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Original Investigation |

A Cost-effectiveness Analysis of Early vs Late Tracheostomy ONLINE FIRST

C. Carrie Liu, MD, MPH1; Luke Rudmik, MD, MSc1
[+] Author Affiliations
1Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
JAMA Otolaryngol Head Neck Surg. Published online July 28, 2016. doi:10.1001/jamaoto.2016.1829
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Importance  The timing of tracheostomy in critically ill patients requiring mechanical ventilation is controversial. An important consideration that is currently missing in the literature is an evaluation of the economic impact of an early tracheostomy strategy vs a late tracheostomy strategy.

Objective  To evaluate the cost-effectiveness of the early tracheostomy strategy vs the late tracheostomy strategy.

Evidence Acquisition  This economic analysis was performed using a decision tree model with a 90-day time horizon. The economic perspective was that of the US health care third-party payer. The primary outcome was the incremental cost per tracheostomy avoided. Probabilities were obtained from meta-analyses of randomized clinical trials. Costs were obtained from the published literature and the Healthcare Cost and Utilization Project database. A multivariate probabilistic sensitivity analysis was performed to account for uncertainty surrounding mean values used in the reference case.

Results  The reference case demonstrated that the cost of the late tracheostomy strategy was $45 943.81 for 0.36 of effectiveness. The cost of the early tracheostomy strategy was $31 979.12 for 0.19 of effectiveness. The incremental cost-effectiveness ratio for the late tracheostomy strategy compared with the early tracheostomy strategy was $82 145.24 per tracheostomy avoided. With a willingness-to-pay threshold of $50 000, the early tracheostomy strategy is cost-effective with 56% certainty.

Conclusions and Relevance  The adaptation of an early vs a late tracheostomy strategy depends on the priorities of the decision-maker. Up to a willingness-to-pay threshold of $80 000 per tracheostomy avoided, the early tracheostomy strategy has a higher probability of being the more cost-effective intervention.

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Figure 1.
Decision Tree Model of Early Tracheostomy Strategy vs Late Tracheostomy Strategy

A decision tree model with a 90-day time horizon. c Indicates cost; comp, complication; decan, decannulation; dist, distribution; e, effect; ICU, intensive care unit; p, probability; trach, tracheotomy; #, 1 – (the probability of the event of the complement branch) (eg, the probability of receiving an early tracheostomy (pEarlyTrach) = 0.81. In this case, # represents the probability of not receiving a tracheostomy. Therefore, # for “no trach” is 0.19 (ie, 1 – 0.81).

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Figure 2.
Cost-effectiveness Acceptability Curve for the Early vs Late Tracheostomy Strategies

At a willingness-to-pay (WTP) threshold of $50 000, the early tracheostomy strategy is cost-effective with 56% certainty. Up to a WTP threshold of $80 000, the early tracheostomy strategy has a higher probability of being the cost-effective decision compared to the late tracheostomy strategy.

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Figure 3.
Incremental Cost-effectiveness Ratio (ICER) Scatterplot of the Early vs Late Tracheostomy Strategies

The model was run 15 000 times using a range of values for each model input. The resulting ICER from each simulation is plotted around the $50 000 willingness to pay (WTP) threshold (dashed line). Values falling to the right of the dashed line in quadrants I and III, as well as all ICERs in quadrant II, are considered cost-effective.

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