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

Wilcox, M. Elizabeth MD, MPH1; Vaughan, Kelsey MSc, MPP2; Chong, Christopher A. K. Y. MD3; Neumann, Peter J. ScD4; Bell, Chaim M. MD, PhD5

doi: 10.1097/CCM.0000000000003768
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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.

1University Health Network and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.

2Bang for Buck Consulting, Amsterdam, The Netherlands.

3Section of General Internal Medicine, Lakeridge Health Oshawa, Oshawa, ON, Canada.

4Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA.

5Sinai Health System and the Department of Medicine, University of Toronto, Toronto, ON, Canada.

*See also p. 1150.

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Dr. Bell disclosed that he is a medical consultant to the Ontario Ministry of Health and Long-Term Care. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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