Khan Iftekhar, Maredza Mandy, Dritsaki Melina, Mistry Dipesh, Lall Ranjit, Lamb Sarah E, Couper Keith, Gates Simon, Perkins Gavin D, Petrou Stavros
Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK.
Centre for Statistics in Medicine, University of Oxford, Oxford, OX3 9DU, UK.
Pharmacoecon Open. 2020 Dec;4(4):697-710. doi: 10.1007/s41669-020-00210-1.
Optimising techniques to wean patients from invasive mechanical ventilation (IMV) remains a key goal of intensive care practice. The use of non-invasive ventilation (NIV) as a weaning strategy (transitioning patients who are difficult to wean to early NIV) may reduce mortality, ventilator-associated pneumonia and intensive care unit (ICU) length of stay.
Our objectives were to determine the cost effectiveness of protocolised weaning, including early extubation onto NIV, compared with weaning without NIV in a UK National Health Service setting.
We conducted an economic evaluation alongside a multicentre randomised controlled trial. Patients were randomised to either protocol-directed weaning from mechanical ventilation or ongoing IMV with daily spontaneous breathing trials. The primary efficacy outcome was time to liberation from ventilation. Bivariate regression of costs and quality-adjusted life-years (QALYs) provided estimates of the incremental cost per QALY and incremental net monetary benefit (INMB) overall and for subgroups [presence/absence of chronic obstructive pulmonary disease (COPD) and operative status]. Long-term cost effectiveness was determined through extrapolation of survival curves using flexible parametric modelling.
NIV was associated with a mean INMB of £620 ($US885) (cost-effectiveness threshold of £20,000 per QALY) with a corresponding probability of 58% that NIV is cost effective. The probability that NIV is cost effective was higher for those with COPD (84%). NIV was cost effective over 5 years, with an estimated incremental cost-effectiveness ratio of £4618 ($US6594 per QALY gained).
The probability of NIV being cost effective relative to weaning without NIV ranged between 57 and 59% overall and between 82 and 87% for the COPD subgroup.
优化患者从有创机械通气（IMV）撤机的技术仍然是重症监护实践的关键目标。使用无创通气（NIV）作为一种撤机策略（将难以撤机的患者过渡到早期NIV）可能会降低死亡率、呼吸机相关性肺炎以及重症监护病房（ICU）住院时间。
我们的目的是在英国国民医疗服务体系（NHS）环境中，确定与不使用NIV撤机相比，包括早期拔管至NIV的程序化撤机的成本效益。
我们在一项多中心随机对照试验的同时进行了一项经济评估。患者被随机分配至机械通气的程序化撤机组或每日进行自主呼吸试验的持续IMV组。主要疗效结局是通气解放时间。对成本和质量调整生命年（QALY）进行双变量回归，得出每QALY的增量成本和总体及亚组[有无慢性阻塞性肺疾病（COPD）和手术状态]的增量净货币效益（INMB）估计值。通过使用灵活参数模型外推生存曲线来确定长期成本效益。
NIV的平均INMB为620英镑（885美元）（每QALY成本效益阈值为20,000英镑），NIV具有成本效益的相应概率为58%。COPD患者NIV具有成本效益的概率更高（84%）。NIV在5年内具有成本效益，估计增量成本效益比为4618英镑（每获得1个QALY为6594美元）。
总体而言，NIV相对于不使用NIV撤机具有成本效益的概率在57%至59%之间，COPD亚组在82%至87%之间。
