Gray James, Geva Alon, Zheng Zheng, Zupancic John A F
Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA.
Pediatrics. 2008 Jan;121(1):28-36. doi: 10.1542/peds.2007-0633.
A selective head-cooling device for the treatment of moderate to severe hypoxic-ischemic encephalopathy has been approved by the Food and Drug Administration for use in the United States. To reflect the complexity of health care delivery at the systems level, we used the industrial modeling technique of discrete event simulation to analyze the impact of various deployment strategies for selective head cooling and its partner technology, amplitude-integrated electroencephalography.
We modeled the course through the perinatal system of all births in Massachusetts over a 1-year period. Cohort and care characteristics were drawn from existing databases. Results of a recently published trial were used to estimate the effects of selective head cooling. One thousand cohort replications were conducted to assess uncertainty. Several policy alternatives were examined, including no use of selective head cooling and scenarios that altered the number and placement of selective head-cooling and amplitude-integrated electroencephalography units throughout the state. Patient-level outcome and cost data were assessed.
For all scenarios tested, the use of amplitude-integrated electroencephalography/selective head cooling resulted in better outcomes at lower cost. However, substantial differences in transfer rates, failure-to-cool rates, and total costs were seen across scenarios. Optimal decision-making regarding the number and placement of devices led to a 16% improvement in cost savings and a 10-fold decrease in failure-to-cool rates, compared with other deployment scenarios. These results were insensitive to significant changes in model inputs.
On the basis of currently available data, the package of amplitude-integrated electroencephalography and selective head cooling seems to be an economically desirable intervention. Quantifiable techniques to assess system-wide technology performance provide a powerful approach to informing decisions regarding the structure and function of health care systems.
一种用于治疗中重度缺氧缺血性脑病的选择性头部冷却装置已获美国食品药品监督管理局批准在美国使用。为反映系统层面医疗保健服务的复杂性，我们采用离散事件模拟的工业建模技术来分析选择性头部冷却及其配套技术——振幅整合脑电图的各种部署策略的影响。
我们对马萨诸塞州一年内所有出生婴儿的围产期系统病程进行了建模。队列和护理特征取自现有数据库。利用最近发表的一项试验结果来估计选择性头部冷却的效果。进行了1000次队列重复以评估不确定性。研究了几种政策选择，包括不使用选择性头部冷却以及改变全州选择性头部冷却和振幅整合脑电图设备数量与放置地点的方案。评估了患者层面的结局和成本数据。
对于所有测试的方案，使用振幅整合脑电图/选择性头部冷却均能以更低成本取得更好的结局。然而，不同方案在转运率、冷却失败率和总成本方面存在显著差异。与其他部署方案相比，关于设备数量和放置地点的最优决策使成本节约提高了16%，冷却失败率降低了10倍。这些结果对模型输入的显著变化不敏感。
基于现有数据，振幅整合脑电图和选择性头部冷却组合似乎是一种经济上可取的干预措施。评估全系统技术性能的可量化技术为指导有关医疗保健系统结构和功能的决策提供了一种有力方法。
