van Hooijdonk Roosmarijn T M, Steuten Lotte M G, Kip Michelle M A, Monteban Helma, Mulder Marianne R, van Braam Houckgeest Floris, van der Sluijs Johannes P, Abu-Hanna Ameen, Spronk Peter E, Schultz Marcus J
Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,
Appl Health Econ Health Policy. 2015 Aug;13(4):399-407. doi: 10.1007/s40258-015-0174-5.
Point-of-care testing of blood glucose (BG-POCT) is essential for safe and effective insulin titrations in critically ill patients under glucose control with insulin. The costs associated with this practice are considered substantial, especially when more frequent blood glucose (BG) testing is needed, as with more strict glucose control (SGC) aiming for lower BG levels.
The objective of this study was to estimate, from a hospital perspective, the incremental cost effectiveness of an SGC guideline, aiming for BG levels of 4.4-6.1 mmol/L, compared to the situation before implementation of that guideline (aiming for BG levels <8.3 mmol/L), both using BG-POCT.
This is a secondary analysis of a guideline implementation project aiming for implementation of a guideline of SGC in three intensive care units in The Netherlands. A Markov model including the four health states 'target glucose', 'hyperglycaemia' (defined as BG levels >6.1 mmol/L), 'hypoglycaemia' (defined as BG levels <4.4 mmol/L) and 'in-hospital death' was developed to compare expected costs, number of patients within target and number of life-years saved before and after implementation of the SGC guideline. The effectiveness estimates are based on empirical data from 3195 patients 12 and 24 months before and after implementation of the guideline, respectively. All costs have been converted to price year 2013, and are estimated based on hospital data, the literature and available price lists.
The number of BG-POCT increased from 4.8 [interquartile range (IQR) 2.6-6.7] to 8.0 [IQR 4.1-11.2] per patient per day, accruing 58% higher costs for BG-POCT (€13.56 vs. €8.57 per patient) in the SGC protocol versus the situation before implementation. When taking total hospital costs and clinical effects into account, implementation of the SGC guideline increased total hospital costs per patient by 1.8%, i.e., €355 (from €20,617 to €20,972) during the inpatient stay, while the number of patients in target glucose levels increased by 1.4% (i.e., from 881 to 895 per 1000 patients). This translates to an incremental cost-effectiveness ratio of €25 per additional patient within the target glucose level. The model outcomes are most sensitive to changes in ICU length of stay.
The increase in the number of patients and time within target glucose levels is achieved with a small increase in total direct hospital costs.
对于使用胰岛素进行血糖控制的危重症患者，即时检测血糖（BG-POCT）对于安全有效地调整胰岛素剂量至关重要。这种做法的相关成本被认为很高，尤其是在需要更频繁地检测血糖时，比如在旨在实现更低血糖水平的更严格血糖控制（SGC）情况下。
本研究的目的是从医院角度估算，与该指南实施前（目标血糖水平<8.3 mmol/L）的情况相比，目标血糖水平为4.4 - 6.1 mmol/L的SGC指南的增量成本效益，两者均采用BG-POCT。
这是一项对指南实施项目的二次分析，该项目旨在在荷兰的三个重症监护病房实施SGC指南。开发了一个马尔可夫模型，包括“目标血糖”“高血糖（定义为血糖水平>6.1 mmol/L）”“低血糖（定义为血糖水平<4.4 mmol/L）”和“院内死亡”这四种健康状态，以比较SGC指南实施前后的预期成本、目标范围内的患者数量和挽救的生命年数。有效性估计分别基于指南实施前12个月和实施后24个月的3195例患者的经验数据。所有成本已换算为2013年价格，并根据医院数据、文献和可用价格清单进行估算。
每位患者每天的BG-POCT检测次数从4.8次[四分位间距（IQR）2.6 - 6.7]增加到8.0次[IQR 4.1 - 11.2]，SGC方案中BG-POCT的成本比实施前的情况高58%（每位患者13.56欧元对8.57欧元）。考虑到医院总成本和临床效果，SGC指南的实施使每位患者的住院期间医院总成本增加了1.8%，即355欧元（从20,617欧元增至20,972欧元），而目标血糖水平内的患者数量增加了1.4%（即每1000例患者从881例增至895例）。这意味着每增加一名目标血糖水平内的患者，增量成本效益比为25欧元。模型结果对ICU住院时间的变化最为敏感。
在医院直接总成本略有增加的情况下，目标血糖水平内的患者数量和时间有所增加。
