Increasing the survival of extremely-immature (24- to 28-weeks' gestation) infants--at what cost?

In one tertiary perinatal centre, the advent of positive-pressure assisted ventilation in the 1970s improved the survival of neonates of 24 to 28 completed weeks of gestation. However, the rate of increase in the resources for assisted ventilation and the improvements in survival rates were stepwise and not smooth. Consequently, it has been possible to calculate the cost-effectiveness of neonatal intensive care up to the time of hospital discharge over two separate eras of stable consumption of resources for assisted ventilation. During 1977-1983, to produce one survivor at 24-weeks' gestation compared with one at 28-weeks' gestation consumed 14.4-times the number of patient-days of assisted ventilation, and 4.9-times more of the total nursery resources; the cost-effectiveness of intensive care during this period decreased with decreasing maturity. The over-all cost-effectiveness up to the time of hospital discharge for infants of 24- to 28-weeks' gestation during 1977-1983, compared with 1971-1974, when assisted ventilation was rare, was $62,268 per additional survivor. After 1983, the consumption of resources for assisted ventilation more than doubled in infants of 24- to 28-weeks' gestation. However, there was a diminishing return with respect to the gains in survival during 1984-1986 and the costs per additional survivor averaged $99,574, which was 60% more than were those for 1977-1983. We speculate that to improve survival further in the most-immature infants by increasing resources for assisted ventilation only can be more difficult and more expensive, and even less cost-effective.