Cost-effectiveness of drotrecogin alfa (activated) in the treatment of severe sepsis with multiple organ failure

[Realist protocol for implementing integrated care pathways in France (waivers 51)]

The paradox of real world researches supposedly conducted in real life is that they did not succeeded in freeing themselves from the techniques of the randomised trials which they pretended to escape. In the successionist perspective of classical experimental or quasi-experimental methods, the cause always precedes the effect in a linear manner, and any interference that is likely to threaten the stability of this relationship must be neutralised by mobilising the appropriate statistical techniques. In complex systems where everything moves at the same time due to multiple interrelationships that make it impossible to construct a counterfactual, these elements are no longer considered as confounding factors that need to be controlled, but as decisive factors in the smooth running of the experiment. The protocol presented in this article proposes an alternative evaluative technique mobilising the teachings of critical realism, which seems to us to be the most appropriate for understanding what happens "in the black box" recording the events that occur between the implementation of the Article 51 experiments and the observed results. The role of the evaluator is to put the actors back at the heart of the change, since it is achieved (or not) according to their reactions and the contextual elements. This credible explanatory theory allows us to understand: how does it work? For whom does it work? Why do losers lose, winners win? and under what circumstances?

Cost-Effectiveness Studies in the ICU: A Systematic Review

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.

Health economic evaluations of sepsis interventions in critically ill adult patients: a systematic review

Background

Sepsis is a global health priority. Interventions to reduce the burden of sepsis need to be both effective and cost-effective. We performed a systematic review of the literature on health economic evaluations of sepsis treatments in critically ill adult patients and summarised the evidence for cost-effectiveness.

Methods

We systematically searched MEDLINE, Embase, and the Cochrane Library using thesaurus (e.g. MeSH) and free-text terms related to sepsis and economic evaluations. We included all articles that reported, in any language, an economic evaluation of an intervention for the management of sepsis in critically ill adult patients. Data extracted included study details, intervention details, economic evaluation methodology, and outcomes. Included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Results

We identified 50 records representing 46 economic evaluations for a variety of interventions including antibiotics (n = 5), fluid therapy (n = 2), early goal-directed therapy and other resuscitation protocols (n = 8), immunoglobulins (n = 2), and interventions no longer in clinical use such as monoclonal antibodies (n = 7) and drotrecogin alfa (n = 13). Twelve (26%) evaluations were of excellent reporting quality. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (lower costs and higher effectiveness) for early goal-directed therapy, albumin, and a multifaceted sepsis education program to dominated (higher costs and lower effectiveness) for polymerase chain reaction assays (LightCycler SeptiFast testing MGRADE®, SepsiTest™, and IRIDICA BAC BSI assay). ICERs varied widely across evaluations, particularly in subgroup analyses.

Conclusions

There is wide variation in the cost-effectiveness of sepsis interventions. There remain important gaps in the literature, with no economic evaluations identified for several interventions routinely used in sepsis. Given the high economic and social burden of sepsis, high-quality economic evaluations are needed to increase our understanding of the cost-effectiveness of these interventions in routine clinical practice and to inform decision makers.

Trial registration

PROSPERO CRD42018095980

Hospital-related cost of sepsis: A systematic review

OBJECTIVES

This article systematically reviews research on the costs of sepsis and, as a secondary aim, evaluates the quality of economic evaluations reported in peer-reviewed journals.

METHODS

We systematically searched the MEDLINE, National Health Service (Abstracts of Reviews of Effects, Economic Evaluation and Health Technology Assessment), Cost-effectiveness Analysis Registry and Web of Knowledge databases for studies published between January 2005 and June 2015. We selected original articles that provided cost and cost-effectiveness analyses, defined sepsis and described their cost calculation method. Only studies that considered index admissions and re-admissions in the first 30 days were published in peer-reviewed journals and used standard treatments were considered. All costs were adjusted to 2014 US dollars. Medians and interquartile ranges (IQRs) for various costs of sepsis were calculated. The quality of economic studies was assessed using the Drummond 10-item checklist.

RESULTS

Overall, 37 studies met our eligibility criteria. The median of the mean hospital-wide cost of sepsis per patient was $32,421 (IQR $20,745-$40,835), and the median of the mean ICU cost of sepsis per patient was $27,461 (IQR $16,007-$31,251). Overall, the quality of economic studies was low.

CONCLUSIONS

Estimates of the hospital-related costs of sepsis varied considerably across the included studies depending on the method used for cost calculation, the type of sepsis and the population that was examined. A standard model for conducting cost improve the quality of studies on the costs of sepsis.

Evaluation of different approaches for confounding in nonrandomised observational data: a case-study of antipsychotics treatment

Although randomised controlled trials are regarded as the gold standard for treatments efficacy, evidence from observational studies remains relevant. To address the problem of possible confounding in these studies, investigators must employ analysis methods that adjust for confounders and lead to an unbiased estimation of the treatment effect. In this paper, the authors describe two relevant statistical methods. The first method represents the classical approach consisting of a multiple regression model including the effects of treatment and covariates. This approach considers the relation between prognostic factors and the outcome variable as a relevant criterion for adjustment. The second method is based on the propensity score, and focuses on the relation between prognostic factors and treatment assignment. These approaches were applied to a cohort of 183 French schizophrenic patients who were followed for a 2-year period (from 1998 to 2000). The probability of relapse according to antipsychotic treatment exposure was modelled using Cox regression models with the two statistical methods. Goodness-of-fit criteria were used to compare the modelling approaches. This study demonstrates that the propensity score, a predicted probability, has an important balancing property that underscores its value in strengthening the results of nonrandomised observational studies.

Are clinical trials dealing with severe infection fitting routine practices? Insights from a large registry

Introduction

Guidelines dealing with severe sepsis and septic shock mostly rely on randomized controlled trials (RCTs) to ensure the best standards of care for patients. However, patients included in high-quality studies may differ from the routine population and alter external validity of recommendations. We aimed to determine to what extent non-inclusion criteria of RCTs dealing with severe sepsis and septic shock may affect application of their conclusions in routine care.

Methods

In a first step, the MEDLINE database was searched for RCTs treating severe sepsis and septic shock patients between 1992 and 2008, and non-inclusion criteria for these studies were abstracted. Two reviewers independently evaluated the articles, which were checked by a third reviewer. We extracted data on the study design, main intervention, primary endpoint, criteria for inclusion, and criteria for non-inclusion. In a second step, the distribution of the non-inclusion criteria was observed in a prospective multicenter cohort of severe sepsis and septic shock patients (Cub-Rea network, 1992 to 2008).

Results

We identified 96 articles out of 7,012 citations that met the screening criteria. Congestive heart failure (35%) and cancer (30%) were frequent exclusion criteria in selected studies, as well as other frequent disorders such as gastrointestinal and liver diseases and all causes of immune suppression. Of the 67,717 patients with severe sepsis and septic shock in the Cub-Rea database, 40,325 (60%) experienced at least one of the main exclusion criteria, including 11% of congestive heart failure patients and 11% of cancer patients. In addition, we observed a significant trend for increasing number of patients with these criteria along time.

Conclusion

Current exclusion criteria for RCTs dealing with severe sepsis and septic shock excluded most patients encountered in daily practice and limit external validity of the results of high-quality studies.

Contribution of modeling approaches and virtual populations in transposing the results of clinical trials into real life and in enlightening public health decisions

Modeling consists in aggregating separate pieces of knowledge, according to a given structure and rules. It allows studying the behavior of more or less complex systems by simulation techniques. Modeling is used in different state-of-the-art technological domains (meteorology, aeronautics). Its use has grown for the evaluation of medicines and medical devices, from conception to prescription (marketing authorization, reimbursement, price setting and re-registrations). It follows a scientific approach and is the object of good practice recommendations. Coupling models to virtual populations allows obtaining realistic results at the population level, testing diagnostic or therapeutic strategies, as well as estimating the consequences of transposing the results of clinical trials to the population. Through examples, the participants of the Round Table analyzed the contributions of the coupling of models and realistic virtual populations, and proposed guidelines for their judicious and systematic use.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been used to reduce the high rate of death by severe sepsis or septic shock. This is an update of a Cochrane review (originally published in 2007 and updated in 2008).

OBJECTIVES

We assessed the clinical effectiveness and safety of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH METHODS

For this updated review we searched CENTRAL (The Cochrane Library 2010, Issue 6); MEDLINE (1966 to June 2010); EMBASE (1980 to July 1, 2010); BIOSIS (1965 to July 1, 2010); CINAHL (1982 to 16 June 2010) and LILACS (1982 to 16 June 2010). There was no language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28, at the end of study follow up, and hospital mortality as the primary outcomes.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, risk of bias assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model.

MAIN RESULTS

We identified one new RCT in this update. We included a total of five RCTs involving 5101 participants. For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.97, 95% confidence interval (CI) 0.78 to 1.22; P = 0.82, I(2) = 68%). APC use was associated with an increased risk of bleeding (RR 1.47, 95% CI 1.09 to 2.00; P = 0.01, I(2) = 0%). In paediatric patients, APC did not reduce the risk of death (RR 0.98, 95% CI 0.66 to 1.46; P = 0.93). Although the included trials had no major limitations most of them modified their original completion or recruitment protocols.

AUTHORS' CONCLUSIONS

This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC is associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.Warning: On October 25th 2011, the European Medicines Agency issued a press release on the worldwide withdrawal of Xigris (activated protein C / drotrecogin alfa) from the market by Eli Lilly due to lack of beneficial effect on 28-day mortality in the PROWESS-SHOCK study. Furthermore, Eli Lily has announced the discontinuation of all other ongoing clinical trials. The final results of the PROWESS-SHOCK study are expected to be published in 2012. This systematic review will be updated when results of the PROWESS-SHOCK or other trials are published.

The economics of sepsis

Sepsis, severe sepsis, and septic shock impose a growing economic burden on health care systems globally. This article first describes the epidemiology of sepsis within the United States and internationally. It then reviews costs associated with sepsis and its management in the United States and internationally, including general cost sources in intensive care, direct costs of sepsis, and indirect costs of the burden of illness imposed by sepsis. Finally, it examines the cost-effectiveness of sepsis interventions, focusing on formal cost-effectiveness analyses of nosocomial sepsis prevention strategies, drotrecogin alfa (activated),and integrated sepsis protocols.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been used to reduce the high rate of death by severe sepsis or septic shock. This is an update of a Cochrane review (originally published in 2007 and updated in 2008).

OBJECTIVES

We assessed the clinical effectiveness and safety of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH STRATEGY

For this updated review we searched CENTRAL (The Cochrane Library 2010, Issue 6); MEDLINE (1966 to June 2010); EMBASE (1980 to July 1, 2010); BIOSIS (1965 to July 1, 2010); CINAHL (1982 to 16 June 2010) and LILACS (1982 to 16 June 2010). There was no language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28, at the end of study follow up, and hospital mortality as the primary outcomes.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, risk of bias assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model.

MAIN RESULTS

We identified one new RCT in this update. We included a total of five RCTs involving 5101 participants. For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.97, 95% confidence interval (CI) 0.78 to 1.22; P = 0.82, I(2) = 68%). APC use was associated with an increased risk of bleeding (RR 1.47, 95% CI 1.09 to 2.00; P = 0.01, I(2) = 0%). In paediatric patients, APC did not reduce the risk of death (RR 0.98, 95% CI 0.66 to 1.46; P = 0.93). Although the included trials had no major limitations most of them modified their original completion or recruitment protocols.

AUTHORS' CONCLUSIONS

This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC is associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.

Cost of intensive care in India

Critical care is often described as expensive care. However, standardized methodology that would enable determination and international comparisons of cost is currently lacking. This article attempts to review this important issue and develop a framework through which cost of critical care in India could be analyzed.

Treatment of the critically ill patient with protein C: is it worth the cost?

INTRODUCTION

We have shown that low protein C levels predict poor survival up to five years in a general intensive care unit patient material and hypothesize that treatment with protein C is beneficial. The objectives were to calculate costs of protein C treatment, at best-case scenario, per statistical life saved.

MATERIALS AND METHODS

Ninety-two patients with deranged global haemostatic tests admitted to the mixed surgical medical intensive care unit, Malmö University Hospital. We hypothesized that increasing protein C levels in patients with low levels would enhance survival to the same rate as a cohort with higher protein C. Number of statistical lives saved were estimated using survival analysis. Costs per life saved at 30days were calculated.

RESULTS

Total costs per life saved in 2007 prices (upper limit of 95% CI) were calculated at euro 50,200 (recombinant activated protein C, drotrecogin alfa (activated), Xigris) and euro 46,000 (zymogen protein C, Ceprotin), which may be compared to the value of a statistical life (euro 937,000).

CONCLUSIONS

Our theoretical model of converting a low protein C group to a higher protein C group by treating with activated protein C or the protein zymogen showed no major difference between the treatments in terms of costs, and that costs are lower than the value of a statistical life. Although our study has several caveats the results support the PROWESS study, in that patients with a very severe disease, having low protein C levels, may benefit from protein C treatment in a cost effective way.

Drotrecogin alfa's impact on intensive care workload in real life practice: a propensity score approach

OBJECTIVES

To estimate the impact of drotrecogin alfa (DA) on intensive care workload in an observational study while illustrating the use of propensity score (PS) matching to control for recruitment bias.

METHODS

PREMISS is a prospective, multicenter pre-post study. Its goal was to evaluate DA in the treatment of severe sepsis with multiple organ failure. Inclusions took place before (control patients) and after (DA-treated patients) the drug's market authorization. Workload was measured in euros using the French classification of medical procedures. It was compared between the groups via random effects gamma regression using two techniques: 1) regression adjusting for the patients' initial characteristics on the whole population; and 2) PS matching. A structural equation model was used to explore the pathways leading to a workload increase.

RESULTS

Drotrecogin alfa is estimated to increase intensive care unit (ICU) workload by 20% (P = 0.045) according to the multivariate model and 34% (P = 0.002) according to the PS-matched one. In the structural equation model fitted, only DA's direct effect on the occurrence of bleeding events reaches significance (P = 0.024).

CONCLUSIONS

We found a significant effect of DA on ICU workload with both standard methods of adjustment and PS matching. This effect appears to be mainly due to DA's effect on bleeding events. The analysis illustrated the usefulness of PS methods in the analysis of observational data, as it leads to conclusions similar to the traditional multivariate regression approaches while avoiding making too many adjustments, allowing focusing on the treatment effect.

Year in review 2007: Critical Care--intensive care unit management

With the development of new technologies and drugs, health care is becoming increasisngly complex and expensive. Governments and health care providers around the world devote a large proportion of their budgets to maintaining quality of care. During 2007, Critical Care published several papers that highlight important aspects of critical care management, which can be subdivided into structure, processes and outcomes, including costs. Great emphasis was given to quality of life after intensive care unit stay, especially the impact of post-traumatic stress disorder. Significant attention was also given to staffing level, optimization of intensive care unit capacity, and drug cost-effectiveness, particularly that of recombinant human activated protein C. Managing costs and providing high-quality care simultaneously are emerging challenges that we must understand and meet.

Activated protein C: cost-effective or costly?

The authors offer a commentary on the study by Dhainaut et al. on the cost-effectiveness of activated protein C in severe sepsis. Using data from "real world" conditions, the results of this economic evaluation are consistent with previous analyses, and highlight the need for "real world" investigations of new health technologies in critical care.

Cost-effectiveness of activated protein C in real-life clinical practice

BACKGROUND

Recombinant human activated protein C (rhAPC) has been reported to be cost-effective in severely ill septic patients in studies using data from a pivotal randomized trial. We evaluated the cost-effectiveness of rhAPC in patients with severe sepsis and multiple organ failure in real-life intensive care practice.

METHODS

We conducted a prospective observational study involving adult patients recruited before and after licensure of rhAPC in France. Inclusion criteria were applied according to the label approved in Europe. The expected recruitment bias was controlled by building a sample of patients matched for propensity score. Complete hospitalization costs were quantified using a regression equation involving intensive care units variables. rhAPC acquisition costs were added, assuming that all costs associated with rhAPC were already included in the equation. Cost comparisons were conducted using the nonparametric bootstrap method. Cost-effectiveness quadrants and acceptability curves were used to assess uncertainty of the cost-effectiveness ratio.

RESULTS

In the initial cohort (n = 1096), post-license patients were younger, had less co-morbid conditions and had failure of more organs than did pre-license patients (for all: P < 0.0001). In the matched sample (n = 840) the mean age was 62.4 +/- 14.9 years, Simplified Acute Physiology Score II was 56.7 +/- 18.5, and the number of organ failures was 3.20 +/- 0.83. When rhAPC was used, 28-day mortality tended to be reduced (34.1% post-license versus 37.4% pre-license, P = 0.34), bleeding events were more frequent (21.7% versus 13.6%, P = 0.002) and hospital costs were higher (47,870 euros versus 36,717 euros, P < 0.05). The incremental cost-effectiveness ratios gained were as follows: 20,278 euros per life-year gained and 33,797 euros per quality-adjusted life-year gained. There was a 74.5% probability that rhAPC would be cost-effective if there were willingness to pay 50,000 euros per life-year gained. The probability was 64.3% if there were willingness to pay 50,000 euros per quality-adjusted life-year gained.

CONCLUSION

This study, conducted in matched patient populations, demonstrated that in real-life clinical practice the probability that rhAPC will be cost-effective if one is willing to pay 50,000 euros per life-year gained is 74.5%.

Practical aspects of treatment with drotrecogin alfa (activated)

In November 2001, drotrecogin alfa (activated) was approved by the US Food and Drug Administration; in August 2002 it was approved by the European Medicines Agency. Since the approval of drotrecogin alfa (activated), however, critical care physicians have been faced with several challenges, namely its costs, selection of patients who are more likely to benefit from it, and the decision regarding when to start drotrecogin alfa (activated) treatment. There are also operational issues such as how to manage the infusion to deliver an effective treatment while minimizing the risk for bleeding, particularly in patients with deranged clotting, at around the time of surgery or during renal replacement therapy. While addressing these issues, this review remains practical but evidence based as much as possible.

Simplified pharmacoeconomics of critical care and severe sepsis

Understanding pharmacoeconomic evaluation can empower clinicians to be stronger decision makers. However, cost-effectiveness analyses (CEAs) in critical care are sometimes not easy to understand and often not placed in context with other interventions. The purpose of this article is to clarify and simplify the CEA process using examples from critical care and severe sepsis. First discussed is cost-effectiveness as a framework for clinical decision making and how it compares to other types of economic evaluations. Then important considerations when conducting or reviewing CEAs are explored, such as perspective, discounting, sensitivity analysis, and grading of CEAs, as well as shortcomings and resistance to using CEAs. Next, applications of CEA in critical care and severe sepsis are reviewed. Included is the Food and Drug Administration-approved drug for severe sepsis, drotrecogin alfa (activated), as an example of a recently new critical care intervention that resulted in significant interest in understanding cost-effectiveness. Finally, CEAs of other medical and nonmedical interventions are placed in context with CEAs from critical care. Understanding pharmacoeconomic evaluation can empower clinicians to be stronger decision makers. CEAs provide decision makers a quantitative measure of the value of therapeutic options that can guide clinicians toward balancing the cost burdens of therapy with their profound effects and choosing between options that compete for funding.

Drotrecogin alpha (activated): the treatment for severe sepsis?

Severe sepsis is common and increasing in incidence. Mortality rates remain high. Discovery of the link between the coagulation system and the inflammatory response to sepsis led to the development of drotrecogin alpha (activated). This recombinant form of the natural anticoagulant, activated protein C, was shown to reduce 28-day mortality from severe sepsis in a large, randomised, placebo-controlled, multi-centre Phase III study. Although subsequent studies have demonstrated that drotrecogin alpha (activated) is not of benefit to all patients with severe sepsis, it does reduce mortality rates in patients at a high risk of death. Drotrecogin alpha (activated) is associated with an increased risk of bleeding. Recent studies have shed light on its mode of action, which is primarily attributed today to cytoprotective effects especially on the endothelium with improved microcirculation. Ongoing studies will help define which patients are most likely to benefit, perhaps with the help of biochemical markers.

Drotrecogin alfa (activated) in severe sepsis: a systematic review and new cost-effectiveness analysis

BACKGROUND

Activated drotrecogin alfa (human activated protein C, rhAPC), is produced by recombinant DNA technology, and purports to improve clinical outcomes by counteracting the inflammatory and thrombotic consequences of severe sepsis. Controversy exists around the clinical benefits of this drug and an updated economic study that considers this variability is needed.

METHODS

A systematic literature review was performed using Medline, Embase and the International Network of Agencies for Health Technology Assessment (INAHTA) databases to determine efficacy, safety and previous economic studies. Our economic model was populated with systematic estimates of these parameters and with population life tables for longer term survival information. Monte Carlo simulations were used to estimate the incremental cost-effectiveness ratios (ICERs) and variance for the decision analytic models.

RESULTS

Two randomized clinical trials (RCTS) of drotrecogin alfa in adults with severe sepsis and 8 previous economic studies were identified. Although associated with statistical heterogeneity, a pooled analysis of the RCTs did not show a statistically significant 28-day mortality benefit for drotrecogin alfa compared to placebo either for all patients (RR: 0.93, 95% CI: 0.69, 1.26) or those at highest risk as measured by APACHE II >or= 25 (RR: 0.90, 95% CI: 0.54, 1.49). Our economic analysis based on the totality of the available clinical evidence suggests that the cost-effectiveness of drotrecogin alfa is uncertain (< 59% probability that incremental cost-effectiveness ratio (ICER) life year gained (LYG) <or= $50,000/LYG) when applied to all patients with severe sepsis. The economic attractiveness of this therapy improves when administered to those at highest risk as assessed by APACHE II >or= 25 (93% probability ICER <or= $50,000/LYG) but these results are not robust to different measures of disease severity.

CONCLUSION

The evidence supporting the clinical and economic attractiveness of drotrecogin alfa is not conclusive and further research appears to be indicated.

The COASST study: cost-effectiveness of albumin in severe sepsis and septic shock

INTRODUCTION

The cost-effectiveness of albumin-based fluid support in patients with severe sepsis is not known.

METHODS

We compared standard medical practice and systematic albumin infusion. The study population consisted of patients with severe sepsis and/or septic shock admitted to one of the 35 intensive care units belonging to the Cub-Réa regional database between 1 January 1998 and 31 December 2002. Only stays longer than 24 hours and only patients with a minimum of circulatory, renal, or respiratory failure were considered. Cost estimates were based on French diagnosis-related groups and fixed daily prices. A 4.6% reduction in mortality was expected in the albumin arm, as observed in the Saline vs Albumin Fluid Evaluation (SAFE) Study. Life expectancy was estimated with the declining exponential approximation of life expectancy method, based on age, sex, Simplified Acute Physiology Score II, and McCabe score.

RESULTS

The number of lives saved among the 11137 patients was 513. The average life expectancy of the 5156 patients who left the hospital alive was estimated to be 9.78 years. The costs per life saved and per year life saved were 6037 euro and 617 euro, respectively. Sensitivity analyses confirmed the robustness of the results.

CONCLUSION

The application of the SAFE Study results to CUB-Réa data shows that albumin infusion is cost-effective in severe sepsis.

Use of drotrecogin alfa (activated) for severe sepsis in New Jersey acute care hospitals

PURPOSE

The use of drotrecogin alfa (activated) for the treatment of severe sepsis in acute care hospitals in New Jersey was evaluated.

SUMMARY

An observational study was conducted to determine the prevalence of severe sepsis and drotrecogin alfa use in hospitalized patients in New Jersey. In November 2003, a survey was mailed to the pharmacy directors of 84 acute care hospitals (teaching, major teaching, nonteaching) in New Jersey to collect information about the monthly use of drotrecogin alfa in 2002 and 2003. Health Care Financing Administration Uniform Bill of 1992 patient discharge data from New Jersey for the same period were analyzed to identify patients with severe sepsis and calculate the rate of drug use for their treatment. The survey received a total response rate of 55%. Among 7292 patients with severe sepsis who were treated in 2002 in participating hospitals, 137 received drotrecogin alfa. From January 2003 to October 2003, the average rate of drotrecogin alfa use in the same hospitals was identical. Drug use in teaching and major teaching hospitals was greater than in nonteaching hospitals. An increase in drotrecogin alfa use in 2003 compared with 2002 was expected; however, a comparison of its use in 2002 and 2003 in New Jersey acute care hospitals found that the rate of drug use remained the same. One tenth of responding hospitals never used drotrecogin alfa during the study period.

CONCLUSION

An observational study showed an apparent underutilization of drotrecogin alfa (activated) for treatment of severe sepsis in acute care hospitals in New Jersey.