Research
Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision
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* Corresponding author: Kate A Halton k.halton@qut.edu.au
1 The Centre for Healthcare Related Infection Surveillance & Prevention, GPO Box 48, Brisbane, Queensland, 4001 Australia
2 Institute of Health & Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Queensland, 4059 Australia
3 Intensive Care Unit, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, 4102 Australia
4 Infection Management Services, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, 4102 Australia
5 University of Queensland, Royal Brisbane & Women's Hospital, Butterfield Street, Herston, Queensland, 4029 Australia
Critical Care 2009, 13:R35 doi:10.1186/cc7744
See related commentary by Safdar, http://ccforum.com/content/13/3/148
Published: 11 March 2009Abstract
Introduction
Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult intensive care unit (ICU) patients.
Methods
We used a Markov decision model to compare the cost effectiveness of A-CVCs relative to uncoated catheters. Four catheter types were evaluated: minocycline and rifampicin (MR)-coated catheters, silver, platinum and carbon (SPC)-impregnated catheters, and two chlorhexidine and silver sulfadiazine-coated catheters; one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per quality-adjusted life year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses.
Results
The baseline analysis, with no consideration of uncertainty, indicated all four types of A-CVC were cost-saving relative to uncoated catheters. MR-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life years, and cost savings (AUD $130,289). After considering uncertainty in the current evidence, the MR-coated catheters returned the highest incremental monetary net benefits of AUD $948 per catheter; however there was a 62% probability of error in this conclusion. Although the MR-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty.
Conclusions
Current evidence suggests that the cost effectiveness of using A-CVCs within the ICU is highly uncertain. Policies to prevent CR-BSI amongst ICU patients should consider the cost effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.