Dataset Information

Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision.

ABSTRACT:

Introduction

Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult intensive care unit (ICU) patients.

Methods

We used a Markov decision model to compare the cost effectiveness of A-CVCs relative to uncoated catheters. Four catheter types were evaluated: minocycline and rifampicin (MR)-coated catheters, silver, platinum and carbon (SPC)-impregnated catheters, and two chlorhexidine and silver sulfadiazine-coated catheters; one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per quality-adjusted life year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses.

Results

The baseline analysis, with no consideration of uncertainty, indicated all four types of A-CVC were cost-saving relative to uncoated catheters. MR-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life years, and cost savings (AUD $130,289). After considering uncertainty in the current evidence, the MR-coated catheters returned the highest incremental monetary net benefits of AUD $948 per catheter; however there was a 62% probability of error in this conclusion. Although the MR-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty.

Conclusions

Current evidence suggests that the cost effectiveness of using A-CVCs within the ICU is highly uncertain. Policies to prevent CR-BSI amongst ICU patients should consider the cost effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.

SUBMITTER: Halton KA

PROVIDER: S-EPMC2689469 | biostudies-literature | 2009

REPOSITORIES: biostudies-literature

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Publications

Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision.

Halton Kate A KA Cook David A DA Whitby Michael M Paterson David L DL Graves Nicholas N

Critical care (London, England) 20090311 2

<h4>Introduction</h4>Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult i ...[more]

PMID: 19284570

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Project description:ObjectiveTo model the cost-effectiveness impact of routine use of an antimicrobial chlorhexidine gluconate-containing securement dressing compared to non-antimicrobial transparent dressings for the protection of central vascular lines in intensive care unit patients.DesignThis study uses a novel health economic model to estimate the cost-effectiveness of using the chlorhexidine gluconate dressing versus transparent dressings in a French intensive care unit scenario. The 30-day time non-homogeneous markovian model comprises eight health states. The probabilities of events derive from a multicentre (12 French intensive care units) randomized controlled trial. 1,000 Monte Carlo simulations of 1,000 patients per dressing strategy are used for probabilistic sensitivity analysis and 95% confidence intervals calculations. The outcome is the number of catheter-related bloodstream infections avoided. Costs of intensive care unit stay are based on a recent French multicentre study and the cost-effectiveness criterion is the cost per catheter-related bloodstream infections avoided. The incremental net monetary benefit per patient is also estimated.Patients1000 patients per group simulated based on the source randomized controlled trial involving 1,879 adults expected to require intravascular catheterization for 48 hours.InterventionChlorhexidine Gluconate-containing securement dressing compared to non-antimicrobial transparent dressings.ResultsThe chlorhexidine gluconate dressing prevents 11.8 infections /1,000 patients (95% confidence interval: [3.85; 19.64]) with a number needed to treat of 85 patients. The mean cost difference per patient of €141 is not statistically significant (95% confidence interval: [€-975; €1,258]). The incremental cost-effectiveness ratio is of €12,046 per catheter-related bloodstream infection prevented, and the incremental net monetary benefit per patient is of €344.88.ConclusionsAccording to the base case scenario, the chlorhexidine gluconate dressing is more cost-effective than the reference dressing.Trial registrationThis model is based on the data from the RCT registered with www.clinicaltrials.gov (NCT01189682).

Project description:IntroductionComparing multiple, diverse outcomes with cost-effectiveness analysis (CEA) is important, yet challenging in areas like palliative care where domains are unamenable to integration with survival. Generic multi-attribute utility values exclude important domains and non-health outcomes, while partial analyses-where outcomes are considered separately, with their joint relationship under uncertainty ignored-lead to incorrect inference regarding preferred strategies.ObjectiveThe objective of this paper is to consider whether such decision making can be better informed with alternative presentation and summary measures, extending methods previously shown to have advantages in multiple strategy comparison.MethodsMultiple outcomes CEA of a home-based palliative care model (PEACH) relative to usual care is undertaken in cost disutility (CDU) space and compared with analysis on the cost-effectiveness plane. Summary measures developed for comparing strategies across potential threshold values for multiple outcomes include: expected net loss (ENL) planes quantifying differences in expected net benefit; the ENL contour identifying preferred strategies minimising ENL and their expected value of perfect information; and cost-effectiveness acceptability planes showing probability of strategies minimising ENL.ResultsConventional analysis suggests PEACH is cost-effective when the threshold value per additional day at home (?1) exceeds $1,068 or dominated by usual care when only the proportion of home deaths is considered. In contrast, neither alternative dominate in CDU space where cost and outcomes are jointly considered, with the optimal strategy depending on threshold values. For example, PEACH minimises ENL when ?1=$2,000 and ?2=$2,000 (threshold value for dying at home), with a 51.6% chance of PEACH being cost-effective.ConclusionComparison in CDU space and associated summary measures have distinct advantages to multiple domain comparisons, aiding transparent and robust joint comparison of costs and multiple effects under uncertainty across potential threshold values for effect, better informing net benefit assessment and related reimbursement and research decisions.

Dataset Information

Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision.

Introduction

Methods

Results

Conclusions

Publications

Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision.

Similar Datasets

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