Merchant Raina M, Becker Lance B, Abella Benjamin S, Asch David A, Groeneveld Peter W
Robert Wood Johnson Foundation Clinical Scholars program, the Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Circ Cardiovasc Qual Outcomes. 2009 Sep;2(5):421-8. doi: 10.1161/CIRCOUTCOMES.108.839605. Epub 2009 Aug 4.
Therapeutic hypothermia can improve survival and neurological outcomes in cardiac arrest survivors, but its cost-effectiveness is uncertain. We sought to evaluate the cost-effectiveness of treating comatose cardiac arrest survivors with therapeutic hypothermia.
A decision model was developed to capture costs and outcomes for patients with witnessed out-of-hospital ventricular fibrillation arrest who received conventional care or therapeutic hypothermia. The Hypothermia After Cardiac Arrest (HACA) trial inclusion criteria were assumed. Model inputs were determined from published data, cooling device companies, and consultation with resuscitation experts. Sensitivity analyses and Monte Carlo simulations were performed to identify influential variables and uncertainty in cost-effectiveness estimates. The main outcome measures were quality-adjusted survival after cardiac arrest, cost of hypothermia implementation, cost of posthospital discharge care, and incremental cost-effectiveness ratios. In our model, postarrest patients receiving therapeutic hypothermia gained an average of 0.66 quality-adjusted life years compared with conventional care, at an incremental cost of $31,254. This yielded an incremental cost-effectiveness ratio of $47,168 per quality-adjusted life year. Sensitivity analyses demonstrated that poor neurological outcome postcooling and costs associated with posthypothermia care (in-hospital and long term) were the most influential variables in the model. Even at extreme estimates for costs, the cost-effectiveness of hypothermia remained less than $100,000 per quality-adjusted life year. In 91% of 10,000 Monte Carlo simulations, the incremental cost-effectiveness ratio was less than $100,000 per quality-adjusted life year.
In cardiac arrest survivors who meet HACA criteria, therapeutic hypothermia with a cooling blanket improves clinical outcomes with cost-effectiveness that is comparable to many economically acceptable health care interventions in the United States.
治疗性低温可改善心脏骤停幸存者的生存率和神经功能结局，但其成本效益尚不确定。我们旨在评估对昏迷的心脏骤停幸存者进行治疗性低温治疗的成本效益。
建立了一个决策模型，以获取接受常规治疗或治疗性低温治疗的院外目击心室颤动性心脏骤停患者的成本和结局。假定符合心脏骤停后低温治疗（HACA）试验的纳入标准。模型输入数据来自已发表的数据、降温设备公司以及与复苏专家的咨询。进行了敏感性分析和蒙特卡罗模拟，以确定影响成本效益估计的变量和不确定性。主要结局指标为心脏骤停后的质量调整生存期、低温治疗实施成本、出院后护理成本以及增量成本效益比。在我们的模型中，与常规治疗相比，接受治疗性低温治疗的心脏骤停后患者平均获得了0.66个质量调整生命年，增量成本为31,254美元。这产生了每质量调整生命年47,168美元的增量成本效益比。敏感性分析表明，降温后神经功能不良结局以及与低温治疗后护理（住院和长期）相关的成本是模型中最具影响力的变量。即使在成本的极端估计情况下，低温治疗的成本效益仍低于每质量调整生命年100,000美元。在10,000次蒙特卡罗模拟中的91%中，增量成本效益比低于每质量调整生命年100,000美元。
在符合HACA标准的心脏骤停幸存者中，使用降温毯进行治疗性低温可改善临床结局，其成本效益与美国许多经济上可接受的医疗保健干预措施相当。
