- Open Access
Number needed to treat and cost-effectiveness in the prevention of ventilator-associated pneumonia
Critical Care volume 16, Article number: 430 (2012)
While clinicians continue to redefine ventilator-associated pneumonia (VAP), numerous innovations that claim to reduce pulmonary microaspiration and its consequences - that is, novel endotracheal cuff shapes and cuff materials, subglottic drainage, automatic cuff pressure controllers, oral anti-septics, selective digestive decontamination (SDD), and devices to combat biofilm formation within the lumen of the tracheal tube - are coming to the market [1, 2]. There are two questions that clinicians ask when deciding whether to incorporate a new product or intervention into a VAP prevention bundle. Firstly, what are its efficacy and effectiveness? In other words, what is the relative risk reduction (RRR) and therefore the number needed to treat (NNT) to prevent one additional VAP. Secondly, is this new intervention cost-effective in my local patients?
To answer the first question, one needs data from clinical trials and the knowledge of the baseline VAP rate with the likely RRR of the local case mix. We have calculated (Table 1) the NNT required to prevent one additional VAP for patients who require intubation and mechanical ventilation (MV) for more than 72 hours and an average time of MV of 10 days. The NNTs are based on an RRR ranging from 5% to 50% and a control event rate for VAP ranging from 1% to 20%, given a uniform distribution of NNTs across the range of RRRs. For example, with a VAP rate of approximately 8% and an intervention that reduces VAP by 45%, the NNT is 28 - a scenario that is realistic given a recent meta-analysis of one particular intervention .
To establish whether the intervention is cost-effective, further knowledge of the cost of the intervention and the cost to treat an episode of VAP is required. A recent US study estimated the cost of VAP to be nearly $40,000 (£25,000 or €30,000) . If costs are assumed to be lower in Europe, then a conservative estimate of the cost per episode of VAP would still be around £10,000, which is equivalent to an extra 7 days of intensive care unit (ICU) stay. What should we consider when assessing the cost-effectiveness of VAP prevention?
We have calculated (Table 2) the additional money (in pounds) that can be spent to prevent an episode of VAP (per 10 days of MV) to achieve cost-neutrality. If we assume a hypothetical VAP cost of £10,000, then with a VAP rate of 8% and an RRR of 45%, it is cost-effective to spend up to £360 . Furthermore, even for an ICU with a VAP rate of only 4% and an intervention that reduces VAP by just 25%, it is still cost-effective to spend up to £100 per 10 days of MV. It should be noted that some VAP prevention interventions (for example, a modified tracheal tube cuff) require just a 'one-off' initial cost whereas other interventions (for example, SDD) require an 'ongoing' daily cost.
We think that this analysis might help clinicians in making the important economic decision of whether to adopt a new VAP prevention device or procedure. Our calculations can easily be adapted to local currencies and circumstances worldwide.
intensive care unit
number needed to treat
relative risk reduction
selective digestive decontamination
Zolfaghari PS, Wyncoll DL: The tracheal tube: gateway to ventilator-associated pneumonia. Crit Care 2011, 15: 310. 10.1186/cc10352
Coppadoro A, Bittner E, Berra L: Novel preventive strategies for ventilator-associated pneumonia. Crit Care 2012, 16: 210. 10.1186/cc11225
Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK: Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med 2011, 39: 1985-1991. 10.1097/CCM.0b013e318218a4d9
Kollef MH, Hamilton CW, Ernst FR: Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 2012, 33: 250-256. 10.1086/664049
LC declares that he has no competing interests. DW has given paid lectures or consulted for Kimberly-Clark (Irving, TX, USA), Covidien (Mansfield, MA, USA), ConvaTec (Skillman, NJ, USA), Iskus Health (Dublin, Ireland), Sage Products (Cary, IL, USA), Eli Lilly and Company (Indianapolis, IN, USA), and Pfizer Inc (New York, NY, USA) and has a stock interest in Biovo Technologies (Tel Aviv, Israel). The authors declare that they have no personal financial interests.
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