Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome

PURPOSE: Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. SUBJECTS AND METHODS: We studied 1,005 patients enrolled in a five-center s tudy of seriously ill patients (the Study to Understand Prognoses and Prefe rences for Outcomes and Risks of Treatments [SUPPORT]) with acute respirato ry failure (pneumonia or acute respiratory distress syndrome and an Acute P hysiology Score greater than or equal to 10) who required ventilator suppor t. We estimated life expectancy based on long-term follow-up of SUPPORT pat ients. Utilities were estimated using time-tradeoff questions. Costs (in 19 98 dollars) were based on hospital fiscal data and Medicare data. RESULTS: Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 depend ence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator sup port was withheld, the median survival was 3 days. Among patients whose est imated probability of surviving at least 2 months from the time of ventilat or support ("prognostic estimate") was 70% or more, the incremental cost pe r quality-adjusted life-year (QALY) saved by providing rather than withhold ing ventilator support and aggressive care was $29,000. For medium-risk pat ients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate less than or equal to 50%), it was $110,000 per QALY. When assumptions were vari ed from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76,000 for medium-risk p atients, and from $67,000 to $200,000 for high-risk patients. CONCLUSIONS: Ventilator support and intensive care for acute respiratory fa ilure due to pneumonia or acute respiratory distress syndrome are relativel y cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival less than or equal to 50%, the cost per QALY is more than threefold greater at >$100,000. (C) 2000 by Excerpta Medica, Inc.