Cost effectiveness of aggressive care for patients with nontraumatic coma.
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.
Hamel
Mary Beth
MB
Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Phillips
Russell
R
Teno
Joan
J
Davis
Roger B
RB
Goldman
Lee
L
Lynn
Joanne
J
Desbiens
Norman
N
Connors
Alfred F
AF
Tsevat
Joel
J
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