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Lau VI, Xie F, Fowler RA, Rochwerg B, Johnstone J, Lauzier F, Marshall JC, Basmaji J, Henderson W, Khwaja K, Loubani O, Niven DJ, Zarychanski R, Arabi YM, Cartin-Ceba R, Thabane L, Heels-Ansdell D, Cook DJ. Health economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (E-PROSPECT): a cost-effectiveness analysis. Can J Anaesth 2022; 69:1515-1526. [PMID: 36289153 DOI: 10.1007/s12630-022-02335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/06/2022] [Accepted: 06/21/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We sought to compare the cost-effectiveness of probiotics and usual care with usual care without probiotics in mechanically ventilated, intensive care unit patients alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT). METHODS We conducted a health economic evaluation alongside the PROSPECT randomized control trial (October 2013-March 2019). We adopted a public healthcare payer's perspective. Forty-four intensive care units in three countries (Canada/USA/Saudi Arabia) with adult critically ill, mechanically ventilated patients (N = 2,650) were included. Interventions were probiotics (Lactobacillus rhamnosus GG) vs placebo administered enterally twice daily. We collected healthcare resource use and estimated unit costs in 2019 United States dollars (USD) over a time horizon from randomization to hospital discharge/death. We calculated incremental cost-effectiveness ratios (ICERs) comparing probiotics vs usual care. The primary outcome was incremental cost per ventilator-associated pneumonia (VAP) event averted; secondary outcomes were costs per Clostridioides difficile-associated diarrhea (CDAD), antibiotic-associated diarrhea (AAD), and mortality averted. Uncertainty was investigated using nonparametric bootstrapping and sensitivity analyses. RESULTS Mean (standard deviation [SD]) cost per patient was USD 66,914 (91,098) for patients randomized to probiotics, with a median [interquartile range (IQR)] of USD 42,947 [22,239 to 76,205]. By comparison, for those not receiving probiotics, mean (SD) cost per patient was USD 62,701 (78,676) (median [IQR], USD 41,102 [23,170 to 75,140]; incremental cost, USD 4,213; 95% confidence interval [CI], -2,269 to 10,708). Incremental cost-effectiveness ratios for VAP or AAD events averted, probiotics were dominated by usual care (more expensive, with similar effectiveness). The ICERs were USD 1,473,400 per CDAD event averted (95% CI, undefined) and USD 396,764 per death averted (95% CI, undefined). Cost-effectiveness acceptability curves reveal that probiotics were not cost-effective across wide ranges of plausible willingness-to-pay thresholds. Sensitivity analyses did not change the conclusions. CONCLUSIONS Probiotics for VAP prevention among critically ill patients were not cost-effective. Study registration data www. CLINICALTRIALS gov (NCT01782755); registered 4 February 2013.
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Affiliation(s)
- Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. .,Department of Critical Care, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 Street, Edmonton, AB, Canada.
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Programs for Health Economics and Outcomes Measures, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jennie Johnstone
- Department of Infection Prevention and Control, Sinai Health, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - François Lauzier
- Departments of Medicine, Anesthesiology & Critical Care, Université Laval, Quebec, QC, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - John Basmaji
- Division of Critical Care Medicine, Department of Medicine, Western University, London, ON, Canada
| | - William Henderson
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kosar Khwaja
- Departments of Surgery and Critical Care Medicine, McGill University, Montreal, QC, Canada
| | - Osama Loubani
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ryan Zarychanski
- Sections of Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Yaseen M Arabi
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine and Critical Care, Department of Critical Care, Mayo Clinic, Phoenix, AZ, USA
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
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