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The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome

Baston, Cameron M. MD1,2; Coe, Norma B. PhD1,3,4,5; Guerin, Claude MD, PhD6; Mancebo, Jordi MD7; Halpern, Scott MD, PhD1,2,3,4

doi: 10.1097/CCM.0000000000003617
Online Clinical Investigations

Objectives: Despite strong evidence supporting proning in acute respiratory distress syndrome, few eligible patients receive it. This study determines the cost-effectiveness of interventions to increase utilization of proning for severe acute respiratory distress syndrome.

Design: We created decision trees to model severe acute respiratory distress syndrome from ICU admission through death (societal perspective) and hospital discharge (hospital perspective). We assumed patients received low tidal volume ventilation. We used short-term outcome estimates from the PROSEVA trial and longitudinal cost and benefit data from cohort studies. In probabilistic sensitivity analyses, we used distributions for each input that included the fifth to 95th percentile of its CI.

Setting: ICUs that care for patients with acute respiratory distress syndrome.

Subjects: Patients with moderate to severe acute respiratory distress syndrome.

Interventions: The implementation of a hypothetical intervention to increase the appropriate utilization of prone positioning.

Measurements and Main Results: In the societal perspective model, an intervention that increased proning utilization from 16% to 65% yielded an additional 0.779 (95% CI, 0.088–1.714) quality-adjusted life years at an additional long-term cost of $31,156 (95% CI, –$158 to $92,179) (incremental cost-effectiveness ratio = $38,648 per quality-adjusted life year [95% CI, $1,695–$98,522]). If society was willing to pay $100,000 per quality-adjusted life year, any intervention costing less than $51,328 per patient with moderate to severe acute respiratory distress syndrome would represent good value. From a hospital perspective, the intervention yielded 0.072 (95% CI, 0.008–0.147) more survivals-to-discharge at a cost of $5,242 (95% CI, –$19,035 to $41,019) (incremental cost-effectiveness ratio = $44,615 per extra survival [95% CI, –$250,912 to $558,222]). If hospitals were willing to pay $100,000 per survival-to-discharge, any intervention costing less than $5,140 per patient would represent good value.

Conclusions: Interventions that increase utilization of proning would be cost-effective from both societal and hospital perspectives under many plausible cost and benefit assumptions.

1Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

2Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

3Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

4Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.

5National Bureau of Economic Research, Cambridge, MA.

6Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université de Lyon, INSERM 955, Créteil, France.

7Servicio de Medicina Intensiva Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.

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Dr. Baston received financial support from the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute T32 HL-007891, and he received support for article research from the NIH. Dr. Mancebo received funding from Faron, Medtronic, and IMTmedical (travel and accommodation), and Fisher Paykel, General Electric, and A-Lung provided equipment to conduct clinical research. The remaining authors have not disclosed any potential conflicts of interest.

This work was performed at the University of Pennsylvania.

Address requests for reprints to: Cameron M Baston, 3400 Spruce St, Philadelphia, PA 19104. E-mail:

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