Early Goal-Directed Therapy Can Save Lives (and Money)
EDs and ICUs should work together to implement this treatment for patients with severe sepsis and septic shock.
Although early goal-directed therapy (EGDT) has been shown to improve outcomes in severe sepsis and septic shock, clinical implementation has been slow. Barriers such as cost, emergency department overcrowding, lack of training, and institutional resistance present significant challenges to use of EGDT. To assess the economic consequences of implementing EGDT, researchers conducted a decision analysis of three implementation strategies: ED-centric (all treatment administered in the ED), mobile intensive care unit (ICU) team (ED screens patients and then alerts the ICU team, which provides EGDT), and ICU-centric (EGDT administered in the ICU after ED transfer).
Estimates were derived using data from multiple sources, including the Henry Ford Health System, Medicare, the U.S. Public Health Service, and the American Thoracic Society. Analyses were based on assumptions that an average ED has an annual volume of 29,100 visits and 91 cases of severe sepsis and septic shock. The authors estimated that start-up costs would range from US$13,000 (ICU-centric) to $30,000 (ED-centric) and that additional annual costs would be $100,000.
Compared with usual care, EGDT saved an estimated mean of $8,666 per patient, representing a 22.9% reduction in hospital costs per patient and a yearly savings of nearly $800,000 per hospital. The savings were due primarily to a reduction in length of ICU stay. Although the ICU-centric model was the least costly, it was also the least effective because of time delays. In sensitivity analysis, EGDT remained cost-effective in all three models even when the mortality benefit was reduced by almost half. Cost per quality-adjusted life-year was $7,019 in the ED-centric model, $6,931 in the ICU-team model, and $2,749 in the ICU-centric model.
Comment: EGDT can save lives and money — even according to a conservative model that was created with bias against EGDTs cost-effectiveness by assigning substantial start-up costs. In addition, EGDT remained cost-effective in sensitivity analysis that was further biased against it by substantially reducing the mortality benefit. Although EDs have the infrastructure to manage critically ill cases, the authors included in their analyses costs not only for increased staffing, training, and screening but also for upgrading two additional rooms for invasive monitoring. EDs and ICUs should work together to implement EGDT, as it benefits both hospitals and patients.
Published in Journal Watch Emergency Medicine November 2, 2007
Huang DT et al. Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis. Crit Care Med 2007 Sep; 35:2090.
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