(including direct and indirect costs) to patients, their families, and society. Cost-benefit studies are difficult to evaluate (73). In addition, one study empirically examined whether an ethically sound birth weight-specific cutoff for resuscitation would result in substantial savings in the cost of NICU treatment (74).

By using data from large national surveys of health behaviors and medical expenditures, it was estimated that LBW infants incurred more than one-third of all infant health care costs in the first year of life in 1988 ($4 billion of the $11.4 billion spent for all infants). The costs for an individual infant increased as gestational age decreased (75). Similarly, in a single-center retrospective study of preterm infants and hospital charges, gestational age, LOS, and survival were all independently related to cost (76).

In a single-center retrospective review and questionnaire study from an academic medical center in Finland, it was found that ELBW infants incurred significantly increased costs in the first year of life, including hospitalization costs, rehabilitation costs, loss of earnings for care givers, and travel costs. The study was limited by parental recall and participation bias, but the authors concluded that the total costs for ELBW infants, even those who were normally developed, were higher than those for normal-birth-weight infants (77).

The costs of caring for nonsurvivors are less than 10 percent of the overall costs of inpatient care for premature infants. Relative to the total cost of prematurity, the costs associated with NICU “trials of therapy” are small.

In a retrospective look at all ELBW infants born at the University of Chicago between 1991 and 2001, it was found that although the median LOS for nonsurvivors had increased significantly, the NICU bed-days occupied by nonsurvivors remained low (~7 percent) because of the overall improvement in survival (51).

In the retrospective study from Finland, the costs attributed to nonsurvivors constituted 9 percent of overall costs for ELBW infants. The authors concluded that the reason for the low proportion of costs attributable to nonsurvivors was their short life span (77).

A population-based cohort study of ELBW infants born in Victoria, Australia, determined that although the effectiveness of neonatal care had increased from 1979 to 1997 (as demonstrated by threefold increases in survival rates and quality-adjusted survival rates), efficiency (as measured by cost-effectiveness and cost-utility ratios) had remained relatively unchanged in nearly two decades (78, 79).

Stolz and McCormick evaluated whether restricting access to neonatal care on the basis of reasonable birth weight cutoffs would result in substan-