Increasing O2 Delivery in High-Risk Surgical Patients is Cost-Effective
ABSTRACT & COMMENTARY
Guest et al investigated the cost implications of perioperatively increasing oxygen delivery (DO2) in high-risk surgical patients. The authors retrospectively analyzed a previous study showing a significant reduction in mortality and morbidity rates in high-risk surgical patients in whom DO2 had been deliberately increased (Boyd O, et al. JAMA 1993;270:2699-2707). That study included 107 surgical patients, who were randomly assigned either to a control group that received standard perioperative care or to a protocol group that, in addition, had deliberate increase of DO2 to ³ 600 mL/min/m2 by infusion of dopexamine.
In the current study, the authors reviewed the clinical trial records and hospital notes of the earlier work to identify and quantify the National Health Service resources that were used to manage the complications, and for investigations, interventions and drug treatments. Departmental purchasing records and business managers were consulted to identify the unit cost of these resources, and the cost of treating each patient was calculated on this basis. Guest et al found that the median cost of treating a protocol patient was lower than for a control patient (£6525 vs £7784). This difference was due both to the higher incidence of complications in the control group and the higher cost of treating individual complications in this group. A sensitivity analysis showed that a protocol patient’s hospital stay would have to be substantially longer for the potential cost savings to be cancelled out. The authors also performed a cost effectiveness analysis reporting that the cost per survivor was 31% lower in the protocol group. (Guest JF, et al. Intensive Care Med 1997;23:85-90.)
COMMENT BY FRANCISCO BAIGORRI, MD, PhD
It is well known that survivors of critical illnesses have higher cardiac output DO2 and oxygen uptake (VO2) than nonsurvivors. Consequently, several prospective randomized trials have evaluated the clinical benefit of maximizing oxygen delivery in critically ill patients. A meta-analysis of these studies has been published recently (Heyland DK, et al. Crit Care Med 1996;24:517-524). Although this meta analysis showed that interventions designed to achieve supraphysiologic goals of cardiac index, DO2, and VO2 did not significantly reduce mortality rates in all critically ill patients, it suggested that there may be a benefit in those patients in whom the therapy is initiated preoperatively. This is consistent with the hypothesis that supranormal DO2 may be effective in preventing tissue hypoxia.
One of the studies showing the benefit of deliberate perioperative increase of DO2 on mortality in high-risk surgical patients is analyzed by Guest et al. This cost analysis adds important information that shows that deliberate perioperative increase of DO2 in high-risk surgical patients does not increase financial costs and may even result in net cost savings due to the reduced cost of treating complications. This is especially relevant at a time when critical care units are under intense scrutiny as a large consumer of health care resources. At present, we have to provide quality care in a health care economy driven by cost containment, and every health care professional involved in caring for the critically ill must become proactive in reassessing and modifying his or her practices in an attempt to make critical care both quality driven and cost effective (Fein A. Crit Care Clinics 1993;9:401-413). Complementary information such as that adduced by Guest et al will play an important role in influencing the management of our patients.
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