Huang David T, Clermont Gilles, Dremsizov Tony T, Angus Derek C
Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory (CRISMA), Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
Crit Care Med. 2007 Sep;35(9):2090-100. doi: 10.1097/01.ccm.0000281636.82971.92.
Early goal-directed therapy (EGDT) reduced mortality from septic shock in a single-center trial. However, implementation of EGDT faces several barriers, including perceived costs and logistic difficulties. We conducted a decision analysis to explore the potential costs and consequences of EGDT implementation.
Estimates of effectiveness and resource use were based on data from the original trial and published sources. Implementation costs and lifetime projections were modeled from published sources and tested in sensitivity analyses. We generated incremental cost-effectiveness ratios from the hospital (short-term) and U.S. societal (lifetime) perspectives, excluding nonhealthcare costs, and applying a 3% annual discount.
Simulation of an average U.S. emergency department.
Total of 1,000 simulation cohorts (n = 263 for each cohort) of adult patients with severe sepsis/septic shock.
EGDT under three alternative implementation strategies: emergency department-based, mobile intensive care unit team, and intensive care unit-based (after emergency department transfer).
For an average emergency department, we estimated 91 cases per yr, start-up costs from $12,973 (intensive care unit-based) to $26,952 (emergency department-based), and annual outlay of $100,113. EGDT reduced length of stay such that net hospital costs fell approximately 22.9% ($8,413-$8,978). EGDT implementation had a 99.4% to 99.8% probability of being dominant (saved lives and costs) from the hospital perspective, and cost from $2,749 (intensive care unit-based) to $7019 (emergency department-based) per quality-adjusted life-yr with 96.7% to 97.7% probability of being <$20,000 per quality-adjusted life-yr from the societal perspective. The intensive care unit-based strategy was the least expensive, because of lower start-up costs, but also least effective, because of implementation delay, and all three strategies had similar cost-effectiveness ratios. Sensitivity analyses showed these estimates to be particularly sensitive to EGDT's effect on mortality and intensive care unit length of stay, but insensitive to other variables.
EGDT has important start-up costs, and modest delivery costs, but assuming LOS and mortality are reduced, EGDT can be cost-saving to the hospital and associated with favorable lifetime cost-effectiveness projections.
在一项单中心试验中，早期目标导向治疗（EGDT）降低了感染性休克的死亡率。然而，EGDT的实施面临若干障碍，包括感知到的成本和后勤困难。我们进行了一项决策分析，以探讨EGDT实施的潜在成本和后果。
有效性和资源使用的估计基于原始试验和已发表资料的数据。实施成本和终生预测根据已发表资料进行建模，并在敏感性分析中进行检验。我们从医院（短期）和美国社会（终生）角度生成了增量成本效益比，排除了非医疗成本，并应用3%的年贴现率。
模拟美国一家普通急诊科。
共1000个模拟队列（每个队列n = 263）的成年严重脓毒症/感染性休克患者。
在三种替代实施策略下的EGDT：基于急诊科、移动重症监护病房团队和基于重症监护病房（急诊科转诊后）。
对于一家普通急诊科，我们估计每年有91例病例，启动成本从12,973美元（基于重症监护病房）到26,952美元（基于急诊科），每年支出100,113美元。EGDT缩短了住院时间，使医院净成本下降了约22.9%（8413美元至8978美元）。从医院角度来看，EGDT实施具有99.4%至99.8%的概率占优（挽救生命并节省成本），每质量调整生命年的成本从2749美元（基于重症监护病房）到7019美元（基于急诊科），从社会角度来看，每质量调整生命年成本<20,000美元的概率为96.7%至97.7%。基于重症监护病房的策略成本最低，因为启动成本较低，但效果也最差，因为实施延迟，且所有三种策略的成本效益比相似。敏感性分析表明，这些估计对EGDT对死亡率和重症监护病房住院时间的影响特别敏感，但对其他变量不敏感。
EGDT有重要的启动成本和适度的实施成本，但假设住院时间和死亡率降低，EGDT对医院可节省成本，并具有良好的终生成本效益预测。
