The ABCs of CEAs: Building blocks for decision making

Critical care researchers increasingly recognize mortality as a problematic endpoint in critical care studies for a multitude of reasons, including heterogeneous populations, underpowered studies, and mortality often being a positive outcome in clinical practice. This has been temporally associated with a rapid growth in economic outcome publications, including cost-effectiveness and cost-minimization. Manuscripts utilizing these methods, however, frequently lack direct access to the financial and accounting data subsequent to study completion, must translate proprietary cost algorithms of health systems, and in the end have been limited in their ability to change clinical practice as they depend on the results of the frequently null interventional studies which they are analyzing. In contrast, with the exception of the most expensive interventions (e.g., transplantation, extracorporeal membranous oxygenation), a large mortality benefit will drive economic outcomes. Regardless of clinical outcome, however, economic studies remain useful to inform healthcare cost containment, as healthcare spending accounts for over 15% of the United States’ gross domestic product. Additionally, the coronavirus disease 2019 pandemic has reinforced the importance of consistently performing evidence-based interventions in order to improve patient-centered outcomes and associated cost-effectiveness.

Such interventions include multiple examples of protocolized care, including checklists and bundles for fluid management, ventilator care, central venous catheter insertion, and family communication. One of the most comprehensive bundles is the Awakening and Breathing Coordination of daily sedation and ventilator removal trials; Choice of sedative or analgesic exposure; Delirium monitoring and management; and Early mobility and Exercise (ABCDE), incorporating multiple evidence-based interventions into a single checklist. Over 1,000 studies have been published assessing the efficacy, effectiveness, implementation, feasibility, staffing, knowledge, and opinions regarding the ABCDE bundle, as well as expanding the bundle to include Family engagement and empowerment. While individual components of the ABCDE bundle have been evaluated for economic impact, only a small pre-post study of 83 patients has evaluated the overall cost-effectiveness of bundle adherence .

In this issue of Critical Care Medicine, Collinsworth et al report the results of a 2-year prospective cohort study among nearly 3,000 patients admitted to 12 ICUs in Texas from July 2013 to June 2015. They evaluated the association of high ABCDE bundle adherence on hospital mortality, discharge destination, hospital length of stay (LOS), and costs using propensity-score adjusted regression, and, in an exploratory analysis, estimated the effect of high bundle adherence on healthcare costs and quality-adjusted life-years (QALYs) in the year following ICU admission.

National Heart, Lung, and Blood Institute (NHLBI)