{ Challenges in cost-utility analysis in the critical care setting Ville Pettilä MD, PhD, A/P Helsinki University Hospital VP SFAI- veckan / Kalmar
CCM 2006
- only 19 papers - max $958,423/ QALY -$1,150 - $575,000 / life-year - many < $50,000 /QALY -
41 studies in critical/intensive care quality assessed as poor to moderate
Boston- CEA Registry- Quality of cost-utility analyses
{.. In the ideal world VP
Sintonen 1994
{
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Angus D AMJRCCM 2001 ARDS N=200
Angus DC et al. CCM 2006 Quality-adjusted survival
{ Challenge No 1: Inter-patient variability
Costs and QALYs – the real world in the ICU
Räsänen P et al. HQLO 2006 Cost-effectiveness planes for a treatment
Crit Care Med 2003
{ Challenge No 2: Inter-diagnoses variability
{ Challenge No 3: How to adjust for non-survivors?
Angus D et al. CCM 2006
{ Challenge No 4: Which instrument to use for quality of life (QOL)?
{ (1) What is an OPTIMAL QOL measure ? SF- (RAND- 36) EQ-5D Nottingham Health Profile (NPH) SIP etc.
{ EQ-5D *simple *ESICM recommendation *one number between 0 and 1 * enables QALY calculations
{ (2) QOL – target population ? selected vs. unselected defined vs. all trauma ?, sepsis? ARDS? timing of measurement 6(-12) months post/ICU ? a cohort or an RCT?
{ (3) QOL- missing data Proportion of missing data - < 10%? How to handle missing data ? Comparison of patients with missing data to those with available data ! Adequate sample size !
{ (4) QOL- follow-up and adjustment ? Were all patients followed ? What is the optimal time for QOL measurement ?
Dowdy et al ICM 2006
references studies -21 different patient populations -21 studies included -Different instruments, patient populations Dowdy et al. ICM 2005
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{ Challenge No 5: How to calculate/ estimate quality of life (QOL)?
{ Challenge No 6: How accurate are the costs? Indirect costs ? Costs after hospital discharge?
{ Challenge No 7: What is the time-frame? Should it be life-time?
Kaarlola A, Tallgren M, Pettilä V CCM 2006
QALYs after critical care [N=2873] Kaarlola et al. CCM 2006
Cost-utility after intensive care [N=2873] Kaarlola et al. CCM 2006
{ Cost per QALY in severe sepsis (Finnsepsis study) N=480 Karlsson et al CCM 2009 Key finding: The estimated life-time cost-utility using QOL at 2 years after discharge is very reasonable (median 1720€/QALY)
Mean of costs, costs/QALYs and estimated QALYs with 95% CIs in different age groups for acute respiratory failure patients. FINNALI, Linko et al. Critical Care 2010 Cost per QALY in acute respiratory failure (FINNALI study) N= VP
Table 3. Predicted cost-utilities in subgroups of patients with acute respiratory failure. n Gained survival (yrs)QALYs (yrs) Cost/hospital survivor Cost/QALY mean (SD) € € Age (yrs) ≤ (19)25 (16) (11)11 (8) (8)6 (6) ≥ (5)3 (3) SAPS II (points) ≤ (18)20 (15) (16)11 (12) (15)8 (11) ≥ (13)5 (9) Admission type Elective13316 (14)12 (12) Emergency82117 (18)11 (13) Ventilatory support NIV only10515 (17)11 (14) Invasive ventilation only (17)12 (13) NIV and invasive ventilation before 6 hours4311 (16)6 (9) NIV and invasive ventilation after 6 hours3513 (17)8 (11) ARF risk factors 48 hours before Sepsis13614 (15)9 (12) Cardiac insufficiency1929 (12)6 (8) Pneumonia11414 (16)9 (12) Post-operative with ventilatory support<1 day13217 (15)12 (12) Chronic diseases: chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, chronic heart disease, diabetes mellitus, immunodeficiency, neuromuscular disease Linko et al. Critical Care 2010 accepted Cost-utility – acute respiratory failure – life-time scale –FINNALI Linko et al Critical Care VP
{ Challenge No 8: Discount for costs and QALYs included in the calculations?
{ Challenge No 9 How to present willingness to pay and probabilities?
{ Challenge No 9: How to present willingness to pay and probabilities? CEAC- cost effectiveness acceptability curve
Cost-effectiveness acceptability curves-CEACs Subgroups of patients according to gained QALYs
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Cost utility studies in critical care lack scientific validity and robustness Conclusions VP 46
Cost utility studies in critical care lack scientific validity and robustness No consensus regarding utility instrument, calculations, adjustment for missing data, and representation of data exist Conclusions VP 47
Cost utility studies in critical care lack scientific validity and robustness No consensus regarding utility instrument, calculations, adjustment for missing data, and representation of data exists At their best the available cost utility studies in critical care may be seen as clinically valuable estimations of benefit/ harm of the treatment Conclusions VP 48
Conclusion Cost-utility –studies…. …..the gold standard 1. Representative non-selected population 2. Defined diagnostic group 3. Standardized utility instrument 4. Life-time scale for QALYs gained 5. Preferably all hospital costs/reliable estimate 6. Discount rate 7. Sensitivity analysis regarding different age and severity of disease 8. Cost-effectivenss plane 9. CEA-curve VP