of pulmonary interstitial emphysema (PIE), and a marginal decrease in the incidence of pneumothorax. They required fewer days on the ventilator and consumed less of the scarce financial resources. There was no difference in the mortality rate among the two groups. The changes seen were more evident among those infants between 30 and 31 weeks gestation, compared to those < 28 weeks.

Cost implications of different approaches to the prevention of respiratory distress syndrome.

Because the incidence of both neonatal respiratory distress syndrome and neonatal mortality can be reduced by giving corticosteroids to women expected to deliver preterm and by giving surfactant to babies at high risk of developing hyaline membrane disease, we have considered what effects the adoption of one or both of these preventive policies would have on the costs of neonatal care. We have estimated the effects of treatment from overviews of the relevant controlled trials, and estimated costs from observations of care at one neonatal unit. Our results suggest that if either of these policies is adopted for all babies under 35 weeks' gestation at a drug cost of 150 pounds or less/baby, the overall costs of care would be reduced by between 1 and 10%. The cost per survivor would be reduced by up to 16% even if the drug cost were to be as high as pounds 550/baby. If the policies were to be adopted only for babies under 31 weeks' gestation, both policies would result in a reduction in cost of between 5 and 16%/survivor, although the increased survival resulting from the policies would lead to an increase in overall costs for babies of less then 31 weeks' gestation of between 7 and 32%.

Newborn risk factors and costs of neonatal intensive care.

To understand the sources of the high costs of neonatal intensive care, financial and medical information on 1,185 admissions to an intensive care nursery was gathered. Multiple regression analysis showed that a significant portion of the variation in individual costs was explained by three measures of risk: low birth weight, surgical intervention, and assisted ventilation. There was a highly skewed distribution of costs. Nearly half of all admissions had none of the above risk factors, had an average cost of about $2,000, and accounted for only 13% of the total costs for the whole sample. In contrast, less than one quarter of the admissions had two or more of the risk factors, had an average cost of $19,800, and accounted for nearly 60% of the total costs. Models that predict costs and length of stay on a basis of seven risk factors were developed to allow for differences in patient populations.