Number needed to treat and cost-effectiveness in the prevention of ventilator-associated pneumonia

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 ​(Table1)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 [3]. 
 
 
 
Table 1 
 
Number needed to treat in ventilator-associated pneumonia 
 
 
 
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) [4]. 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 ​(Table2)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. 
 
 
 
Table 2 
 
Cost-effectiveness of an intervention based on baseline ventilator-associated pneumonia rate and its relative risk reduction 
 
 
 
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.

While clinicians continue to redefi ne 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 biofi lm formation within the lumen of the tracheal tube -are coming to the market [1,2]. Th ere 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 effi cacy and eff ectiveness? 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-eff ective in my local patients?
To answer the fi rst 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. Th e 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 [3].
To establish whether the intervention is cost-eff ective, 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) [4]. 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 costeff ectiveness 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-eff ective 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-eff ective to spend up to £100 per 10 days of MV. It should be noted that some VAP prevention interventions (for example, a modifi ed 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.