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Cost and outcome of intensive care for patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure |
Wachter R M, Luce J M, Safrin, S, Berrios D C, Charlebois E, Scitovsky A A |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Intensive care for patients with AIDS-related Pneumocystis carinii pneumonia and severe respiratory failure.
Economic study type Cost-effectiveness analysis
Study population Patients with AIDS, microbiologically documented PCP and respiratory failure requiring mechanical ventilation.
Setting Hospital intensive care unit. The economic study was carried out in San Francisco, USA.
Dates to which data relate 1981-1991 effectiveness and cost data.1991 prices were used.
Source of effectiveness data The evidence of effectiveness was based on one study.
Link between effectiveness and cost data Costs were collected retrospectively on patients included in the trial.
Study sample Patients with AIDS, microbiologically documented PCP and respiratory failure requiring mechanical ventilation who were admitted to the intensive care unit at San Francisco General Hospital 1981-1991. The sample size was n=113, separated into three cohorts: era I (1981-1984) n=43; era II (1986-1988) n=33; era III (1989-1991) n=37. Power calculations did not determine sample size.
Study design This was a single centre, cohort study but it is not clear whether the analysis was retrospective or prospective. The duration of follow-up was lifelong.
Analysis of effectiveness One of the main outcome measureswas survival time. The analysis was based onintention to treat.
Effectiveness results Twenty-eight (25%) of the 113 patients with PCP and respiratory failure survived to hospital discharge: six (14%) of the 43 patients in era I (1981-1985); thirteen (39%) of the 33 patients in era II (1986-1988) and nine (24%) of the 37 patients in era III(1989-1991). (p=.02 for era I vs era II; p=.21 for era II vs era III, overall p=.04). For these twenty-eight patients, the mean survival after discharge was 16.2 months (p=0.9 for differences between eras).
Clinical conclusions For patients in era III, two predictors of mortality included low admission CD4 cell counts and the development of pneumothorax due to barotrauma.
Measure of benefits used in the economic analysis Direct costs The cost-analysis was conducted from the payer's perspective. Some costs and quantities were reported separately. Costs included all hospital charges, in particular room chargesand charges for laboratory, respiratory and radiology services. Pharmaceuticals and supplies used during an ICU stay were subsumed under the ICU room charges (in an audit, these billing room charges werefound to reflect correctly 97% of actual charges).31 out of the 76 patients' charges for eras I and II patients were unavailable and were estimated based on the ICU length of stay. Any subsequent hospitalisations were considered, until the patients' death. All charges were adjusted to 1991 US dollars using the medical care component of the consumer price index for the San Francisco Bay Area.
Statistical analysis of costs For cost and some resource data, P-values, means, and standard deviations were reported.
Estimated benefits used in the economic analysis For those twenty-eight patients who survived to hospital discharge, the mean survival time was 16.2 months.
Cost results Mean charges for ICU stays declined between eras I and II ($43,125 era I and $25,614 era II, P=.02) and rose in era III ($47,083, P=.03 compared with era II). The total post-ICU admission charges remained steady during first two eras ($53,336 vs $52,038) but increased in era III ($68,351 P=.30 compared with era II).
Synthesis of costs and benefits The cost of ICU admission and subsequent hospitalisation averaged $174,781 per year of life saved: $305,795 in era I, $94,528 in era II and $215,233 in era III.
Authors' conclusions The cost-effectiveness of intensive care for patients with PCP and severe respiratory failure improved during the first 8 years of the AIDS epidemic but fell in recent years such that it is now below that of many accepted medical interventions.
CRD Commentary Although a generally well conducted study, the researchers underplayed the possibility that era III'scosts may beinflated and effectiveness reduced through an increasedreferral of progressively worse patients. Thestudy also suffered from what appears to be a retrospective cohort analysis, and predictive information such as CD4 counts are unreported for era I and II. Moreover, the assumption of a zero cost zero life for the alternative to ICU may underestimate the costs borne by those cases not referred to ICU.
Source of funding AIDS Clinical Research Center, University of California, San Francisco.
Bibliographic details Wachter R M, Luce J M, Safrin, S, Berrios D C, Charlebois E, Scitovsky A A. Cost and outcome of intensive care for patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure. JAMA 1995; 273(3): 230-235 Indexing Status Subject indexing assigned by NLM MeSH AIDS-Related Opportunistic Infections /complications /economics /mortality /therapy; Adult; Cost-Benefit Analysis; Female; Hospital Charges /statistics & Hospital Mortality; Hospitals, Teaching /economics /statistics & Humans; Intensive Care Units /economics; Length of Stay; Logistic Models; Male; Middle Aged; Pneumonia, Pneumocystis /complications /economics /mortality /therapy; Respiration, Artificial /economics; Respiratory Insufficiency /economics /etiology /mortality /therapy; San Francisco; Survival Rate; Treatment Outcome; Value of Life; numerical data; numerical data AccessionNumber 21995005004 Date bibliographic record published 19/02/1996 Date abstract record published 19/02/1996 |
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