FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.
Department of Pulmonary Allergy and Critical Care Medicine, University of Massachusetts Medical School, Worcester, MA
∗CORRESPONDENCE TO: Craig M. Lilly, MD, FCCP, Department of Pulmonary Allergy and Critical Care Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, 55 Lake Ave N, Worcester, MA 01655
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
The importance of resuscitation for surviving critical illness and injury has long been recognized and is now a standard and integral part of critical care practice. Our approach to resuscitation has evolved over the past century, encouraged by intense research efforts that have led to clinical trials of alternative resuscitation fluids including hydroxyethyl starch (HES). One of the key understudied aspects of resuscitation is its effect on the duration of illness or injury in relation to the costs of care. It is estimated that each year, 20 to 30 million patients worldwide will receive resuscitation as part of their care. For an integral aspect of commonly delivered care, there is considerable variation in clinical practice regarding the choice of fluid, in part influenced by product availability, local preferences, and costs.
In the current issue of The Lancet Respiratory Medicine, Taylor and colleagues report findings of a preplanned cost-effectiveness analysis from a CHEST trial. The CHEST trial was a randomized clinical trial that compared mortality and health-care costs in critically ill adults receiving a 6% HES resuscitation protocol with those of a group managed with saline. The cost-effectiveness analyses were performed according to established standards as preconceived outcomes of this clinical trial. Another meritorious aspect of the trial is that it analyzed data derived from extended follow-up of patients rather than extrapolations from mathematical models.
The authors report an 11% probability that the use of 6% HES could achieve an incremental cost-effectiveness ratio below the willingness-to-pay threshold of $50,000 per quality-adjusted life-year at 6 months and a 29% probability of achieving an incremental cost-effectiveness ratio below an established threshold of $100,000 per quality-adjusted life-year at 24 months. The CHEST trial did not detect differences for 90-day mortality between these groups and reported a signiﬁcant increase in the use of renal replacement therapy for patients managed with the HES resuscitation protocol. The authors conclude that no justiﬁcation exists for the use of 6% HES in preference to saline for fluid resuscitation in critically ill adults.
High-quality cost-effectiveness analyses of interventions for critically ill adults represent a necessary fundamental resource that allows us to better understand how to provide access to effective critical care services at affordable costs. In the United States, annual adult critical care costs are estimated to exceed $80 billion, representing 4.1% of overall health-care expenditures and 0.66% of the gross domestic product. Fluid resuscitation is fundamental to the care of critically ill patients, yet there are few studies looking at the cost-effectiveness outcomes of alternative resuscitation strategies. In their publication, Taylor et al help to fill that void, using established standard methods. Importantly, their findings are robust regarding differences in national healthcare finance strategy and appear to be broadly applicable.
In conclusion, the study by Taylor et al represents an important advance in the study of cost-effectiveness analysis of fluid resuscitation for critically ill adults by adding to the body of evidence of the cost-effectiveness of fluid resuscitation. This contribution establishes a foundation for understanding the cost-effectiveness of other aspects of resuscitation management that are associated with improved clinical outcomes.
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