Affiliations: Pulmonary Consultants and Sleep Specialists, Medford, OR,
Carolinas Medical Center, Charlotte, NC
Correspondence to: Petey Laohaburanakit, MD, FCCP, Pulmonary Consultants and Sleep Specialists, 555 Black Oak Dr, Suite 300, Medford, OR 97504; e-mail: firstname.lastname@example.org
In a recent issue of CHEST (August 2007), I read the commendable work of Jones et al1 with great interest. In their study, the authors found that the hospital length of stay (LOS) was 1.2 days longer in the early goal-directed therapy (EGDT) group (7.9 vs 9.1 days, respectively), whereas the mean ICU LOS was 1.8 days longer in the EGDT group (2.0 vs 3.8 days, respectively).1 These findings deserve further mention.
In their landmark study, Rivers et al2 reported a similar hospital LOS between an EGDT group and a standard-therapy group (13.0 vs 13.2 days, respectively). The difference in the LOS observed in the reports by Jones et al1and Rivers et al2 could be attributed to the dissimilar severity of the conditions of the patients studied, as was mentioned by Jones et al.1 Another likely explanation is, in the study by Jones et al,1 the utilization of vasopressors and mechanical ventilation was more prevalent in the EGDT group. While the number of ventilator days were not different between the two groups, the use of mechanical ventilation and vasopressors might inadvertently lengthen ICU LOS by increasing the need for ICU-based monitoring and observation.
Speculations aside, an important point is that resource utilization was increased when EGDT was implemented in patients with fewer risks of death from septic shock. A recent analysis by Huang et al3 found that EGDT could be cost-effective, assuming that LOS and mortality are reduced. While more reproducible cost-benefit analyses of EGDT are needed, clinicians should perhaps be wary of the potential unfavorable effects on hospital resource allocation when EGDT is used in less critically ill patients with low predicted mortality rates.
The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
We would like to thank Dr. Laohaburanakit1for his interest in our study. We agree that our findings of an increase in resource utilization, in the form of prolonged ICU and hospital lengths of stay, increased vasopressor utilization, and increased rate of endotracheal intubation, are important and warrant further investigation.2As Dr. Laohaburanakit correctly points out, the increase in resources utilized was found in the face of lower severity of illness than had been reported by Rivers et al3in the original early goal-directed therapy (EGDT) study. We are presently undertaking a comprehensive economic analysis of our EGDT implementation experience. Our preliminary economic results indicate that our hospital incurred an increased cost to treat each patient with EGDT, as well as an increased cost per life saved. It also appears as though the net margin of the hospital was increased during the protocol implementation period. Another point to consider is not only costs, but also the crowding burden that the EGDT protocol may add to emergency departments and ICUs.4 In conclusion, we would encourage others to consider an economic analysis when implementing EGDT locally, and we would echo the call of Dr. Laohaburanakit for more formal and reproducible cost-benefit analyses of EGDT as a part of future studies.
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