Are aggressive treatment strategies less cost-effective for older patients? The case of ventilator support and aggressive care for patients with acute respiratory failure

Mary Beth Hamel, Russell S. Phillips, Roger B. Davis, Joan Teno, Norman Desbiens, Joanne Lynn, Joel Tsevat

Research output: Contribution to journalArticle

22 Citations (Scopus)

Abstract

OBJECTIVES: A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estimated the incremental cost-effectiveness of providing mechanical ventilation and intensive care for patients of various ages who had acute respiratory failure. DESIGN: Retrospective analysis of data on acute respiratory failure from Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Acute hospital. PARTICIPANTS: 1,005 with acute respiratory failure; 963 received ventilator support and 42 had ventilator support withheld. MEASUREMENTS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (SUPPORT) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score ≥10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUPPORT patients and estimated utilities (quality-of-life weights) using time-tradeoff questions. We used hospital fiscal data and Medicare data to estimate healthcare costs. We divided patients into three age groups (<65, 65-74, and ≥75 years); for each age group, we performed separate analyses for patients with a ≤50% probability of surviving at least 2 months (high-risk group) and those with a >50% probability of surviving at least 2 months (low-risk group). RESULTS: Of the 963 patients who received ventilator support, 44% were female; 48% survived 6 months; and the median (25th, 75th percentile) age was 63 (46, 75) years. For the 42 patients for whom ventilator support was withheld, the median survival was 3 days. For low-risk patients (>50% estimated 2-month survival), the incremental cost (1998 dollars) per quality-adjusted life-year (QALY) saved by providing ventilator support and aggressive care increased across the three age groups ($32,000 for patients age <65, $44,000 for those age 65-74, and $46,000 for those age ≥75). For high-risk patients, the incremental cost-effectiveness was much less favorable and was least favorable for younger patients ($130,000 for patients age <65, $100,000 for those age 65-74, and $96,000 for those age ≥75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensitive to the costs of the index hospitalization. CONCLUSIONS: For patients with relatively good short-term prognoses, we found that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor short-term prognoses, ventilator support and aggressive care were much less cost-effective for adults of all ages.

Original languageEnglish (US)
Pages (from-to)382-390
Number of pages9
JournalJournal of the American Geriatrics Society
Volume49
Issue number4
DOIs
StatePublished - May 12 2001
Externally publishedYes

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Mechanical Ventilators
Respiratory Insufficiency
Patient Care
Costs and Cost Analysis
Therapeutics
Cost-Benefit Analysis
Age Groups
Survival
Quality-Adjusted Life Years
Adult Respiratory Distress Syndrome
Critical Care
Medicare
Life Expectancy
Artificial Respiration
Health Care Costs

Keywords

  • Aggressive treatment
  • Older patients
  • Respiratory failure
  • Ventilator

ASJC Scopus subject areas

  • Geriatrics and Gerontology

Cite this

Are aggressive treatment strategies less cost-effective for older patients? The case of ventilator support and aggressive care for patients with acute respiratory failure. / Hamel, Mary Beth; Phillips, Russell S.; Davis, Roger B.; Teno, Joan; Desbiens, Norman; Lynn, Joanne; Tsevat, Joel.

In: Journal of the American Geriatrics Society, Vol. 49, No. 4, 12.05.2001, p. 382-390.

Research output: Contribution to journalArticle

Hamel, Mary Beth ; Phillips, Russell S. ; Davis, Roger B. ; Teno, Joan ; Desbiens, Norman ; Lynn, Joanne ; Tsevat, Joel. / Are aggressive treatment strategies less cost-effective for older patients? The case of ventilator support and aggressive care for patients with acute respiratory failure. In: Journal of the American Geriatrics Society. 2001 ; Vol. 49, No. 4. pp. 382-390.
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AU - Desbiens, Norman

AU - Lynn, Joanne

AU - Tsevat, Joel

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N2 - OBJECTIVES: A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estimated the incremental cost-effectiveness of providing mechanical ventilation and intensive care for patients of various ages who had acute respiratory failure. DESIGN: Retrospective analysis of data on acute respiratory failure from Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Acute hospital. PARTICIPANTS: 1,005 with acute respiratory failure; 963 received ventilator support and 42 had ventilator support withheld. MEASUREMENTS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (SUPPORT) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score ≥10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUPPORT patients and estimated utilities (quality-of-life weights) using time-tradeoff questions. We used hospital fiscal data and Medicare data to estimate healthcare costs. We divided patients into three age groups (<65, 65-74, and ≥75 years); for each age group, we performed separate analyses for patients with a ≤50% probability of surviving at least 2 months (high-risk group) and those with a >50% probability of surviving at least 2 months (low-risk group). RESULTS: Of the 963 patients who received ventilator support, 44% were female; 48% survived 6 months; and the median (25th, 75th percentile) age was 63 (46, 75) years. For the 42 patients for whom ventilator support was withheld, the median survival was 3 days. For low-risk patients (>50% estimated 2-month survival), the incremental cost (1998 dollars) per quality-adjusted life-year (QALY) saved by providing ventilator support and aggressive care increased across the three age groups ($32,000 for patients age <65, $44,000 for those age 65-74, and $46,000 for those age ≥75). For high-risk patients, the incremental cost-effectiveness was much less favorable and was least favorable for younger patients ($130,000 for patients age <65, $100,000 for those age 65-74, and $96,000 for those age ≥75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensitive to the costs of the index hospitalization. CONCLUSIONS: For patients with relatively good short-term prognoses, we found that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor short-term prognoses, ventilator support and aggressive care were much less cost-effective for adults of all ages.

AB - OBJECTIVES: A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estimated the incremental cost-effectiveness of providing mechanical ventilation and intensive care for patients of various ages who had acute respiratory failure. DESIGN: Retrospective analysis of data on acute respiratory failure from Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Acute hospital. PARTICIPANTS: 1,005 with acute respiratory failure; 963 received ventilator support and 42 had ventilator support withheld. MEASUREMENTS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (SUPPORT) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score ≥10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUPPORT patients and estimated utilities (quality-of-life weights) using time-tradeoff questions. We used hospital fiscal data and Medicare data to estimate healthcare costs. We divided patients into three age groups (<65, 65-74, and ≥75 years); for each age group, we performed separate analyses for patients with a ≤50% probability of surviving at least 2 months (high-risk group) and those with a >50% probability of surviving at least 2 months (low-risk group). RESULTS: Of the 963 patients who received ventilator support, 44% were female; 48% survived 6 months; and the median (25th, 75th percentile) age was 63 (46, 75) years. For the 42 patients for whom ventilator support was withheld, the median survival was 3 days. For low-risk patients (>50% estimated 2-month survival), the incremental cost (1998 dollars) per quality-adjusted life-year (QALY) saved by providing ventilator support and aggressive care increased across the three age groups ($32,000 for patients age <65, $44,000 for those age 65-74, and $46,000 for those age ≥75). For high-risk patients, the incremental cost-effectiveness was much less favorable and was least favorable for younger patients ($130,000 for patients age <65, $100,000 for those age 65-74, and $96,000 for those age ≥75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensitive to the costs of the index hospitalization. CONCLUSIONS: For patients with relatively good short-term prognoses, we found that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor short-term prognoses, ventilator support and aggressive care were much less cost-effective for adults of all ages.

KW - Aggressive treatment

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