title: Cost effectiveness of aggressive care for patients with nontraumatic coma.
abstract: OBJECTIVE
  To estimate the cost effectiveness of aggressive care for patients with nontraumatic coma.
  
  
  METHODS
  Cost-effectiveness analysis.
  
  
  METHODS
  Five academic medical centers.
  
  
  METHODS
  Patients with nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Patients with reversible metabolic causes of coma such as diabetic ketoacidosis or uremia were excluded.
  
  
  METHODS
  We calculated the incremental cost effectiveness of continuing aggressive care vs. withholding cardiopulmonary resuscitation and ventilatory support after day 3 of coma. We estimated life expectancy based on up to 4.6 yrs of follow-up. Utilities (quality-of-life weights) were estimated using time-tradeoff questions. Costs were based on hospital fiscal data and Medicare data. Separate analyses were conducted for two prognostic groups based on five risk factors assessed on day 3 of coma: age > or = 70 yrs, abnormal brainstem response, absent verbal response, absent withdrawal to pain, and serum creatinine > or = 132.6 micromol/L (1.5 mg/dL).
  
  
  RESULTS
  For the 596 patients studied, the median (25th, 75th percentile) age was 67 yrs (range, 55-77), and 52% were female. By 2 months after enrollment, 69% had died, 19% were severely disabled, 7% had survived without severe disability, and 4% had survived with unknown functional status. The incremental cost effectiveness of the more aggressive care strategy was $140,000 (1998 dollars) per quality-adjusted life year (QALY) for high-risk patients (3-5 risk factors, 93% 2-month mortality) and $87,000/QALY for low-risk patients (0-2 risk factors, 49% mortality). In sensitivity analyses, the incremental cost per QALY did not fall below $50,000/QALY, even with wide variation in our baseline estimates.
  
  
  CONCLUSIONS
  Continuing aggressive care after day 3 of nontraumatic coma is associated with a high cost per QALY gained, especially for patients at high risk for poor outcomes. Earlier decisions to withhold life-sustaining treatments for patients with very poor prognoses may yield considerable cost savings.
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Mary Beth
authors.initials: MB
authors.lastname: Hamel
authors.forename: Russell
authors.initials: R
authors.lastname: Phillips
authors.forename: Joan
authors.initials: J
authors.lastname: Teno
authors.forename: Roger B
authors.initials: RB
authors.lastname: Davis
authors.forename: Lee
authors.initials: L
authors.lastname: Goldman
authors.forename: Joanne
authors.initials: J
authors.lastname: Lynn
authors.forename: Norman
authors.initials: N
authors.lastname: Desbiens
authors.forename: Alfred F
authors.initials: AF
authors.lastname: Connors
authors.forename: Joel
authors.initials: J
authors.lastname: Tsevat
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D016887:Cardiopulmonary Resuscitation; D003128:Coma / Q000191:economics* / Q000401:mortality; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000191:economics*; D003657:Decision Making; D005260:Female; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D019057:Quality-Adjusted Life Years; D012307:Risk Factors