title: Goal-Directed Fluid Therapy Guided by Cardiac Monitoring During High-Risk Abdominal Surgery in Adult Patients: Cost-Effectiveness Analysis of Esophageal Doppler and Arterial Pulse Pressure Waveform Analysis.
abstract: BACKGROUND
  Several minimally invasive techniques for cardiac output monitoring such as the esophageal Doppler (ED) and arterial pulse pressure waveform analysis (APPWA) have been shown to improve surgical outcomes compared with conventional clinical assessment (CCA).
  
  
  OBJECTIVE
  To evaluate the cost-effectiveness of these techniques in high-risk abdominal surgery from the perspective of the French public health insurance fund.
  
  
  METHODS
  An analytical decision model was constructed to compare the cost-effectiveness of ED, APPWA, and CCA. Effectiveness data were defined from meta-analyses of randomized clinical trials. The clinical end points were avoidance of hospital mortality and avoidance of major complications. Hospital costs were estimated by the cost of corresponding diagnosis-related groups.
  
  
  RESULTS
  Both goal-directed therapy strategies evaluated were more effective and less costly than CCA. Perioperative mortality and the rate of major complications were reduced by the use of ED and APPWA. Cost reduction was mainly due to the decrease in the rate of major complications. APPWA was dominant compared with ED in 71.6% and 27.6% and dominated in 23.8% and 20.8% of the cases when the end point considered was "major complications avoided" and "death avoided," respectively. Regarding cost per death avoided, APPWA was more likely to be cost-effective than ED in a wide range of willingness to pay.
  
  
  CONCLUSIONS
  Cardiac output monitoring during high-risk abdominal surgery is cost-effective and is associated with a reduced rate of hospital mortality and major complications, whatever the device used. The two devices evaluated had negligible costs compared with the observed reduction in hospital costs. Our comparative studies suggest a larger effect with APPWA that needs to be confirmed by further studies.
authors: Department of Urology and Transplantation, Saint-Louis Hospital, Paris, France; Center of Research, Medicine, Sciences, Mental Health, Society (CERMES 3), Villejuif, France. Electronic address: legrandguillaum@gmail.com.
authors: Guillaume
authors: G
authors: Legrand
authors: Department of Anesthesia and Reanimation, Bicêtre Hospital, Le Kremlin Bicêtre, France.
authors: Laura
authors: L
authors: Ruscio
authors: Department of Anesthesia and Reanimation, Bicêtre Hospital, Le Kremlin Bicêtre, France; French Society of Anesthesia and Reanimation (SFAR), Paris, France.
authors: Dan
authors: D
authors: Benhamou
authors: Team 1 "Health Economic - research on Health Service". Center of Research in Epidemiology and Health of Populations (UMR 1018), Villejuif, France.
authors: Nathalie
authors: N
authors: Pelletier-Fleury
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000368:Aged; D062186:Arterial Pressure; D001795:Blood Pressure Determination / Q000191:economics* / Q000295:instrumentation; D002302:Cardiac Output; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D015150:Echocardiography, Doppler / Q000191:economics* / Q000295:instrumentation; D004947:Esophagus / Q000000981:diagnostic imaging*; D005440:Fluid Therapy / Q000191:economics*; D005602:France; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D008875:Middle Aged; D018803:Models, Economic; D016343:Monitoring, Intraoperative / Q000191:economics* / Q000295:instrumentation / Q000379:methods; D009010:Monte Carlo Method; D009313:National Health Programs / Q000191:economics; D011183:Postoperative Complications / Q000191:economics / Q000401:mortality / Q000517:prevention & control; D011237:Predictive Value of Tests; D017150:Public Sector / Q000191:economics; D016896:Treatment Outcome
keywords: abdominal surgery; arterial pulse pressure waveform analysis; cost-effectiveness; esophageal Doppler; goal-directed fluid therapy