Cost-Effectiveness Studies in the ICU: A Systematic Review.

OBJECTIVES: Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs. DESIGN: We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist. SETTING: Critical care units. PATIENTS OR SUBJECTS: Critical care patients. INTERVENTIONS: Identified studies with cost-effectiveness analyses. MEASUREMENTS AND MAIN RESULTS: We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]). CONCLUSIONS: Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.

Using stroke thrombolysis to describe the role of repetition in learning a cognitive skill.

OBJECTIVE: To empirically describe how independent physicians develop a new cognitive clinical skill through repetition using the initiation of a stroke thrombolysis programme as a model. METHODS: This was a retrospective cohort study from April 2009 to March 2013. The setting was a single-centre, Canadian tertiary-care community hospital. The participants were 52 physicians with no prior formal training in stroke thrombolysis assuming a new role of being front-line hyperacute stroke physicians. The main outcome measures were: time needed to accrue experience, door-to-needle time (DTN), with achievement of expertise defined as an average of ≤ 60 minutes, computed tomography (CT)-to-needle time (CTN), with achievement of expertise defined as an average of ≤ 35 minutes, usage of an outside expert stroke telemedicine service, and complication rates with intracranial haemorrhage (ICH). RESULTS: Seven hundred and fifteen cases of hyperacute stroke were seen over the 4-year study period. On average, a physician saw 0.025 cases per hour of code stroke coverage provided; only seven (13.5%) accrued more than 20 code stroke cases and only six (11.6%) ordered thrombolysis more than 10 times. By regression analysis, the average first DTN was 81.0 minutes (95% confidence interval [CI], 77.1-84.9 minutes) and incrementally improved linearly by 0.259 minutes per case seen (95% CI, 0.182-0.337 minutes per case). An estimated 71 cases needed to be seen for the average physician to achieve expertise. Results using CTN were highly similar. Overall, physicians used the external stroke telemedicine providers 23.2% of the time for their first five cases, a rate that decreased to about 5% by the 45th case. Over time, ICH rates were kept at expected benchmarks. CONCLUSIONS: Accruing sufficient experience of a new cognitive clinical skill can be challenging for independent physicians, with expertise gradually emerging in a largely linear fashion only after much repetition.

Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review.

IMPORTANCE: Thoracentesis is performed to identify the cause of a pleural effusion. Although generally safe, thoracentesis may be complicated by transient hypoxemia, bleeding, patient discomfort, reexpansion pulmonary edema, and pneumothorax. OBJECTIVE: To identify the best means for differentiating between transudative and exudative effusions and also to identify thoracentesis techniques for minimizing the risk of complications by performing a systematic review the evidence. DATA SOURCES: We searched The Cochrane Library, MEDLINE, and Embase from inception to February 2014 to identify relevant studies. STUDY SELECTION: We included randomized and observational studies of adult patients undergoing thoracentesis that examined diagnostic tests for differentiating exudates from transudates and evaluated thoracentesis techniques associated with a successful procedure with minimal complications. DATA EXTRACTION AND SYNTHESIS: Two investigators independently appraised study quality and extracted data from studies of laboratory diagnosis of pleural effusion for calculation of likelihood ratios (LRs; n = 48 studies) and factors affecting adverse event rates (n = 37 studies). RESULTS: The diagnosis of an exudate was most accurate if cholesterol in the pleural fluid was greater than 55 mg/dL (LR range, 7.1-250), lactate dehydrogenase (LDH) was greater than 200 U/L (LR, 18; 95% CI, 6.8-46), or the ratio of pleural fluid cholesterol to serum cholesterol was greater than 0.3 (LR, 14; 95% CI, 5.5-38). A diagnosis of exudate was less likely when all Light's criteria (a ratio of pleural fluid protein to serum protein >0.5, a ratio of pleural fluid LDH to serum LDH >0.6, or pleural fluid LDH >two-thirds the upper limit of normal for serum LDH) were absent (LR, 0.04; 95% CI, 0.02-0.11). The most common complication of thoracentesis was pneumothorax, which occurred in 6.0% of cases (95% CI, 4.0%-7.0%). Chest tube placement was required in 2.0% of procedures (95% CI, 0.99%-2.9%) in which a patient was determined to have radiographic evidence of a pneumothorax. With ultrasound, a radiologist's marking the needle insertion site was not associated with decreased pneumothorax events (skin marking vs no skin marking odds ratio [OR], 0.37; 95% CI, 0.08-1.7). Use of ultrasound by any experienced practitioner also was not associated with decreased pneumothorax events (OR, 0.55; 95% CI, 0.06-5.3). CONCLUSIONS AND RELEVANCE: Light's criteria, cholesterol and pleural fluid LDH levels, and the pleural fluid cholesterol-to-serum ratio are the most accurate diagnostic indicators for pleural exudates. Ultrasound skin marking by a radiologist or ultrasound-guided thoracentesis were not associated with a decrease in pneumothorax events.

Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses.

OBJECTIVE: To determine the effect of different intensivist staffing models on clinical outcomes for critically ill patients. DATA SOURCES: A sensitive search of electronic databases and hand-search of major critical care journals and conference proceedings was completed in October 2012. STUDY SELECTION: Comparative observational studies examining intensivist staffing patterns and reporting hospital or ICU mortality were included. DATA EXTRACTION: Of 16,774 citations, 52 studies met the inclusion criteria. We used random-effects meta-analytic models unadjusted for case-mix or cluster effects and quantified between-study heterogeneity using I. Study quality was assessed using the Newcastle-Ottawa Score for cohort studies. DATA SYNTHESIS: High-intensity staffing (i.e., transfer of care to an intensivist-led team or mandatory consultation of an intensivist), compared to low-intensity staffing, was associated with lower hospital mortality (risk ratio, 0.83; 95% CI, 0.70-0.99) and ICU mortality (pooled risk ratio, 0.81; 95% CI, 0.68-0.96). Significant reductions in hospital and ICU length of stay were seen (-0.17 d, 95% CI, -0.31 to -0.03 d and -0.38 d, 95% CI, -0.55 to -0.20 d, respectively). Within high-intensity staffing models, 24-hour in-hospital intensivist coverage, compared to daytime only coverage, did not improved hospital or ICU mortality (risk ratio, 0.97; 95% CI, 0.89-1.1 and risk ratio, 0.88; 95% CI, 0.70-1.1). The benefit of high-intensity staffing was concentrated in surgical (risk ratio, 0.84; 95% CI, 0.44-1.6) and combined medical-surgical (risk ratio, 0.76; 95% CI, 0.66-0.83) ICUs, as compared to medical (risk ratio, 1.1; 95% CI, 0.83-1.5) ICUs. The effect on hospital mortality varied throughout different decades; pooled risk ratios were 0.74 (95% CI, 0.63-0.87) from 1980 to 1989, 0.96 (95% CI, 0.69-1.3) from 1990 to 1999, 0.70 (95% CI, 0.54-0.90) from 2000 to 2009, and 1.2 (95% CI, 0.84-1.8) from 2010 to 2012. These findings were similar for ICU mortality. CONCLUSIONS: High-intensity staffing is associated with reduced ICU and hospital mortality. Within a high-intensity model, 24-hour in-hospital intensivist coverage did not reduce hospital, or ICU, mortality. Benefits seen in mortality were dependent on the type of ICU and decade of publication.

Does implementation of a hospitalist program in a Canadian community hospital improve measures of quality of care and utilization? an observational comparative analysis of hospitalists vs. traditional care providers.

BACKGROUND: Despite the growth of hospitalist programs in Canada, little is known about their effectiveness for improving quality of care and use of scarce healthcare resources. The objective of this study is to compare measures of cost and quality of care (in-hospital mortality, 30-day same-facility readmission, and length of stay) of hospitalists vs. traditional physician providers in a large Canadian community hospital setting. METHODS: We performed a retrospective analysis of data from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database, using multivariate logistic and linear regression analyses comparing performance of four provider groups of traditional family physicians (FPs), traditional internal medicine subspecialists (other-IM), family physician-trained hospitalists (FP-Hospitalist), and general internal medicine-trained hospitalists (GIM-Hospitalist). RESULTS: Compared to traditional FPs, FP-Hospitalists and GIM-Hospitalists demonstrate lower mortality [OR 0.881, (CI 0.779 - 0.996); and OR 0.355, (CI 0.288 - 0.436)] and readmission rates [OR 0.766, (CI 0.678 - 0.867); and OR 0.800, (CI 0.675 - 0.948)]. Compared to traditional FPs, GIM-Hospitalists appear to improve length of stay [OR-2.975, (CI -3.302 - -2.647)] while FP-Hospitalists perform similarly [OR 0.096, (CI -0.136 - 0.329)]. Compared to other-IM, GIM-Hospitalists have similar performance on all measures while FP-Hospitalists show a mixed impact. CONCLUSIONS: Compared to traditional family physicians, hospitalists appear to improve measures of quality and resource utilization. Specifically, hospitalists demonstrate lower in-hospital mortality and 30-day readmission rates while improving (or at least showing similar) length of stay. Compared to traditional subspecialists, hospitalists demonstrate similar performance despite looking after sicker and more complex medical patients.

How well do guidelines incorporate evidence on patient preferences?

BACKGROUND: Clinical practice guidelines (CPG) are meant to consider important values such as patient preferences. OBJECTIVE: To assess how well clinical practice guidelines (CPGs) integrate evidence on patient preferences compared with that on treatment effectiveness. DESIGN: A cross-sectional review of a listing in 2006 of CPGs judged to be the best in their fields by an external joint government and medical association body. STUDY SELECTION: Exclusion criterion was unavailability in electronic format. Sixty-five of 71 listed CPGs met selection criteria. MEASUREMENTS: Two instruments originally constructed to evaluate the overall quality of CPGs were adapted to specifically assess the quality of integrating information on patient preference vs. treatment effectiveness. Counts of words and references in each CPG associated with patient preferences vs. treatment effectiveness were performed. Two reviewers independently assessed each CPG. MAIN RESULTS: Based on our adapted instruments, CPGs scored significantly higher (p < 0.001) on the quality of integrating treatment effectiveness compared with patient preferences evidence (mean instrument one scores on a scale of 0.25 to 1.00: 0.65 vs. 0.43; mean instrument two scores on a scale of 0 to 1: 0.58 vs. 0.18). The average percentage of the total word count dedicated to treatment effectiveness was 24.2% compared with 4.6% for patient preferences. The average percentage of references citing treatment effectiveness evidence was 36.6% compared with 6.0% for patient preferences. CONCLUSION: High quality CPGs poorly integrate evidence on patient preferences. Barriers to incorporating preference evidence into CPGs should be addressed.

Health-state utilities in a prisoner population: a cross-sectional survey.

BACKGROUND: Health-state utilities for prisoners have not been described. METHODS: We used data from a 1996 cross-sectional survey of Australian prisoners (n = 734). Respondent-level SF-36 data was transformed into utility scores by both the SF-6D and Nichol's method. Socio-demographic and clinical predictors of SF-6D utility were assessed in univariate analyses and a multivariate general linear model. RESULTS: The overall mean SF-6D utility was 0.725 (SD 0.119). When subdivided by various medical conditions, prisoner SF-6D utilities ranged from 0.620 for angina to 0.764 for those with none/mild depressive symptoms. Utilities derived by the Nichol's method were higher than SF-6D scores, often by more than 0.1. In multivariate analysis, significant independent predictors of worse utility included female gender, increasing age, increasing number of comorbidities and more severe depressive symptoms. CONCLUSION: The utilities presented may prove useful for future economic and decision models evaluating prison-based health programs.

A review and meta-analysis of prostate cancer utilities.

BACKGROUND: Health-related quality of life is a key issue in prostate cancer (PC) management. The authors summarized published utilities for common health-related quality of life outcomes of PC and determined how methodological factors affect them. METHODS: In their systematic review, the authors identified 23 articles in English, providing 173 unique utilities for PC health states, each obtained from 2 to 422 respondents. Data were pooled using linear mixed-effects modeling with utilities clustered within the study, weighted by the number of respondents divided by the variance of each utility. RESULTS: In the base model, the estimated utility of the reference case (scenario of a metastatic PC patient with severe sexual symptoms, rated by non-PC patients using time tradeoff) was 0.76. Disease stage, symptom type and severity, source of utility, and scaling method were associated with utility differences of 0.10 to 0.32 (P < 0.05). Utilities from PC patients rating their own health were 0.14 higher than those from the reference case, but utilities from PC patients rating scenarios were lowest. Time tradeoff yielded the highest utilities. Computer administration yielded lower utilities than personal interview (P = 0.02). Neither the scale's high anchor nor study purpose had significant effects on utilities. CONCLUSIONS: This study provides pooled utility estimates for common PC health states and describes how clinical and methodological factors can significantly affect these values. When possible, utility estimates for a modeling application should be derived similarly. Formal data synthesis methods might be useful to researchers integrating utility data from heterogeneous sources. Further exploration of these methods for this purpose is warranted.

An unadjusted NNT was a moderately good predictor of health benefit.

BACKGROUND AND OBJECTIVE: Whether the number needed to treat (NNT) is sufficiently precise to use in clinical practice remains unclear. We compared unadjusted NNTs to quality-adjusted life years (QALYs) gained, a more comprehensive measures of health benefit. STUDY DESIGN AND SETTING: From a subset (n = 65) of a dataset of 228 cost-effectiveness analyses, we compared how well NNTs predicted clinically important QALY gains using correlation analysis, multivariable models and receiver-operator curve (ROC) analysis. RESULTS: NNT was inversely correlated with QALY gains (P < .001); this relationship was affected by quality of life and life-expectancy gains of treatment (P 15 had a sensitivity of 82% to 100%. For ruling in therapies with high QALY gains (threshold >or=0.125 to >or=0.5 QALYs), an NNT 15 to rule in and out therapies with large QALY gains may provide general guidance regarding the magnitude of health benefit.

An unexpected case of coumarin poisoning with coumatetralyl.

A healthy man in his 40s presented with a 1-month history of haemoptysis and was unexpectedly found to have an elevated international normalised ratio (INR). He denied any known exposures to anticoagulants. Testing for the possible aetiologies of a high INR revealed coumarin poisoning with coumatetralyl as the cause. The approach to an elevated INR and management and diagnosis of suspected coumarin poisoning is reviewed.

Health-state utilities and quality of life in hepatitis C patients.

OBJECTIVE: Health-state utilities are global measurements of quality of life on a scale from 0 (death) to 1 (full health). Utilities are used to evaluate health outcomes and are the preferred outcome measure for policy models that determine the cost-effectiveness of treatments. Currently, utilities for hepatitis C virus (HCV)-infected patients have been estimated using expert judgments. The purpose of this study was to elicit HCV utilities directly from patients. METHODS: We assessed the utilities of 193 outpatients at various stages of chronic HCV progression by using a visual analog scale, the standard gamble technique, the Health Utilities Index Mark 3 survey, and the EuroQol Index survey. We also incorporated the nonutility-based Short Form-36v2 survey, which provides a detailed profile of health status. RESULTS: The mean standard gamble utilities were: 0.78 for patients without a recent liver biopsy and no signs of cirrhosis; 0.79 for mild to moderate chronic HCV infection; 0.80 for compensated cirrhosis; 0.60 for decompensated cirrhosis; 0.72 for hepatocellular carcinoma; 0.73 for transplant; and 0.86 for sustained virological responders to interferon +/- ribavirin treatment. The Health Utilities Index Mark 3 survey and the EuroQol Index survey utilities were lower than Canadian population norms (p < 0.001). Patient-elicited utilities were lower than previous expert estimates for mild/moderate chronic infection and sustained virological responders, but higher for decompensated cirrhosis and hepatocellular carcinoma. The Short Form-36v2 survey scores revealed several significant health impairments (p < 0.005) when compared with U.S. population norms. CONCLUSIONS: These findings 1) suggest that quality of life (QOL) differences across the HCV clinical spectrum are smaller than previously believed; 2) support other evidence suggesting that QOL is significantly diminished in HCV patients; and 3) provide utility values derived directly from HCV patients.