Page 76 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

44 PART 1: An Overview of the Approach to and Organization of Critical Care

happiness); (2) All utilities are equal within the metric used to measure • Kahn JM, Rubenfeld GD, Rohrbach J, Fuchs BD. Cost sav-
them; (3) Loss of benefit to some individuals is balanced by benefit to ings attributable to reductions in intensive care unit length of
others. stay for mechanically ventilated patients. Med Care. 2008;46:
As a simple example, consider the decision to fund a childhood
immunization program rather than a chemotherapy program to treat a 1226-1233.
rare cancer. This decision assumes that spending resources on immuni- • Rollins KE, Shak J, Ambler GK, Tang TY, Hayes PD, Boyle JR.
zations will maximize the community’s utility (health) more than money Mid-term cost-effectiveness analysis of open and endovascu-
spent on treating a rare cancer. Social utilitarianism acts to maximize the lar repair for ruptured abdominal aortic aneurysm. Br J Surg.
health and happiness (utility) of the community, and consequently leads 2014;101(3):225-231.
to maximum efficiency in use of health care resources for community • Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC. The
benefit. Cost-effectiveness analysis is designed to result in a ranked list role of cost-effectiveness analysis in health and medicine. JAMA.
https://kat.cr/user/tahir99/
of community benefits and cost outlays. While cost-effectiveness analy- 1996;276:1172.
ses can inform us about where to spend money to improve utility, they • Siegel JE, Weinstein MC, Russell LB, Gold MR. Recommendations
cannot say how much should be spent to improve health care overall. for reporting cost-effectiveness analyses. JAMA. 1996;276:1339.
If monies were unlimited, we would focus on treatment options that
minimized patient morbidity and mortality, and cost-effectiveness • Understanding costs and cost-effectiveness in critical care:
analysis would be unnecessary. In the real world, however, with a con- report from the second American Thoracic Society workshop on
strained budget, we must focus on relative value. The rigorous appli- outcomes research. Am J Respir Crit Care Med. 2002;165:
cation of cost-effectiveness analysis methodology enables a rational 540-550.
basis for comparisons between therapies and programs. To the extent • Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB.
that market forces alone will not result in pareto optimal health condi- Recommendations of the panel on cost-effectiveness in health and
tions, health policy will have a role in maintaining social utilitarianism. medicine. JAMA. 1996;276:1253.
Robust economic evaluations of new therapies, procedures, protocols, • Wunsch H, Guerra C, Barnato AE, Angus DC, Li G, Linde-Zwirble
and interventions are a crucial underpinning of these policies, especially WT. Three-year outcomes for Medicare beneficiaries who survive
in the complex world of critical care medicine. intensive care. JAMA. 2010;303:849-856.

CONCLUSION
The health care industry has been issued a mandate: Improve the REFERENCES
return on your investment. Cost-effectiveness analysis provides an
economic basis for comparing medications, procedures, protocols, Complete references available online at www.mhprofessional.com/hall
and interventions. Critical care, with its inherent complexity, frequent
innovations, and high cost, is well suited for these analyses. While the
studies cannot tell us what proportion of overall resources should be
spent on health care or even critical care, they can tell us what should CHAPTER Interpreting and Applying
be considered within a given budget. Clear and consistent reporting of
cost- effectiveness analyses is essential as its audience grows to include 7 Evidence in Critical Care
health policy authors, entitlement adjudicators, hospital administra-
tors, ICU directors, and ultimately individual clinicians. Transparency Medicine
and rigor will allow better choices to be made, and in turn, improve the
public health. Elizabeth Lee Daugherty Biddison
Douglas B. White

KEY POINTS
KEY REFERENCES
• Effective critical care practice requires a rational approach to
• Angus DC, Linde-Zwirble WT, Sirio CA, et al. The effect of man- understanding, interpreting, and integrating clinical research
aged care on ICU length of stay: Implications for Medicare. JAMA. studies, outcome measures, measures of association, and statistical
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• Arrow KJ. Uncertainty and the welfare economics of medical care. • Clinical research studies generally fall into one of two categories:
Am Econ Rev. 1963;53:941-973. observational studies or experimental studies, and each study type
• Doubilet P, Weinstein MC, McNeil BJ. Use and misuse of the term has different strengths and weaknesses.
“cost effective” in medicine. N Engl J Med. 1986;314:253-256. • The goal of the observation is to evaluate associations between
• Ehlenbach WJ, Hough CL, Crane PK, et al. Association between exposures and one or more outcomes of interest to investigators.
acute care and critical illness hospitalization and cognitive func- The randomized controlled trial (RCT) is an important experi-
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• From the bench to the bedside: the future of sepsis research. • Critical care research frequently relies on surrogate end points that
Executive summary of an American College of Chest Physicians, allow demonstration of treatment effect with fewer patients over
National Institute of Allergy and Infectious Disease, and National less time. Trials using surrogate end points should be interpreted
Heart, Lung, and Blood Institute Workshop. Chest. 1997;111: with great caution.
744-753. • Appropriate interpretation of the results of treatment trials requires
• Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive clear understanding of measures of association, including both
impairment and functional disability among survivors of severe relative risk and absolute and relative risk reduction (RRR). Making
sepsis. JAMA. 2010;304:1787-1794. an educated decision about the application of a study’s findings

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