Cost-effectiveness of a quality improvement bundle for emergency laparotomy

BACKGROUND

The recent Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) study showed that the use of a specific care bundle reduced mortality in patients undergoing emergency laparotomy. However, the costs of implementation of the ELPQuiC bundle remain unknown. The aim of this study was to assess the in-hospital and societal costs of implementing the ELPQuiC bundle.

METHODS

The ELPQuiC study employed a before-after approach using quality improvement methodology. To assess the costs and cost-effectiveness of the bundle, two models were constructed: a short-term model to assess in-hospital costs and a long-term model (societal decision tree) to evaluate the patient's lifetime costs (in euros).

RESULTS

Using health economic modelling and data collected from the ELPQuiC study, estimated costs for initial implementation of the ELPQuiC bundle were €30 026·11 (range 1794·64-40 784·06) per hospital. In-hospital costs per patient were estimated at €14 817·24 for standard (non-care bundle) treatment versus €15 971·24 for the ELPQuiC bundle treatment. Taking a societal perspective, lifetime costs of the patient in the standard group were €23 058·87, compared with €19 102·37 for patients receiving the ELPQuiC bundle. The increased life expectancy of 4 months for patients treated with the ELPQuiC bundle was associated with cost savings of €11 410·38 per quality-adjusted life-year saved.

CONCLUSION

Implementation of the ELPQuiC bundle is associated with lower mortality and higher in-hospital costs but reduced societal costs.

Update on hemodynamic monitoring and management in septic patients

Severe sepsis and septic shock are associated with significant mortality. Effective management of this clinical syndrome includes early resuscitation with fluids and vasoactive drugs to maintain vital organ perfusion and oxygen delivery. Understanding the different approach to the management of sepsis during the resuscitation and ongoing management phases is essential to initiate context- and time-specific interventions. Manipulation of hemodynamic variables to achieve a balance between oxygen delivery and consumption forms the cornerstone of hemodynamic optimisation. Minimally invasive and completely non-invasive cardiac output monitors have been developed, but require validation in this specific cohort of patients. The trend in hemodynamic parameters is particularly important when any intervention to augment cardiac output is carried out (functional hemodynamic monitoring). Cardiac output monitors and surrogates of tissue oxygenation are only able to guide management, as patient outcome is determined by acquisition and interpretation of accurate data, and suitable management decisions.