Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision
Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision
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DOI：
10.1186/cc7744
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发表时间：
2009-01-01
期刊：
影响因子：
15.1
通讯作者：
Graves, Nicholas
中科院分区：
文献类型：
--
作者：
Halton, Kate A.;Cook, David A.;Graves, Nicholas
前言某些类型的抗菌涂层中心静脉导管(A-CVC)已被证明在预防导管相关性血流感染(CR-BSI)方面具有成本效益。然而，并不是所有类型的研究都进行了评估，人们对这些早期研究的质量和有用性表示担忧。临床医生对使用A-CVC(如果有的话)存在不确定性。我们重新评估了所有商用A-CVC预防成人重症监护病房(ICU)患者CR-BSI的成本效益。方法使用马尔可夫决策模型比较A-CCs与未涂层导管的成本-效果。评价了四种导管类型：米诺环素和利福平(MR)涂层导管，银、铂和碳(SPC)浸渍导管，以及两种氯己定和磺胺嘧啶银涂层导管；一种涂在外表面(CH/SSD(EXT))，另一种涂在两表面(CH/SSD(INT/EXT))。估算了每获得一个质量调整寿命年的增量成本和预期净货币收益。结果在不考虑不确定度的基线分析中，四种类型的A-CVC均比无涂层导管节省了成本。涂有MR涂层的导管每1000根导管可预防15例感染，产生了最大的健康益处、1.6个质量调整寿命年和节省成本(130,289澳元)。在考虑了现有证据中的不确定性后，MR涂层导管的货币净收益增量最高，为每根导管948澳元；然而，这一结论有62%的错误概率。虽然MR涂层导管在多种情况下具有最高的货币净收益，但这一决定总是与高度的不确定性相关。结论目前的证据表明，在ICU内使用A-CVC的成本效益高度不确定。在ICU患者中预防CR-BSI的政策应该考虑竞争干预措施的成本效益，考虑到这种不确定性。决策者最好考虑到目前在知识方面的差距以及在这一领域提供高质量证据的复杂性。
Introduction Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult intensive care unit (ICU) patients.Methods We used a Markov decision model to compare the cost effectiveness of A-CVCs relative to uncoated catheters. Four catheter types were evaluated: minocycline and rifampicin (MR)-coated catheters, silver, platinum and carbon (SPC)-impregnated catheters, and two chlorhexidine and silver sulfadiazine-coated catheters; one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per quality-adjusted life year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses.Results The baseline analysis, with no consideration of uncertainty, indicated all four types of A-CVC were cost-saving relative to uncoated catheters. MR-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life years, and cost savings (AUD $130,289). After considering uncertainty in the current evidence, the MR-coated catheters returned the highest incremental monetary net benefits of AUD $948 per catheter; however there was a 62% probability of error in this conclusion. Although the MR-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty.Conclusions Current evidence suggests that the cost effectiveness of using A-CVCs within the ICU is highly uncertain. Policies to prevent CR-BSI amongst ICU patients should consider the cost effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.