Chest

Chest

Volume 119, Issue 1, January 2001, Pages 228-235
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Clinical Investigations in Critical Care
Continuous Subglottic Suctioning for the Prevention of Ventilator-Associated Pneumonia: Potential Economic Implications

https://doi.org/10.1378/chest.119.1.228Get rights and content

Study objective:

To determine the cost-effectiveness ofcontinuous subglottic suctioning (CSS) as a strategy to decrease theincidence of ventilator-associated pneumonia (VAP).

Design:

Decision-model analysis of the cost and efficacy ofendotracheal tubes that allow CSS at preventing VAP. The primaryoutcome was cases of VAP averted. Model estimates were based on datafrom published prospective trials of CSS and other prospective studiesof the incidence of VAP. Setting andpatients: Hypothetical cohort of 100 patients requiringnonelective endotracheal intubation and management in an ICU.

Interventions:

In the model, patients were managed witheither traditional endotracheal tubes (ETs) or ETs capable of CSS.

Measurements and main results:

The marginalcost-effectiveness of CSS was calculated as the savings resulting fromcases of VAP averted minus the additional costs of CSS-ETs, andexpressed as cost (or savings) per episode of VAP prevented. Sensitivity analysis of the impact of the major clinical inputs on thecost-effectiveness was performed. The base case assumed that theincidence of VAP in patients requiring > 72 h of mechanicalventilation (MV) was 25%, that CSS-ETs had no impact on patientsrequiring MV for < 72 h, and that CSS-ETs resulted in a relative riskreduction of VAP of 30%. Despite the higher costs of ETs capable of, CSS, this tactic yielded a net savings of $4,992 per case of VAPprevented. For sensitivity analysis, model inputs were adjusted by 50% individually and then simultaneously. This demonstrated the model to beonly moderately sensitive to the calculated cost of VAP. With therelative risk reduction at 50% of the base-case estimate, CSS resultedin $1,924 saved per case of VAP prevented. When all variables wereskewed against CSS, total outlays were trivial (approximately $14 perpatient in the cohort).

Conclusions:

CSS represents astrategy for the prevention of VAP that may result in savings. Furtherstudies are warranted to confirm the efficacy of, CSS.

Section snippets

Materials and Methods

We performed a cost-effectiveness analysis employing adecision-model approach. The recommendations of the Panel on, Cost-Effectiveness in Health and Medicine for reference-cases analyseswere followed.12 We compared health and economic outcomesin terms of VAP prevention with CSS to the use of standard ETs. Wecalculated the marginal cost-effectiveness of CSS as the additionalcosts associated with CSS-ETs minus any cost savings resulting from theuse of CSS-ETs divided by the cases of VAP

Base Case

In the base-case scenario, there are 8.75 instances of VAP when, CSS is employed, compared to 12.5 episodes of VAP with the use ofstandard ETs. Total costs are $61,856 with CSS, as compared to $80,575with conventional ETs. VAP-related costs with CSS-ETs are $18,719 lessthan the costs incurred with standard ETs. Each prevented case of VAP(marginal cost savings) is associated with $4,992 net savings. On aper-patient basis, the use of CSS yields $1,872 in savings for eachindividual in the cohort.

Discussion

This decision model demonstrates that CSS-ETs are not only highlycost-effective but that they may also be associated with significantsavings if regularly employed for all nonelective endotrachealintubations. Although CSS-ETs cost more than traditional ETs, thisdifference is outweighed by the high costs associated with VAP.

To date, the use of CSS-ETs has been limited because few studies existdemonstrating their efficacy.113944 However, forclinicians, predicting whether a specific patient in a

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    The opinions expressed herein are not to be construed as official or asreflecting the policy of the Department of the Army or the Departmentof Defense.

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    Copyright © 2001 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.