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CHAPTER 6: Assessing Cost-Effectiveness in the Intensive Care Unit 41

Require better natural history of ICU conditions
May be instances when provider perspective is

may be useful depending on perspective and modeling or longer follow-up; other outcomes Consider modeling reduced efficacy in sensitivity Standard approach to measuring these costs not yet developed; estimating units of resource use and multiplying by standard costs probably most practical approach currently; detail with which resource use is tracked should be tailored to nature of intervention and likely effects on costs Many existing ICU practices may be ineffective or cost ineffective; therefore, consider comparison to best practice rather than standard practice Multiway sensitiv

Second ATS Workshop on Outcomes Research

Comment • useful • • analysis • • • critical care trials • • domized clinical trial

Include costs of other diseases (too hard to disentangle)

Position Agree Agree Agree Agree Agree Agree Agree Agree Agree Agree Agree Agree

PCEHM Recommendations (Rationale) Societal (ethical, pragmatic) QALYs (pragmatic, conventional) Best-designed, least biased source (pragmatic) Costs to include: health care services; patient time; caregiving; nonhealth impacts (theoretical) Include or exclude other disease costs and test in sensitivity analysis (theoretical, pragmatic, user needs, and accounting) Existing practice (conventional) If existing practice is suspect, consider best-available, viable low cost, or “do nothing” (conventional) Discount costs and effects to present value (theoretical) Use a 3% discount rate (theoret

ICU Specific Long-term follow-up is rare Only hospital costs are usually measured; no international standard Determining standard often difficult Not usually done Not usually done ATS, American Thoracic Society; CEA, cost-effectiveness analysis; ICU, intensive care unit; PCEHM, Panel on Cost-effectiveness in Health and Medicine; QALY, quality-adjusted life years. Data from Angus DC, Clermont G, Watson RS, Linde-Zwirble WT, Clark RH, Roberts MS. Cost-effectiveness of inhaled nitric oxide in the treatment of neonatal respiratory failure in the United States. Pediatrics December 2003;112(6 pt 1):135

Methodological Considerations in Cost-Effectiveness Analysis
Methodologic Problems Comparing CEAs Different Different out- comes Different costs — Different rates — Not standard

Individual CEA Not defined Data are inadequate or dif- ficult to evaluate Data are inadequate or dif- ficult to evaluate Choice distorts results Inadequate representation of the effect of time Inadequate representation of uncertainty on results —

TABLE 6-1 Aspect Perspective Outcomes (effects) Comparators (stan- dard care) Discounting Uncertainty Reporting

Costs

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