Medical Utilization and Costs in Preterm Infants in the First 6 Years of Life After Discharge From Neonatal Intensive Care Unit: A Nationwide Population-Based Study in Korea

BackgroundThe improvement in the survival rate of preterm infants has paradoxically raised the risk of morbidities in childhood. Our objectives were to assess the medical utilization and costs in preterm infants following discharge from the neonatal intensive care unit in the first 6 years of life.MethodsWe conducted a population-based study using the National Health Information Database (2011–2017) provided by the Korean National Health Insurance Service (NHIS). A total of 361,190 children born in Korea between January 1 and December 31, 2011 were divided into four groups according to the gestational age at birth: extremely preterm (less than 28 weeks), very preterm (28–31 weeks), moderate to late preterm (32–36 weeks), and full term (37–41 weeks). The cumulative number of outpatient visits, cumulative length of hospital stay, rate of hospital and intensive care unit admissions, and cumulative medical costs for inpatients and outpatients were compared for each gestational age group.ResultsEarlier gestational age was significantly associated with an increased risk of the cumulative number of outpatient visits, cumulative length of hospital stay, and rate of hospital and intensive care unit admissions for the first 6 years of life. The mean cumulative inpatient and outpatient costs per child significantly decreased with increasing gestational age. When assessed based on population size, the total cumulative medical costs were highest for moderate to late preterm children.ConclusionEarlier gestational age was strongly associated with increased healthcare resource utilization and medical costs. Our findings on the potential long-term socioeconomic impact on public health are expected to aid the development of future health care policies for preterm children.     

Obstetric and perinatal outcome of children conceived from cryopreserved embryos

The main purpose of this study was to evaluate the obstetric and neonatal outcome of children conceived from cryopreserved embryos. The medical records of 270 infants (163 singletons, 98 twins and nine triplets) were reviewed and compared with two control populations of children born after in-vitro fertilization (IVF) with fresh embryos and children born after spontaneous pregnancies. The controls were matched according to maternal age, parity, plurality and date of delivery. In the cryopreserved group the gestational age at delivery for singletons was 279 +/- 13 days with birthweight 3476 +/- 616 g; for twins gestational age was 257 +/- 19 days with birthweight 2574 +/- 560 g; for triplets gestational age was 228 +/- 3 days with birthweight 1752 +/- 183 g. The incidence of preterm birth (< 37 weeks gestation) was 5.6% for singletons, 44.9% for twins and 100% for triplets. Seven children had major malformations (2.7%) and perinatal mortality occurred in two children (8/1000). Gestational age at delivery, birthweight, the incidence of malformations and the perinatal mortality were comparable with the two control groups both for singletons and twins. Significantly more singletons in the cryopreserved group were delivered by Caesarean section compared with the spontaneous group. The number of infants with low Apgar score (< 7 at 5 min) and the number of infants admitted to neonatal intensive care units were similar in the cryopreserved and spontaneous groups. In conclusion, the cryopreservation process did not seem to adversely influence fetal development and no increased perinatal risk was found.      

Economic evaluation of neonatal intensive care of very-low-birth-weight infants

We evaluated the economic aspects of neonatal intensive care of very-low-birth-weight infants, using outcomes and costs of care before and after the introduction of a regional neonatal-intensive-care program. Neonatal intensive care increased both survival rates and costs. For newborns weighing 1000 to 1499 g, the cost (in 1978 Canadian dollars) was $59,500 per additional survivor, $2,900 per life-year gained, and $3,200 per quality-adjusted life-year gained; intensive care resulted in a net economic gain when figures were undiscounted but a net economic loss when future costs, effects, and earnings were discounted at 5 per cent per annum. For infants weighing 500 to 999 g, the corresponding costs were $102,500 per additional survivor, $9,300 per life-year gained, and $22,400 per quality-adjusted life-year gained; intensive care resulted in a net economic loss. By every measure of economic evaluation, the impact of neonatal intensive care was more favorable among infants weighing 1000 to 1499 g than among those weighing 500 to 999 g. A judgment concerning the relative economic value of neonatal intensive care of very-low-birth-weight infants requires a comparison with other health programs.     

Gestational age, birthweight, and neonatal mortality for extremely premature inner-city African-American and Latino infants.

This article analyzes birthweight, gestational age, and inhospital survival for 233 extremely premature infants born at an inner-city hospital over the past 5 years. Results for gestation-specific birthweights and survival did not differ between inner-city Hispanic and African-American infants born at 24 to 28 weeks of gestation. For infants with gestation of 23 to 28 weeks, weight at birth increased by approximately 100 g/week gestation. Survival rates increased from 15% at 23 weeks to 75% by 28 weeks gestation. Survival in this sample was strongly affected by respiratory distress syndrome, air leak, and birthweight. Prenatal steroids administered to the mother had a significant effect on improving survival using univariate analysis and was at the limits of statistical significance using logistic regression. Other maternal, obstetric, and neonatal factors had little or no effects on survival in this group of very immature infants.     

A comparison of glyburide and insulin in women with gestational diabetes mellitus

BACKGROUND: Women with gestational diabetes mellitus are rarely treated with a sulfonylurea drug, because of concern about teratogenicity and neonatal hypoglycemia. There is little information about the efficacy of these drugs in this group of women. METHODS: We studied 404 women with singleton pregnancies and gestational diabetes that required treatment. The women were randomly assigned between 11 and 33 weeks of gestation to receive glyburide or insulin according to an intensified treatment protocol. The primary end point was achievement of the desired level of glycemic control. Secondary end points included maternal and neonatal complications. RESULTS: The mean (+/-SD) pretreatment blood glucose concentration as measured at home for one week was 114+/-19 mg per deciliter (6.4+/-1.1 mmol per liter) in the glyburide group and 116+/-22 mg per deciliter (6.5+/-1.2 mmol per liter) in the insulin group (P=0.33). The mean concentrations during treatment were 105+/-16 mg per deciliter (5.9+/-0.9 mmol per liter) in the glyburide group and 105+/-18 mg per deciliter (5.9+/-1.0 mmol per liter) in the insulin group (P=0.99). Eight women in the glyburide group (4 percent) required insulin therapy. There were no significant differences between the glyburide and insulin groups in the percentage of infants who were large for gestational age (12 percent and 13 percent, respectively); who had macrosomia, defined as a birth weight of 4000 g or more (7 percent and 4 percent); who had lung complications (8 percent and 6 percent); who had hypoglycemia (9 percent and 6 percent); who were admitted to a neonatal intensive care unit (6 percent and 7 percent); or who had fetal anomalies (2 percent and 2 percent). The cord-serum insulin concentrations were similar in the two groups, and glyburide was not detected in the cord serum of any infant in the glyburide group. CONCLUSIONS: In women with gestational diabetes, glyburide is a clinically effective alternative to insulin therapy.     

早产前应用不同疗程地塞米松对于早产孕妇母儿预后的影响

目的探讨产前应用不同疗程地塞米松对于早产孕妇母儿预后的影响。方法回顾性分析85例28-34周早产母儿临床资料。结果在≤34周早产孕妇产前应用地塞米松可以显著降低新生儿呼吸窘迫综合征（NRDS）的发生率（P〈0.05）,多疗程与单疗程治疗组之间无明显差异（P〉0.05）;地塞米松未增加新生儿缺血缺氧性脑病,新生儿感染及新生儿死亡率,对孕妇产褥感染也无明显的影响（P〉0.05）;伴胎膜早破应用多疗程地塞米松组产褥感染率明显增加,高于对照组及单疗程治疗组（P〈0.05）。结论在≤34周早产孕妇应用地塞米松可预防NRDS发生,多疗程应用未增加对NRDS保护作用,对胎膜早破者增加产褥感染机率。     

Effect of telemedicine on health outcomes in 87 infants requiring neonatal intensive care.

OBJECTIVE: This is an evaluation of a telemedicine system for the rapid interpretation of neonatal echocardiograms from a regional, level III neonatal intensive care unit (NICU). The use of telemedicine to support the cardiology needs of NICUs is increasing. However, there is very little published objective information regarding health outcomes or costs resulting from such telemedicine systems. The primary hypothesis tested was that the utilization of a telemedicine system for the interpretation of neonatal echocardiograms reduces the intensive care length of stay of low birthweight (LBW) infants. STUDY DESIGN: All infants who were admitted to neonatal intensive care at New Hanover Regional Medical Center during the first six months of the system were studied by the use of echocardiograms. They were compared with infants who were born in the same period of the previous year. The outcome measures were the intensive care length of stay, rate of transfer to academic medical centers, and mortality rate. RESULTS: A statistically non-significant reduction of 5.4 days in the intensive care length of stay (LOS) of low birthweight infants was observed (p = 0.37). The cost per echocardiogram transmitted was calculated at $33 compared to previous method of sending videotapes via overnight courier. CONCLUSIONS: While the sample size was inadequate to demonstrate improvements in health outcomes, the magnitude of the change and the low costs of the system suggest that this intervention is practical for obtaining rapid diagnostic and treatment support. Larger studies are warranted to confirm these findings and determine whether faster diagnosis and earlier initiation of treatment improve health outcomes of newborn infants.     

Histological chorioamnionitis and neonatal leukemoid reaction in low-birth-weight infants

We investigated whether histological chorioamnionitis (HCA) is a risk factor predisposing to leukemoid reaction (LR) and whether LR is associated with the preterm parturition syndrome and the systemic fetal inflammation response syndrome. A prospective histological study on placentas was performed in preterm infants (相似文献   

Adequacy of prenatal care utilization, maternal ethnicity, and infant birthweight in Chicago.

This study examines the extent to which the Adequacy of Prenatal Care Utilization Index explains the racial disparity in infant birthweight. A stratified analysis was performed on all African-American, Mexican-American, and non-Latino white singleton infants born in Chicago, Illinois between 1982 and 1983. This older cohort was chosen to avoid the confounding effect of cocaine associated with its increased local availability after 1985. The adequacy of prenatal care utilization varied by race and place of residence. However, in moderate-income areas (median family annual income of $20,001 to $30,000), the African-American birthweight disadvantage persisted among infants born to mothers who received adequate and adequate-plus prenatal care. Similarly, although race-specific term (gestational age > 37 weeks) low birthweight rates declined as prenatal care usage rose, the position of African Americans relative to Mexican Americans and whites was essentially unchanged. These findings indicate that maternal race or some factor closely related to it affects pregnancy outcome regardless of the adequacy of prenatal care utilization.     

Secular trends in congenital anomaly-related fetal and infant mortality in Canada, 1985-1996.

Prenatal diagnosis of major congenital anomalies and subsequent termination of affected pregnancies has been widely available as part of routine obstetric care in recent years. In this study, vital statistical data on stillbirths, live births, and infant deaths were used to examine secular trends in gestational age-specific and category-specific fetal and infant mortality due to congenital anomalies in Canada (excluding Ontario and Newfoundland) from 1985-1996. Comparisons of the rates between 1985-1987 and 1994-1996 were made using relative risks and 95% confidence intervals (CI). The overall fetal mortality rate due to congenital anomalies increased significantly, from 68.0 per 100,000 total births in 1985-1987 to 78.6 per 100,000 total births in 1994-1996, while the overall infant mortality rate due to congenital anomalies decreased significantly over the same period, from 2.47 to 1.79 per 1,000 live births. The fetal death rate due to congenital anomalies at 20-21 weeks of gestation increased approximately five-fold (relative risk [RR] = 4.83, 95% CI = 3.28-7.11) from 4.5 to 21.5 per 100,000 fetuses at risk, while the rate at 37-41 weeks decreased by 30% (RR = 0.70, 95% CI = 0.50-0.97). Fetal death rates among pregnancies at 20-25 weeks of gestation increased in all categories of congenital anomaly except anencephaly and respiratory system anomalies. Congenital anomaly-related fetal and infant deaths have increased at early gestation but declined at later gestation in Canada. These changes suggest an increase in prenatal diagnosis and selective termination of pregnancies with congenital anomalies in recent years.     

Attitudes and behaviors of African-American and Mexican-American women delivering newborns in inner-city Los Angeles.

To study some of the factors relating to the care of mothers and newborns in an inner-city hospital, three sources of information were reviewed: an obstetric database including information on prenatal care and perinatal mortality, a database of all admissions to the hospital neonatal intensive care unit over the past 5 years, and a detailed questionnaire concerning attitudes and behaviors of recently delivered women. While analyses from these hospital-based data are not conclusive, the results add evidence for the following propositions: 1) Optimal prenatal care is infrequently obtained by mothers delivering at inner-city hospitals. Lack of prenatal care is clearly associated with increased perinatal mortality. While the need for prenatal care is appreciated by 98% of the mothers in this sample, the most frequent reasons why prenatal care is not obtained earlier or more frequently involve knowledge about and access to prenatal care. 2) Inner-city mothers, in general, manifest attitudes and behaviors that promote the welfare of their pregnancies and newborns. These attitudes and behaviors are in stark contrast to those that are frequently attributed to inner-city women by the media. 3) Acute perinatal medical and nursing care are perceived by many postpartum women as suboptimal, particularly in terms of the lack of respect shown to patients by nurses and doctors. 4) Improved acute obstetric and neonatal care improves perinatal morbidity and mortality of infants delivered at inner-city hospitals.     

Secular trends in congenital anomaly‐related fetal and infant mortality in Canada, 1985–1996

Prenatal diagnosis of major congenital anomalies and subsequent termination of affected pregnancies has been widely available as part of routine obstetric care in recent years. In this study, vital statistical data on stillbirths, live births, and infant deaths were used to examine secular trends in gestational age‐specific and category‐specific fetal and infant mortality due to congenital anomalies in Canada (excluding Ontario and Newfoundland) from 1985–1996. Comparisons of the rates between 1985–1987 and 1994–1996 were made using relative risks and 95% confidence intervals (CI). The overall fetal mortality rate due to congenital anomalies increased significantly, from 68.0 per 100,000 total births in 1985–1987 to 78.6 per 100,000 total births in 1994–1996, while the overall infant mortality rate due to congenital anomalies decreased significantly over the same period, from 2.47 to 1.79 per 1,000 live births. The fetal death rate due to congenital anomalies at 20–21 weeks of gestation increased approximately five‐fold (relative risk [RR] = 4.83, 95% CI = 3.28–7.11) from 4.5 to 21.5 per 100,000 fetuses at risk, while the rate at 37–41 weeks decreased by 30% (RR = 0.70, 95% CI = 0.50–0.97). Fetal death rates among pregnancies at 20–25 weeks of gestation increased in all categories of congenital anomaly except anencephaly and respiratory system anomalies. Congenital anomaly‐related fetal and infant deaths have increased at early gestation but declined at later gestation in Canada. These changes suggest an increase in prenatal diagnosis and selective termination of pregnancies with congenital anomalies in recent years. © 2001 Wiley‐Liss, Inc.     

Cost estimate of hospital stays for premature newborns in a public tertiary hospital in Brazil

OBJECTIVES:

To estimate the direct costs of hospital stays for premature newborns in the Interlagos Hospital and Maternity Center in São Paulo, Brazil and to assess the difference between the amount reimbursed to the hospital by the Unified Health System and the real cost of care for each premature newborn.

METHODS:

A cost-estimate study in which hospital and professional costs were estimated for premature infants born at 22 to 36 weeks gestation during the calendar year of 2004 and surviving beyond one hour of age. Direct costs included hospital services, professional care, diagnoses and therapy, orthotics, prosthetics, special materials, and blood products. Costs were estimated using tables published by the Unified Health System and the Brasíndice as well as the list of medical procedures provided by the Brazilian Classification of Medical Procedures.

RESULTS:

The average direct cost of care for initial hospitalization of a premature newborn in 2004 was $2,386 USD. Total hospital expenses and professional services for all premature infants in this hospital were $227,000 and $69,500 USD, respectively. The costs for diagnostic testing and blood products for all premature infants totaled $22,440 and $1,833 USD. The daily average cost of a premature newborn weighing less than 1,000 g was $115 USD, and the daily average cost of a premature newborn weighing more than 2,500 g was $89 USD. Amounts reimbursed to the hospital by the Unified Health System corresponded to only 27.42% of the real cost of care.

CONCLUSIONS:

The cost of hospital stays for premature newborns was much greater than the amount reimbursed to the hospital by the Unified Health System. The highest costs corresponded to newborns with lower birth weight. Hospital costs progressively and discretely decreased as the newborns'' weight increased.     

Evaluation of Preterm Delivery between 32+0-33+6 Weeks of Gestation

Preterm labor after 34 weeks of gestation has shown no great difference from full-term labor in terms of neonatal morbidity and mortality when proper antepartum management (antibiotics or steroids treatment) is done. However, various studies have discussed different views on the risks and safety of preterm delivery at 32⁺⁰-33⁺⁶ weeks of gestation. We evaluated the complications of different preterm groups that included the neonates born at 32⁺⁰-33⁺⁶ weeks of gestation (142), stratified randomly selected neonates born at 34⁺⁰-36⁺⁶ weeks of gestation (267) and neonates born after 37⁺⁰ weeks of gestation (356) at our hospital between December 1999 and April 2006. As a result, it was found that neonates born at 34⁺⁰-36⁺⁶ weeks of gestation showed no great difference from infants born at full term. However, neonates born at 32⁺⁰-33⁺⁶ weeks were more likely to be admitted to neonatal intensive care unit or develop neonatal complications significantly than the neonates born at 34⁺⁰-36⁺⁶ weeks and at full term. Therefore, it is suggested that neonates born at 32⁺⁰-33⁺⁶ weeks have higher risk of neonatal complications following their preterm labor than those born at later than 34⁺⁰ weeks. Thus, it would be difficult to accept the idea that preterm labor at 32⁺⁰-33⁺⁶ weeks is safe.     

Prenatal genetic diagnosis from maternal blood: simultaneous immunophenotyping and FISH of fetal nucleated erythrocytes isolated by negative and positive magnetic activated cell sorting

Fetal nucleated red blood cells (nRBCs) are rare in maternal circulation, but their presence constitutes a potential source of non-invasive prenatal genetic diagnosis. This study was undertaken to establish a non-invasive prenatal genetic diagnosis method using isolated fetal nRBCs. A multi-step method including triple density gradient and magnetic activated cell sorting (MACS) using CD45 and CD71, cytospin centrifugation, K-B staining, and glycophorin A-immuno fluorescence in situ hybridization (GPA-immuno FISH) was performed. The study population included 65 patients from 8 to 41 weeks of gestation, and fetal nRBC was separated from all cases. The number of fetal nRBCs retrieved was 12.8 +/- 2.7 in 8 to 11 gestational weeks, 15.2 +/- 6.5 in 12 to 18 gestational weeks, 16.4 +/- 6.5 in 19 to 23 gestational weeks, 10.6 +/- 3.2 in 24 to 28 gestational weeks, and 5.5 +/- 1.9 in 35 to 41 gestational weeks: the mean number of nRBCs collected from 20 ml of maternal peripheral blood was 13.7 +/- 6.2. The highest value of yield was 45.6% from 12 to 18 weeks gestation. The fetal sex determination confirmed by amniocentesis or chorionic villus sampling showed 100% sensitivity and 91.7% specificity for males; 91.7% sensitivity and 100% specificity for females. We showed that fetal cells can be reliably enriched from maternal blood and that they can be used for detecting specific chromosomes by FISH with a specificity superior to current non-invasive methods.     

Pregnancy outcome of fetuses with trisomy 18 identified by prenatal sonography and chromosomal analysis in a perinatal center

To investigate the pregnancy outcome of fetuses affected with trisomy 18, we analyzed 63 cases diagnosed at our hospital from January 1993 to December 2004. Twenty-nine were males and 34 were females. Fifty-eight were prenatally diagnosed, and in 16 (27.6%) of them intrauterine fetal death (IUFD) occurred between 28 weeks and 41 weeks gestation (34.6 +/- 3.9 weeks, Mean +/- SD). Ten (17.2%) fetuses died during labor and their age ranged from 30 weeks to 40 weeks of gestation. The total number of cases ending in fetal demise was 26 (44.8%) and the mean gestational age at the time of fetal demise was 35.0 +/- 3.6 weeks (Mean +/- SD). All liveborn infants (n = 36) were born after 31 weeks gestation. In our study the preterm birth ratio for trisomy 18 is 34.8%, which is much higher than the ratio for the general population. Females are more likely than males to be long-term survivors. These data are helpful in the counseling of parents faced with the difficult decision of whether or not to continue a pregnancy with a fetus affected with trisomy 18.     

Prenatal treatment with glucocorticoids sensitizes the hpa axis response to stress among full-term infants

The objective of this study was to determine the consequences for HPA axis functioning among healthy full-term newborns of prenatal treatment with the synthetic glucocorticoid (GC), betamethasone, which is the routine treatment for threatened preterm delivery. Ninety full-term infants were recruited into two study groups (30 betamethasone treated; 60 comparison group matched for GA at birth and sex). The cortisol and behavioral response to the painful stress of a heel-stick blood draw was assessed 24 hr after birth. Full-term infants exposed to prenatal betamethasone displayed a larger cortisol response to the heel-stick procedure, despite no differences in baseline levels. Further, within the recommended window of betamethasone administration (24-34 gestational weeks), infants exposed to betamethasone earlier in gestation displayed the largest cortisol response to the heel-stick. These data add to accumulating evidence that prenatal exposure to elevated GCs programs the development of the HPA axis.     

Cost-effectiveness of genome sequencing for diagnosing patients with undiagnosed rare genetic diseases

PurposeTo estimate the cost-effectiveness of genome sequencing (GS) for diagnosing critically ill infants and noncritically ill pediatric patients (children) with suspected rare genetic diseases from a United States health sector perspective.MethodsA decision-analytic model was developed to simulate the diagnostic trajectory of patients. Parameter estimates were derived from a targeted literature review and meta-analysis. The model simulated clinical and economic outcomes associated with 3 diagnostic pathways: (1) standard diagnostic care, (2) GS, and (3) standard diagnostic care followed by GS.ResultsFor children, costs of GS ($7284) were similar to that of standard care ($7355) and lower than that of standard care followed by GS pathways ($12,030). In critically ill infants, when cost estimates were based on the length of stay in the neonatal intensive care unit, the lowest cost pathway was GS ($209,472). When only diagnostic test costs were included, the cost per diagnosis was $17,940 for standard, $17,019 for GS, and $20,255 for standard care followed by GS.ConclusionThe results of this economic model suggest that GS may be cost neutral or possibly cost saving as a first line diagnostic tool for children and critically ill infants.     

Triplet gestation: clinical outcome of 14 cases

BACKGROUND/OBJECTIVE: To determine maternal complications and fetal outcome of triplet gestations. METHOD: Retrospective study of pregnant women with triplet gestation managed in 10 years. RESULTS: Fourteen women were managed with triplet gestation, of these, (71.4%) were booked for antenatal care and four (28.6%) were unbooked. The mean age of the women was 31.3 years. The age range was between twenty seven years and thirty nine years. The mean gestational age at diagnosis for the booked women was 18.6 weeks. Of the fourteen patients, ten (71.4%) had spontaneous conception, three (21.4%) followed ovulation induction and one (7.2%) resulted from invitro fertilization and embryo transfer. Two (14.3%) patients had cervical cerclage based on their past obstetric history and assessment of the cervix. Six (42.9%) patients were hospitalized and treated for preeclampsia 3 patients, spontaneous abortion 1 patient and cervical incompetence 2 patients. Eleven (78.6%) patients had preterm birth. The mean gestational age at delivery was 33.4 weeks. Of the thirteen deliveries, nine (69.2%) had caesarean section and four (30.8%) delivered per vaginam. A total of thirty nine babies were delivered, thirty four (87.2%) babies survived and five (12.8%) died. Perinatal mortality was 11.9% and the "take home" baby rate was 81%. CONCLUSION: Antenatal care with initiation of specialized prenatal care and planned delivery in triplet gestation improves fetal outcome.     

Long-term impact of highly active antiretroviral therapy on HIV-related health care costs

CONTEXT: Highly active antiretroviral therapy (HAART) is associated with decreased opportunistic infections, hospitalization, and HIV-related health care costs over relatively short periods of time. We have previously demonstrated that decreases in total HIV cost are proportional to penetration of protease inhibitor therapy in our clinic. OBJECTIVE: To determine the effects of HAART on HIV health care use and costs over 44 months. SETTING: A comprehensive HIV service within a Veterans Affairs Medical Center. DESIGN: A cost-effectiveness analysis of HAART. MAIN OUTCOME MEASUREMENTS: The mean monthly number of hospital days, infectious diseases clinic visits, emergency room visits, non-HIV-related outpatient visits, inpatient costs, and antiretroviral treatment costs per patient were determined by dividing these during the period from January 1995 through June 1998 into four intervals. Viral load tests were available from October 1996. Cost-effectiveness of HAART was evaluated by determining the costs of achieving an undetectable viral load over time. RESULTS: Mean monthly hospitalization and associated inpatient costs decreased and remained low 2 years after the introduction of protease inhibitors (37 hospital days per 100 patients). Total cost decreased from $1905 per patient per month during the first quarter to $1090 per patient per month in the third quarter but increased to $1391 per patient per month in the fourth quarter. Antiretroviral treatment costs increased throughout the entire observation period from $79 per patient per month to $518 per patient per month. Hospitalization costs decreased from $1275 per patient per month in the first quarter to less than $500 per patient per month in each of the third and fourth quarters. The percentage of patients with a viral load <500 copies/mL increased from 21% in October 1996 to 47% in June of 1997 (p =.014). The cost of achieving an undetectable viral load decreased from $4438 per patient per month to $2669 per patient per month, but this trend did not reach statistical significance (p =.18). CONCLUSIONS: After an initial decrease, there was an increase in the total monthly cost of caring for HIV patients. Cost increases were primarily due to antiretroviral treatment costs, but these costs were offset by a marked decrease in inpatient-related costs. Increases in costs were not related to antiretroviral treatment failures as measured by the proportion of patients with low or undetectable viral loads. The cost of achieving an undetectable viral load remained stable despite increases in the cost of procuring antiretroviral agents.