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* From the Pulmonary & Critical Care Medicine Service (Dr. Shorr) and the General Internal Medicine Service (Dr. O’Malley), Walter Reed Army Medical Center, Washington, DC and the Uniformed Services University for Health Sciences, Bethesda, MD.
Correspondence to: Andrew F. Shorr, MD, MPH, Pulmonary & Critical Care Medicine Service, Department of Medicine, Walter Reed Army Medical Center, 6900 Georgia Ave, NW, Washington, DC 20307; e-mail: AFSHORR{at}DNAMAIL.COM
Study objective: To determine the cost-effectiveness of continuous subglottic suctioning (CSS) as a strategy to decrease the incidence of ventilator-associated pneumonia (VAP).
Design: Decision-model analysis of the cost and efficacy of endotracheal tubes that allow CSS at preventing VAP. The primary outcome was cases of VAP averted. Model estimates were based on data from published prospective trials of CSS and other prospective studies of the incidence of VAP. Setting and patients: Hypothetical cohort of 100 patients requiring nonelective endotracheal intubation and management in an ICU.
Interventions: In the model, patients were managed with either traditional endotracheal tubes (ETs) or ETs capable of CSS.
Measurements and main results: The marginal cost-effectiveness of CSS was calculated as the savings resulting from cases of VAP averted minus the additional costs of CSS-ETs, and expressed as cost (or savings) per episode of VAP prevented. Sensitivity analysis of the impact of the major clinical inputs on the cost-effectiveness was performed. The base case assumed that the incidence of VAP in patients requiring > 72 h of mechanical ventilation (MV) was 25%, that CSS-ETs had no impact on patients requiring MV for < 72 h, and that CSS-ETs resulted in a relative risk reduction 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 VAP prevented. For sensitivity analysis, model inputs were adjusted by 50% individually and then simultaneously. This demonstrated the model to be only moderately sensitive to the calculated cost of VAP. With the relative risk reduction at 50% of the base-case estimate, CSS resulted in $1,924 saved per case of VAP prevented. When all variables were skewed against CSS, total outlays were trivial (approximately $14 per patient in the cohort).
Conclusions: CSS represents a strategy for the prevention of VAP that may result in savings. Further studies are warranted to confirm the efficacy of CSS.
Key Words: cost • cost-effectiveness • endotracheal tube • pneumonia • prevention • subglottic • suctioning • ventilator
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