Page 75 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 6: Assessing Cost-Effectiveness in the Intensive Care Unit 43

$1500
More costly More costly
Less effective $100,000/1 year survivor More effective
$1000
Difference in costs (thousand dollars) −$500

$500

$0
https://kat.cr/user/tahir99/

−$1000
Less costly Less costly
Less effective More effective
−$1500
−0.1 −0.05 0 5 10 15 20
Difference in effectiveness
FIGURE 6-4. Monte Carlo simulation of incremental effectiveness. The plot shows 1000 simulated trials of inhaled nitric oxide therapy in neonatal respiratory failure, varying conditions in
the estimates for each trial. Inhaled nitric oxide is demonstrated to be a dominant strategy, as it is both cheaper and more effective than standard therapy in the majority of simulations (71.6%).
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The reference case point estimate is $440,000 saved and 2.8 QALYs gained at 1 year for every 100 patients treated. (Reproduced with permission from Angus et al. )
Intervention More favorable scenario $/QALY Less favorable scenario $/QALY

Statins 35 For secondary prevention with 1,600 For primary and secondary 48,000
stepped care vs niacin prevention vs secondary only
Neonatal Vs standard neonatal care for 7,100 Vs standard neonatal care for 49,000
intensive care 36 infants 1-1.5 kg infants 0.5-1 kg
CABG 37 For left main vessel disease vs 7,100 For one-vessel disease vs 56,000
medical management of angina medical management
t-PA for AMI 38 For anterior myocardial infarction 18,000 For inferior myocardial 60,000
vs streptokinase infarction vs streptokinase
Drotrecogin For severe sepsis with APACHE II 27,000 For all severe sepsis vs 49,000
alfa 34 25 vs standard therapy standard therapy
Air bags 41 For driver side only vs no air bag 28,000 Dual air bags vs driver-side air 72,000
bag only
Implantable ICD-only regimen vs amiodarone 40,000 Amiodarone to ICD regimen vs 157,000
defibrillators 39 to ICD regimen amiodarone only
Lung Vs standard care, assuming 10- 44,000 Vs standard care, assuming 5- 204,000
transplantation 40 year survival year survival

FIGURE 6-5. League table showing the range of cost-effectiveness ratios for a variety of medical or preventive interventions.

Figure 6-4 shows the base case cost-effectiveness and reference case horizon, provide measurements of uncertainty, and include sensitivity
cost-effectiveness ratio estimates for inhaled nitric oxide generated by analysis. This standardized approach allows for comparisons of results
running 1000 simulations. This is a common graphic representation across studies. The reference case allows us to make inferences about the
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of the output from a rigorously conducted cost-effectiveness analysis. cost-effectiveness of inhaled nitric oxide in neonates compared to a ther-
The x-axis shows incremental effects and the y-axis incremental costs. apy for breast cancer. When compiled, these comparisons can be sorted
Quadrants to the right of the y-axis represent where treatment with by incremental cost-effectiveness in league tables (Fig. 6-5). These tables
inhaled nitric oxide was associated with a net gain in effect. Quadrants can include interventions against specific disease states (eg, myocardial
above the x-axis represent a net increase in cost. The majority of the infarction, stroke, lung transplantation) 35-40 and interventions designed
simulation estimates fall within the lower right hand quadrant, indicating to prevent injury or illness (eg, airbags). 41
a net gain in effect with a decrease in cost (less costly, more effective).
POLICY IMPLICATIONS
REPORTING AND THE PCEHM REFERENCE CASE
Decision making based on the results of a cost-effectiveness analysis is
The PCEHM and ATS advocate standardized reporting for cost- founded on the idea of social utilitarianism. The assumptions are that
effectiveness studies. Studies must generate a reference case, indicate the (1) Good is determined by consequences at the community level—
perspective chosen, determine costs and effects, define the study time these consequences being the sum of individual utilities (health and

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