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Cost-effective method for bedside insertion of vena caval filters in trauma patients |
Nunn C R, Neuzil D, Naslund T, Bass J G, Jenkins J M, Pierce R, Morris J 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 Bedside insertion of inferior vena cava (IVC) filters in trauma patients versus radiology suite or operating room.
Economic study type Cost-effectiveness analysis.
Study population Male and female trauma patients requiring IVC filter placement.
Setting Hospital. The economic study was carried out in Nashville, Tennessee, US.
Dates to which data relate The main effectiveness data were obtained from a single study conducted between 1995 and 1996. Resource and cost data were obtained from 1995-96 sources. The price year was not stated.
Source of effectiveness data The estimates of the number of successful IVC filters placed under ultrasound guidance, and complications were obtained from a single study.
Link between effectiveness and cost data The costing was undertaken retrospectively on the same patient sample as that used in the effectiveness study.
Study sample Of all 3,172 trauma admission, 55 (1.7%) patients were included in the analysis; only 49 (89.1%) of these patients had successful, ultrasound-guided, bedside PGF placement. The mean age was 31 years (range: 14 - 76 years) and the mean Injury Severity Score was 30.3 (range: 16 - 54). The indications for placement in this group included 92% with spinal trauma, 21 (43%) had paraplegia, 16 (33%) quadriplegia, two hemiplegia and five nonparalysing spinal injuries. Of the four patients without spinal trauma, three had pelvic or long bone fractures and two had severe closed head injures. One patient sustained a combined injury. Power calculations to determine the sample size were not undertaken.
Study design Case series. The duration of the follow-up was not stated. The loss to follow-up was six patients (10.9%) when ultrasound guided filter placement failed.
Analysis of effectiveness The analysis of the clinical study was based on successful treatment only. The primary health outcomes used in the analysis were the number of successful IVC filters placed under ultrasound guidance, and complications.
Effectiveness results The number of successful IVC filters placed under ultrasound guidance was 49and failure occurred in 10.9% cases. There were four complications in four patients(8.2%).
Clinical conclusions Ultrasound guided, bedside placement of IVC filters is a safe method of pulmonaryembolism prophylaxis in select trauma patients.
Measure of benefits used in the economic analysis The authors made the implicit assumption that the effectiveness of the intervention and the two comparators was equivalent. Therefore the main benefits were measured in terms of cost/charge reduction (cost-minimisation).
Direct costs Hospital, radiology, operative and equipment charges wereanalysed for total charges for each of the three methods of PGFplacement. Additional charges for failed placement attempts andthe use of additional filters using ultrasound at the bedside wereincluded in the analysis. For the purposes of the financialanalysis, a zero percent complication and failure rate wasassumed for both the operatively and radiological placed filters. Quantities were reported separately from the prices. Discounting was notundertaken due to the short study period. The quantity/costboundary adopted was the hospital. The price year was not stated.
Statistical analysis of costs Sensitivity analysis No sensitivity analysis was performed.
Estimated benefits used in the economic analysis Cost results Charges for the bedside placement technique were less ($3,508) than charges forplacement in the operation room ($5,940) or the radiology suite ($4,989). Over 13 months, bedside placement reduced charges when compared with radiology placement($69,800) and operating room ($118,300).
Synthesis of costs and benefits Bedside placement reduced charges when compared with radiology placement($1,481/patient) and operating room placement ($2,432/patient).
Authors' conclusions Ultrasound guided, bedside placement of IVC filters is a safe, cost-effective method of pulmonaryembolism prophylaxis in select trauma patients.
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparator is clear. The use of the PGF in the general trauma population has become an established means of pulmonary embolism prophylaxis. The chosen comparators are traditional alternatives. As most of the trauma patients are critically ill, it is necessary to identifya means of bedside PGF placement which would obviate the need for transport to theradiology suite or operating room without compromising the safety or efficacy of the filter placement. You, as a user of this database, should consider whether these are widely usedhealth technologies in your own setting. Validity of estimate of measure of benefit No summary benefit measure was used and the authors restricted themselves to an analysis of costs/charges, implicitly assuming the effectiveness to be similar for the alternatives addressed. It is not clear whether this is a valid assumption as health outcomes were not examined for the comparators. In this sense, a limited cost-minimisation analysis was performed. Validity of estimate of costs Resource quantities were reported separately from the prices and adequate details of methods of quantity/charges estimation were given. The use of charges rather than costs limits the generalisability of the results to other settings. The costing methodology lacked some details, withoutthe price year being stated. No statistical analysis was conducted. As the study was retrospective, the charges need to be treated with a degree of caution. Furthermore, as the authors acknowledged, a true cost analysis was not conducted as it was not possible to obtain meaningful cost estimates for suite usage, patient transportation and physicianinvolvement. An assumption of 0% complication rate for costing purposes clearly introduces potential biases. Other issues The issue of generalisability to other settings or countries was notaddressed, although comparisons with other studies, supporting the clinical results from this investigation, were reported in the study. Implications of the study A true cost analysis is required. Moreover, a prospective, randomized trial may yield more information regarding the impact of contrast reactions, radiation exposure, and complications related to patient transport and time away from the surgical intensive care unit in select groups of trauma patients. Bibliographic details Nunn C R, Neuzil D, Naslund T, Bass J G, Jenkins J M, Pierce R, Morris J A. Cost-effective method for bedside insertion of vena caval filters in trauma patients. Journal of Trauma 1997; 43(5): 752-758 Other publications of related interest Comment in: Journal of Trauma 1998;44(2):419-20.
Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Aged; Cost-Benefit Analysis; Humans; Injury Severity Score; Male; Methods; Middle Aged; Point-of-Care Systems; Prospective Studies; Pulmonary Embolism /etiology /prevention & Ultrasonography /economics; Vena Cava Filters /economics; Wounds and Injuries /complications /economics /therapy; control AccessionNumber 21998000119 Date bibliographic record published 31/07/1999 Date abstract record published 31/07/1999 |
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