Intensive Care Foundation Research Free Paper Presentations Tuesday December 8 2015

摘要

Early and appropriate nutritional support is recommended for critically ill patients. Evidence is conflicting regarding the optimum route of delivery and robust cost-effectiveness evidence is lacking. The aim of the study was to evaluate the cost-effectiveness of early nutritional support via the parenteral route versus early nutritional support via the enteral route in critically ill adults.We undertook a cost-effectiveness analysis (CEA) using data from a large, pragmatic, multi-centre randomised controlled trial, the CALORIES trial, which recruited patients from 33 adult, general critical care units in England. Resource use and outcome data on 2388 trial patients were used to report cost-effectiveness at 90 days and at 1 year, and to project lifetime cost-effectiveness. The CEA used information on health-related quality of life at 90-days and at 1 year combined with information on vital status to report Quality-Adjusted Life Years (QALYs). Each QALY was valued using the NICE recommended threshold of willingness-to-pay (£20,000 per QALY) in conjunction with the costs of each route to report the incremental net monetary benefits (INB) of early nutritional support via the parenteral versus the enteral route.Mean health-related quality of life at 90 days and 1 year was similar between the randomised groups. At 1 year, the parenteral route group had, on average, higher costs (mean difference £1580, 95% confidence interval [CI] −£792 to £3951), similar QALYs (0.013, 95% CI −0.014 to 0.040) and negative INB (−£1,320, 95% CI −£3709 to £1069) compared to the enteral route group. When a lifetime time horizon was taken, the INB of the parenteral route was positive but with considerable uncertainty surrounding the result (£440, 95% CI −£3586 to £4466). The probability that early nutritional support via the parenteral route is more cost-effective than via the enteral route was 14% at 1 year and 58% over the lifetime.For critically ill adult patients, providing early nutritional support via the parenteral versus the enteral route is unlikely to be cost-effective. However, it should be recognised that considerable uncertainty surrounds the cost-effectiveness results, especially when projected over the patient’s lifetime.