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

OBJECTIVES: A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estim ated 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 St udy to Understand Prognoses and Preferences for Outcomes and Risks of Treat ments (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 greate r than or equal to 10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUP PORT patients and estimated utilities (quality-of-life weights) using time- tradeoff questions. We used hospital fiscal data and Medicare data to estim ate healthcare costs. We divided patients into three age groups (<65, 65-74 , and <greater than or equal to>75 years); for each age group, we performed separate analyses for patients with a less than or equal to 50% probabilit y of surviving at least 2 months thigh-risk group) and those with a >50% pr obability of surviving at least 2 months (low-risk group). RESULTS: Of the 963 patients who received ventilator support, 44% were fema le; 48% survived 6 months; and the median (25th, 75th percentile) age was 6 3 (46, 75) years. For the 42 patients for whom ventilator support was withh eld, 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, $44,0 00 for those age 65-74, and $46,000 for those age <greater than or equal to >75). For high-risk patients, the incremental cost-effectiveness was much l ess favorable and was least favorable for younger patients ($130,000 for pa tients age <65, $100,000 for those age 65-74, and $96,000 for those age <gr eater than or equal to>75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensi tive to the costs of the index hospitalization. CONCLUSIONS: For patients with relatively good shortterm prognoses, we foun d that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor shortterm pro gnoses, ventilator support and aggressive care were much less cost-effectiv e for adults of all ages.