Hydroxyethyl starch versus saline for resuscitation of patients in intensive care: long-term outcomes and cost-effectiveness analysis of a cohort from CHEST.
Hydroxyethyl starch for fluid resuscitation in critically ill patients is not associated with improved short-term patient-centred outcomes compared with crystalloid fluid solutions. However, its effect on longer term health economic outcomes has not been reported.



We did a prespecified cost-effectiveness analysis of a cohort of patients from New South Wales enrolled in the Crystalloid versus Hydroxyethyl Starch Trial (CHEST), who were randomised to treatment with either 6% hydroxyethyl starch with a molecular weight of 130 kD and a molar substitution ratio of 0·4 or 0·9% sodium chloride (saline) for fluid resuscitation. Clinical outcomes were mortality and life-years gained at 6 months and 24 months, health-related quality of life at 6 months, and quality-adjusted life-years gained at 6 months. Health economic outcomes were hospital and intensive-care unit (ICU) resource use and costs at 24 months and cost-effectiveness, which we defined as the probability of reaching a willingness-to-pay threshold of less than A$50 000 per quality-adjusted life-year gained at 6 months and $100 000 per life-year gained at 24 months. CHEST is registered with ClinicalTrials.gov, number NCT00935168.



3537 (51%) of 7000 patients were enrolled into CHEST from New South Wales, of whom 3450 (98%) were included in our cost-effectiveness analysis. Mortality at both 6 months and 24 months did not differ between the hydroxyethyl starch and saline groups (6 months: 397/1684 [24%] vs 382/1706 [22%]; relative risk [RR] 1·05, 95% CI 0·93-1·19; p=0·41; 24 months: 586/1687 [35%] vs 594/1708 [35%]; RR 1·00, 95% CI 0·91-1·10; p=0·89). The mean number of life-years gained at 6 months and 24 months was similar between the hydroxyethyl starch and saline groups (6 months: 0·41 days [SD 0·18] vs 0·41 days [0·17]; p=0·25; 24 months: 1·46 years [SD 0·80] vs 1·47 years [0·79]; p=0·72). At 6 months, the mean health-related quality of life score was 0·67 (SD 0·34) with hydroxyethyl starch versus 0·69 (0·35) with saline (p=0·33). The mean number of quality-adjusted life-years gained did not differ between the hydroxyethyl starch and saline groups at 6 months (0·26 days [SD 0·18] vs 0·26 days [0·18]; p=0·33). Total hospital costs (including ICU costs) at 24 months were similar between the hydroxyethyl starch and saline groups (A$62 196 [55 935] vs $62 617 [56 452]; p=0·83). The probability that hydroxyethyl starch was cost effective was 11% at 6 months and 29% at 24 months.



Although longer term clinical outcomes did not differ between patients resuscitated with hydroxyethyl starch or saline in the ICU, from a health-care payer's perspective, the probability that hydroxyethyl starch is cost effective in these patients is low.



Division of Critical Care and Trauma, George Institute for Global Health.
The George Institute for Global Health, Sydney, NSW, Australia; The University of Sydney, Sydney Medical School, Sydney, NSW, Australia.
Colman
C
Taylor
The George Institute for Global Health, Sydney, NSW, Australia.
Kelly
K
Thompson
The George Institute for Global Health, Sydney, NSW, Australia; The University of Sydney, Sydney Medical School, Sydney, NSW, Australia.
Simon
S
Finfer
Australian and New Zealand Intensive Care Research Centre, Monash School of Public Health and Preventive Medicine, Melbourne, VIC, Australia.
Alisa
A
Higgins
The George Institute for Global Health, Sydney, NSW, Australia.
Stephen
S
Jan
The George Institute for Global Health, Sydney, NSW, Australia.
Qiang
Q
Li
University of New South Wales, School of Public Health and Community Medicine, Sydney, NSW, Australia.
Bette
B
Liu
The George Institute for Global Health, Sydney, NSW, Australia; The University of Sydney, Sydney Medical School, Sydney, NSW, Australia; University of New South Wales, St George Clinical School, Sydney, NSW, Australia. Electronic address: jmyburgh@georgeinstitute.org.au.
John
J
Myburgh
D000368:Aged; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000191:economics / Q000379:methods; D000077324:Crystalloid Solutions; D005260:Female; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000191:economics* / Q000627:therapeutic use; D007552:Isotonic Solutions / Q000191:economics* / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009517:New South Wales; D063868:Patient Outcome Assessment; D010952:Plasma Substitutes / Q000191:economics* / Q000627:therapeutic use; D012151:Resuscitation / Q000191:economics / Q000379:methods*; D012965:Sodium Chloride / Q000191:economics* / Q000627:therapeutic use
D000077324:Crystalloid Solutions; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D010952:Plasma Substitutes; D012965:Sodium Chloride