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. 2014 Jul-Sep;26(3):253-62.
doi: 10.5935/0103-507x.20140036.

The economic effect of extracorporeal membrane oxygenation to support adults with severe respiratory failure in Brazil: a hypothetical analysis

[Article in English, Portuguese]
Marcelo Park  1 , Pedro Vitale Mendes  1 , Fernando Godinho Zampieri  1 , Luciano Cesar Pontes Azevedo  1 , Eduardo Leite Vieira Costa  2 , Fernando Antoniali  3 , Gustavo Calado de Aguiar Ribeiro  3 , Luiz Fernando Caneo  1 , Luiz Monteiro da Cruz Neto  1 , Carlos Roberto Ribeiro Carvalho  4 , Evelinda Marramon Trindade  4 ; ERICC research group; ECMO group Hospital Sírio Libanês and Hospital das Clínicas de São Paulo
Collaborators, Affiliations

The economic effect of extracorporeal membrane oxygenation to support adults with severe respiratory failure in Brazil: a hypothetical analysis

[Article in English, Portuguese]
Marcelo Park et al. Rev Bras Ter Intensiva. 2014 Jul-Sep.

Abstract
in English, Portuguese

Objective: To analyze the cost-utility of using extracorporeal oxygenation for patients with severe acute respiratory distress syndrome in Brazil.

Methods: A decision tree was constructed using databases from previously published studies. Costs were taken from the average price paid by the Brazilian Unified Health System (Sistema Único de Saúde; SUS) over three months in 2011. Using the data of 10,000,000 simulated patients with predetermined outcomes and costs, an analysis was performed of the ratio between cost increase and years of life gained, adjusted for quality (cost-utility), with survival rates of 40 and 60% for patients using extracorporeal membrane oxygenation.

Results: The decision tree resulted in 16 outcomes with different life support techniques. With survival rates of 40 and 60%, respectively, the increased costs were R$=-301.00/-14.00, with a cost of R$=-30,913.00/-1,752.00 paid per six-month quality-adjusted life-year gained and R$=-2,386.00/-90.00 per quality-adjusted life-year gained until the end of life, when all patients with severe ARDS were analyzed. Analyzing only patients with severe hypoxemia (i.e., a ratio of partial oxygen pressure in the blood to the fraction of inspired oxygen <100 mmHg), the increased cost was R$=-5,714.00/272.00, with a cost per six-month quality-adjusted life-year gained of R$=-9,521.00/293.00 and a cost of R$=-280.00/7.00 per quality-adjusted life-year gained.

Conclusion: The cost-utility ratio associated with the use of extracorporeal membrane oxygenation in Brazil is potentially acceptable according to this hypothetical study.

Objetivo: Analisar o custo-utilidade do uso da oxigenação extracorpórea para pacientes com síndrome da angústia respiratória aguda grave no Brasil.

Métodos: Com bancos de dados de estudos previamente publicados, foi construída uma árvore encadeada de decisões. Os custos foram extraídos da média de 3 meses do preço pago pelo Sistema Único de Saúde em 2011. Com 10 milhões de pacientes simulados com desfechos e custos predeterminados, uma análise da relação de incremento de custo e de anos de vida ganhos ajustados pela qualidade (custo-utilidade) foi realizada com sobrevida de 40 e 60% dos pacientes que usaram oxigenação extracorpórea.

Resultados: A árvore de decisões resultou em 16 desfechos com técnicas diferentes de suporte à vida. Com a sobrevida de 40/60%, respectivamente, o incremento de custos foi de R$ -301,00/-14,00, com o preço pago de R$ -30.913,00/-1.752,00 por ano de vida ganho ajustado pela qualidade para 6 meses e de R$ -2.386,00/-90,00 por ano de vida ganho ajustado pela qualidade até o fim de vida, quando se analisaram todos os pacientes com síndrome da angústia respiratória aguda grave. Analisando somente os pacientes com hipoxemia grave (relação da pressão parcial de oxigênio no sangue sobre a fração inspirada de oxigênio <100mmHg), o incremento de custos foi de R$ -5.714,00/272,00, com preço por ano de vida ganho ajustado pela qualidade em 6 meses de R$ -9.521,00/293,00, e com o custo de R$ -280,00/7,00 por ano de vida ganho ajustado pela qualidade.

Conclusão: A relação de custo-utilidade do uso da oxigenação extracorpórea no Brasil foi potencialmente aceitável neste estudo hipotético.

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Conflict of interest statement

Conflicts of interest: The ECMO group of the Hospital Sírio Libanês and Hospital das Clínicas de São Paulo received a grant from MAQUET Cardiovascular (PLS systems) of Brazil in 2010 for equipment and patient support. M Park, LCP Azevedo, ELV Costa, LF Caneo and CRR Carvalho taught courses on respiratory distress that were funded by MAQUET Cardiovascular of Brazil and NIPRO of Brazil.

Figures

Figure 1
Figure 1
General decision trees used in the simulations. Panel (A): the structure of the strategy tree that considers the use of extracorporeal membrane oxygenation (ECMO) for patients with respiratory failure. Panel (B): the structure of the strategy tree that does not include the use of ECMO for patients with respiratory failure. Subpanel (C) the region studied for a sensitivity analysis between the use and non-use of ECMO support for the patients with refractory hypoxemia upon arrival to the intensive care unit. The numbers above the ratings represent the number of patients from the ERICC study and the Brazilian series of patients who received ECMO. The other numbers (with decimal places) represent the probabilities of occurrence of the route in question according to figures cited. Patients who received ECMO also received conventional mechanical ventilation. The black arrow shows the region changed for the analysis with a survival probability of 60% for patients receiving ECMO. In this analysis, the number of survivors was increased to six, and the number of non-survivors was reduced to four. ARDS - acute respiratory distress syndrome; NIV - noninvasive ventilation; CMV - conventional mechanical ventilation; RRT - renal replacement therapy.
Figure 2
Figure 2
Graphs showing the correlations between the cost increase per patient and QALY after using extracorporeal membrane oxygenation (ECMO). Panel (A): the correlation when the total spent per the 1,000 patients (one year) in the overall strategy was estimated, with a survival rate of 40% among patients receiving ECMO. Panel (B): the same type of correlation evaluating only the patients who developed refractory hypoxemia, again with a survival rate of 40% among patients receiving ECMO. Panel (C): the correlation when total cost per the 1,000 patients (one year) in the overall strategy was estimated, with a survival rate of 60% among patients receiving ECMO. Panel (D): the correlation when evaluating only those patients who developed refractory hypoxemia, with a survival rate of 60% among patients receiving ECMO. The graphs were constructed with 10,000 hypothetical years, replicated with randomization. QALY denotes the years of good quality of life gained. Ellipses represent the 95% confidence intervals. The central black dots represent the intersection of the average cost increase with the average QALY.
Figure 3
Figure 3
Graphs showing the correlations between cost increase per patient and QALY using extracorporeal membrane oxygenation (ECMO). The graphs were constructed with 1,000 patients (one year), replicated 10,000 times (i.e., for 10,000 years). Panel (A): the correlation when the total spent for the total respiratory support strategy was estimated, with a survival rate of 40% among patients receiving ECMO. Panel (B): the correlation when evaluating only those patients who developed refractory hypoxemia, again with a survival rate of 40% among patients receiving ECMO. Panel (C): the correlation when total cost per 1,000 patients (one year) in the overall strategy was estimated, and the survival rate was 60% among patients receiving ECMO. Panel (D): the correlation when evaluating only those patients who developed refractory hypoxemia, and the survival rate was 60% among patients receiving ECMO. The graphs were constructed with 10,000 hypothetical years, replicated with randomization. QALY denotes the years of good quality of life gained. Ellipses represent the 95% confidence intervals.
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