When Is Critical Care Medicine Cost-Effective?Presentation Transcript
When is critical care medicine cost-effective? A literature review Joseph Abdelmalak, MD SICU- Aug 8, 2007 D. Talmor et al, Crit Care Med 2006 Vol 34, no 11 , 2738-2747
It has been estimated that ICU costs represent up to one third of all hospital costs
As the elderly population in western countries increases rapidly and improved medical management increases patient survival, more and more people will become critically ill and require treatment in an ICU
The high cost of treating critically ill patients in the ICU is largely attributed to the need for highly trained staff, expensive modern equipment, and intensive use of diagnostic tests, pharmaceuticals, and interventions.
There are two approaches used for economic analyses in health care
Cost-effectiveness analysis (CEA): is a method for comparing the expected benefits of an intervention with its net cost. The most widely used approach is to measure clinical benefits in terms of number of years of lives saved. For example, if a patient’s life is saved by an intervention that leaves that patient dependant on a ventilator, Vs ventilator-free survival.
Cost-utility analysis is considered the gold standard because it examines the costs and effectiveness of therapies using the quality-adjusted life year (QALY) as its unit of effectiveness. QALY= Life years saved X the utility of the health state
A systematic search of the English-language literature for original CEAs of critical are interventions published from 1993 through 2003.
Two independent readers, both with master’s or doctoral degree training in decision analysis and CEA, read each article and then convened for a consensus review to resolve discrepancies.
They converted all non-U.S. currency ratios into U.S. dollars, using the appropriate foreign exchange factor for the relevant year and inflated all cost-effectiveness ratios to 2003 U.S. dollars using the consumer price index
They grouped studies by type of intervention into three broad categories:
1) Treatment of patients with severe sepsis,
2) Treatment of patients with respiratory failure necessitating mechanical ventilation, and
3) other critical care-related interventions or treatments.
19 original CEA studies published between 1993 and 2003 were identified
Twelve of the articles came from the United States, two from Canada, and five from Europe
Results The number of CEAs in this ICU is relatively small compared with interventions in other clinical areas
Results Study funding came from various sources: foundation or a healthcare organization, government funded, and pharmaceutical companies funded
Results The cost-effectiveness of sepsis therapies
All the studies relate to treatment of patients with severe sepsis with activated protein C.
When the populations as a whole are analyzed, The cost/life year saved range from $12,570 to $33,100 and cost/QALY were $20,047 to $48,800,
However, when stratified by risk:
- Patients with an Acute Physiology and Chronic Health Evaluation APACHE II score of <25, the incremental cost-effectiveness ratio reached $575,054/life year saved and $958,423/QALY
- Patients in the higher risk (APACHE II score of > 25) group, $19,732/life year and $32,872/QALY
Results The cost effectiveness of mechanical ventilation
It ranges from $26,283/QALY to $174,200/QALY depending on the risk group.
low-risk populations for whom mechanical ventilation is cost-effective,
Higher-risk patients (i.e. age of > 40 with stroke, human immunodeficiency virus Penumocystis pneumonia , patients with estimated <50% survival), mechanical ventilation is associated with cost-effectiveness ratios of more than $100,000 per life year gained.
$168/QALY for patients admitted with asthma
$189,339/life year saved for patients with hematologic cancers
Intensive care admission in and of itself is a largely cost-effective intervention
Determining the cost-effectiveness of the components of critical care can allow assessment of alternative strategies of patient management and inform decision makers’ and clinicians’ choices on optimal patient care.
Defining whether a therapy is cost-effective requires a judgment about society’s willingness to pay for a life year or QALY gained
In general treatments with a cost-effectiveness ratio of $50,000 to $100,000 per year of life gained are acceptable in the United States
The difficulty in performing large randomized controlled trials in the critical care setting has led to a reliance on evaluation of secondary outcomes such as ventilator-free days, organ failures and short-term mortality, typically at 28 days.
The search strategy was limited to certain key words and databases
The review only includes English-language
Evaluations using other methods (e.g. cost-benefit analysis) or reporting different outcomes (e.g. cost per death avoided) were not included.
The review not include reported analyses published after 2003
The readers were not blinded to articles’ journals and authors, which may have influenced results.
The cost effectiveness ratios they present are not static, This may occur with changed in costs of medications (e.g. a medicine becomes generic), changes in monitoring and interventional device costs, and changes in practice resulting in increases or decreases in ICU lengths of stay over time.
CEAs were performed in different countries affect the resulting ratios and may limit the comparison between studies
Specific interventions such as activated protein C for patients with severe sepsis have been shown to provide good value for money
• The cost-effectiveness of other intensive interventions like Continuous renal replacement therapy, goal-directed therapy for sepsis and 24-hr intensivist coverage ICUs need to be study
Long-term studies looking at the functional outcome of survivors of critical illness should be encouraged