The Cost Effectiveness of Mechanical Ventilation Using PAV+ Mode in Canada
CCCF ePoster library. Karen Bosma R. Nov 8, 2018; 233395
Disclosure(s): Rhodri is the owner of Coreva Scientific, the company works with and has received consultancy fees from multiple medical device companies.
Dr. Rhodri Saunders and Karen Bosma
Dr. Rhodri Saunders and Karen Bosma
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Abstract
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BACKGROUND

Mechanical ventilation (MV) is an integral but expensive part of the intensive care unit (ICU).  Events such as ventilator-associated pneumonia (VAP) and tracheotomy can further increase care costs. Optimizing MV provision could result in substantial cost savings and improved patient outcomes. Here, the health and cost outcomes of proportional assist ventilation plus (PAV+) mode are compared with pressure support ventilation (PSV), incorporating recent data including a randomized-controlled trial1, a meta-analysis2, and an ICU costing study3 published by Canadian institutions in 2018.



METHODS

Data from clinical studies and randomized, controlled trials (RCTs) were used to inform event rates and patient risk in a computational model of a patient’s care pathway once initiated on MV. Care settings include the ICU, general ward, and home. The model estimates patient outcomes (time on MV, days in ICU, days in hospital, and hospital discharge) and safety events, including the incidence of patient-ventilator asynchrony >10%, tracheotomy, VAP, nosocomial infections, spontaneous breathing trial (SBT) failure, and post-liberation hypoxemia. In-hospital and post-discharge mortality were taken from rates in peer-reviewed literature up to 3 years and from Canadian life tables thereafter.

Patients, mean 65 years and 40% female, are on MV until a successful SBT and liberation. Time on MV is influenced by asynchrony >10% and VAP. MV is either PSV or PAV+ mode, with differences between these interventions derived from the weighted mean outcomes of 6 RCTs4-9. PAV+ mode was associated with less asynchrony, shorter time on MV (-1.62) and in the ICU, but longer time in hospital. Quality-adjusted life years (QALYs) used EQ-5D utilities. All event costs are expressed in 2017 CAD. The model’s time horizon runs from 1-40 years with cost and health outcomes after the first year discounted at 1.5% per annum. Probabilistic sensitivity analysis (PSA) provides estimates of outcome significance at the 95% level.



RESULTS

The first year cost of care was $54,253 with PAV+, a saving of $6,200 compared with PSV ($60,452). Outcomes reflected lower resource use with PAV+ mode. Of PAV+ patients, 0.28 QALYs were accumulated with 79% alive at the year end. For PSV, the respective values were 0.25 QALYs and 69% alive. Benefits were reduced mean time on MV (6.2 days) compared with PSV (8.4 days) and a lower rate of VAP.

The 40‑year cost of care ($160,543) was higher with PAV+ mode than with PSV ($153,610). Improvements in QALYs (+0.96) and life expectancy (+1.57 years) were identified with PAV+ mode. Superior to PSV after 1-year, PAV+ was likely (100%) to be considered cost-effective versus PSV at 40 years given a willingness-to-pay threshold of $50,000 per QALY gained. PSA showed that increases in QALYs with PAV+ mode were significant, but differences in costs were not. The mean cost per QALY gained was $7,380 (median $4,955). Results did not differ substantially if PAV+ mode had no impact on asynchrony, meta-analysis informed clinical effectiveness, or different cost sources were used. If future care costs were excluded, PAV+ mode was superior to PSV. Cost and outcomes drivers were time on mechanical ventilation and in the ICU.



CONCLUSIONS

Under modelled conditions, PAV+ mode increased patient quality of life and life expectancy. In the early years, healthcare costs decreased with use of PAV+ mode. Increased life expectancy led to higher long-term costs.


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