Transcript Video How Our Choices Effect the Health EconomyProf. Ferrer & Prof. Lopez de Sa < Back to Boundaries of Temperature Session 6: Choices How Our Choices Effect the Health Economy Presented by Professor Ferrer & Professor Lopez de Sa the next talk is on how our choices affect the health economies. And this talk will be given by two colleagues from spain. The first colleague is Professor Lopez Disa. He's the chair of the acute cardiovascular committee of the spanish society of cardiology. And he is involved in different trials, for example the frost one and 2 trials. And the second part of this presentation will be given by Professor Ricard ferris. You know him already. He gave a talk this morning, he's the head of the ICU department in Barcelona and he is the past president of the spanish Society of intensive care medicine. So the stage this stage is for Madrid and for Barcelona isn't it? Thank you very much for your kind presentation. And also I would like to thank the organizers for inviting me to be here in this very interesting meeting. So this talk is about health economics. So the first part I will talk about what's the benefit of the therapy. I I'm not going to spend much time on that because the two days we are being reviewing all the information that we have with the trials about the efficacy of the this kind of therapy in cardiac arrest. But yes, to make a review, I will present the five, the five most landmark trials studying hypothermia and cardiac after cardiac arrest. This has been presented yesterday by Benjamin and we recognize that are there has been five trials, five important trials, three of them demonstrated benefit of cooling patients at 33 degrees between compared with normal thermal without control. And there are two trials with natural results that are T T T and one and DTM to trial. So After that trial, that is the most important one because it's the biggest trial ever performed after cardiac arrest and with negative results had an impact in guidance. As you you it was already mentioned today and you can see that the European resuscitation council have modified a little bit the guidance of the year 2021 and now they recommend that should be we should prevent fever in patients resuscitated of cardiac arrest. But they also recognize that there is a uh an evidence that probably there is a subgroup of patients recover from an out of hospital cardiac arrest that cooling them with lower temperatures. Probably there is a benefit. So, but we have more information that the information that we have from clinical trials. We have also information about the registry. What is happening in the centers that are treating patients. And there are plenty of information about this. But I'm going to just pick up some of the registries that. So how is the performance of this therapy in several centers for example, this is a registry of the carriers. It's a subgroup of patients from the courage registry that is the patients that were recruited in texas. And you can see that there is a huge variability in the results after cardiac arrest. There are centers that have better results that the meaning of the population of the registry. And also there are some centers that have worse results than all the rest of the centers that were included in this registry. And when analyzed what happened, why these differences and results, we can see that obviously there are there is a value a bility in the um profile of the population and royal in the trial in the registry. If you can see here uh patients divided in quarter miles by the result. Q one is the best centers with centers with the best results. Q four centers with worse results. And you consider our differences in the baseline characteristic such as witness rest higher in the patients with better results. Also more significant, more soluble rims. But what I think is important is also there are differences in the management of the patients. If you see here, the centers with better results perform more uh more rates of temperature management. Also higher, significantly higher left heart catheterization and also P CI. In patients recover from out of hospital cardiac arrest from nearly none in those with Worse results and 11% not all of them, but 11% of patients treated with P. C. I. After recovery of the circulation, spontaneous circulation after the cardiac arrest. Not only this registry, there are other registry, this is another international registries. 25 centers from Europe and the states you see here that there are four centers that have better results than the whole populations and five centers that have worse results than the rest of the centers in that included pacing in this registry. And when analyzing the differences that were in the centers with better results and centers with worse results. We can see that there are some differences in the management. For example, the time to start, target temperature was shorter in high performance centers and lower in low performance centers. Another important issue is that more sentence with better results were treated with sergeant temperature of 33° and on the contrary, higher person, higher percentage of patients were treated with 36 in centers with worse results. And other important issue is cardiac catheterization in unconscious patients with higher performance in the the centers with better results. And also we can see that the centers with better results were centers with higher volume of enrolling patients in this in this registry. This is not the only one. Another registry from California is a registry only performed in centers in PC. I. Centers with 128 centers. It included 27,000 out of hospital patients. And you also can see a high variability with centers with survival rates of 18%. Another and sent another. Centers with survival rates of 40%. And also there are differences in The characteristics of the center. But I think one important issue, as you can see here is that there are centers with do not resuscitate orders in the 1st 24 hours after admission. That with the high variability. There are centers with 50% of do not resuscitate orders after a cardiac arrest. And other group of centers with nearly 4% of do not resuscitate order during the first hour, The 1st 24 hours after admitting. So this variability could be one of the issues that drive drove this uh important such important differences in outcomes. We have now information about communities that do not withdraw life sustaining therapies in out of hospital cardiac arrest patients. As is in South Korea in South Korea. They do not have this kind of orders. And they can see that 24% of the patients that awake late after 72 hours after review rewarming there are some that perform well 66% with CPC one so probably patients who decide to with rubble of care very early sent could have been uh not recover at all afterwards. So, and I think this is one important issue that could happen in DTM to trial. As you remember has been telling about all the sessions patients that for inclusion criteria in T. T. M. To trial, there was a need of the eligible patients for intensive care without restrictions of limitations. So patients included should be patients that you can treat whatever whatever you need. But if you see the what happened in the in the patients enrolled in the trial died 911 patients in the first three months. But one third died in the first five days. Not because of neurological issue because of other than neurological or including neurological issue. But you see that one third of patients with withdrawal in the first five days. Even in the first hour, you see you randomize the patient and in the first hour 15 were withdrawal the 2nd 20. So probably there was something similar that what happened in this registry that I told you about California uh guidance recommend that patients should do not will not with gravel. We don't need to withdrawal therapy before five days. So we need sometimes just to see if the patient recover or not and it hasn't been done in the perfectly in the DTM to trial. Another important issue is the cardiac cath. Now we have three trials, all of them with natural results. Co Act Tomahawk and cooper trial was randomizing patients to send it to cardiac cath or not on arrival. Were patients without segment elevation, none of them. So positive results. And even one. So a trend of words results in those treated for immediately corona and your plastic. So I'm not saying that you don't need to perform in plastic but probably not all the all the patients probably should be only patients with S. T. Segment elevation or those patients with have cardiogenic sort are unstable. So I can I think I can say that clinical trials and observational studies suggest that temperature control has a beneficial impact on outcome and unconscious patients recovered from cardiac arrest. The benefits has concentrated in those patients treated with temperature target Between 32 and 34 to decide with rival of care is necessary to wait at least 96 hours and following guidelines has an impact of outcome that is going to review afterwards. Dr. Ferrer, thank you very much for your attention. So thank you Stephen for your your presentation. So I'm going to to follow with uh some slides regarding our choices. So the title is our choices and how this impact in health economics may have my presentation. Okay, so that's how we make our choices basically. We make our choices based in our knowledge, our skills, our attitude, but also patient values is important in our decisions and also the health care system where we are working the accessibility to the system, the funding and health economics is very important here. So this is the hype cycle for any technology from iphones to T T M for any technology. We have seen a slide of Dr abdullah yesterday showing how the different trials impact in the use of technology. This is exactly what is happening for any any technology. We have a peak of expectations and we have thought of the of disillusionment and then we have a plateau, pro productivity but always with a lot of variability as dr steven Lopez a have have have shown you in fact this translation of knowledge to intensive care is always variable and in general it's low by different reasons we can discuss later but in general is low and he has mentioned several studies showing this variability despite despite some studies show that better performance, better outcomes. There is a lot of variability. So the question is its variability acceptable. Yes, but ability is acceptable if it's coming from the way that we give to different knowledge or different evidence. As you can see, variability is not acceptable if it's coming from knowledge deficits, just forgetting or any other conditions. So we accept variability but between just clinical judgment and just protocol or guidelines, probably the solution is in the middle. So just application of the guidelines protocols based in our and also in combination with our clinical knowledge. So this is I think the best the best strategy. So together with the spanish society of Cardiology, the spanish society of intensive care. So at the end the leadership of Stephen and myself we check which is the situation in spain for TPM implementation is low, there is a lot of variability so there is a lot of room for improvement. That's good. So we're thinking a strategy to improve that situation. So we use the evidence that steven has shown you before the guidelines that we have to compensate these evidence and also we adapted in local protocols and then we think in a way how we can improve the performance, reduce the the unnecessary variability and to improve performance. So the first step was to have a local protocol? I think we don't have to stop in that because most of the recommendations are in the line of the different guidelines. At the end we have a local adaptation of the different international guidelines to our setting. And the next step was to done to to do a survey. So in this survey we try to understand uh asking two different general and cardiology I see us which is the situation in spain and I'm not going to stop in the numbers. But again the situation is variability in the management of patients with cardiac arrest. Specifically for T. T. M. There is a lot of variability. Not only one is applied, how is apply um etcetera. So in part of our decision also the economics, it's an important part of our decisions. So we heard about efficacy, we heard about effectiveness in the real world scenario, but we need also to understand if it's worth doing this. You understand if this if it's worth doing that, we have to analyze the efficiency so which is going to be the improvement for patient and how much it's going to cost this improvement. So for analyzing that we need to analyze all the costs for patient management patients treated and untreated and analyze what is the benefit, the benefit in terms of mortality, but it's better to translate it to life year gain. So not only survival, how much time is going to, how many years is going to survive this patient and how many, how many years is going to survive this patient with with quality of life, especially for the setting of cardiac arrest. I think this is very important and this is the incremental cost effectiveness ratio. The relationship between all the costs and all the benefits in terms of quality and quality adjusted life life years. There are several studies analyzing that. This is a study coming from us. Those patients uh are, so this is a simulation with 100 patients. The patients are patients with the criteria of hacker trial. They analyze all the benefit in terms of mortality. They analyze all the costs from ICU admission, hospital admission, long term facility. All the cost in the two groups, the patients, 100 patients treated with T. T. M. 100 patients non treated with T. T. M. And they try to analyze or they analyze from each CPC category which is the benefit in terms of quality and which is the cost in terms for each group at the end globally. The cost for patients treated with DTM is more than $13 million in this case. And the cost of a patient not treated with T. T. M. Is 10 million. So the increasing cost is more than three millions. The increase in life years gained with with quality of life is 65. So if we divide that It the result is that each year with wood quality of life it costs to the system $47,000. So the question is is our system will will to pay for one year of life €47,000. The answer is more or less. Yes. This is the threshold we have, for example, in spain this is the threshold is for €30,000 for one year of life. For one year of life with wood quality in us is 100,000 dollars. So the system is willing to pay if you're you're if your intervention cost less than $1000 per one year with with quality of life. This threshold of horse depends country to country depends on the system. So it seems it's in a range if we use data from our survey that are little bit different the quality, the quality for patients. We have calculated according our patients. Our survey is 0.3. The cost according to our survey is very small. It's $70. The increasing cost is €70 in that case. And only it cost for one year with good quality of life, €2000. So it's still very cost effective intervention. But if we consider all the indirect costs of treating patients outside of the hospital. So mainly long term facilities then the intervention is dominant. That means that it's safe money. And we have estimated that can save €40 million this type of intervention. So um so apply T. T. M. In this case to all patients with cardiac risk. With with criteria will include I know that I am almost at the end of my time but I want to dedicate one minute to talk about value of healthcare. So our decisions are going to be based for sure in the value we give to patients we give to the system we give to the healthcare workers for sure. And in the in the in the next future um our decisions will be based in the value of the treatments provide to patients. That means that we have to translate instead of paying a cost of buying a machine or buying disposables. We are going to buy service and we're going to buy value. If we are going to buy value we have to work together with companies for selecting the best patients and to provide the best care to give this value to the system. So we don't expect to pay just a cost for a system or a treatment we are expecting just to pay for value. So that's a little bit my conclusion. So we have to think in value. We have to think in when we take our decisions which is the value is going to be translated to the patients. It seems that the intervention we are discussing have efficacy, efficacy but not only efficacy have effectiveness and also efficiency. So thank you for your attention. Created by
