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Exploring Heterogeneity in the Cost-Effectiveness of High-Flow Nasal Cannula Therapy in Acutely Ill Children-Insights
Zaid Hattab1, Silvia Moler-Zapata2, Edel Doherty3
1Discipline of Economics, University of Galway, Galway, Ireland; Department of Mathematics, An-Najah National University, Nablus, State of Palestine.
Insights
High-flow nasal cannula (HFNC) therapy is more cost-effective for certain children than continuous positive airway pressure (CPAP). Patient characteristics significantly influence the economic benefits of HFNC in pediatric respiratory support.
Area of Science:
- Pediatric critical care medicine
- Health economics
- Respiratory support technologies
Background:
- Noninvasive respiratory support is crucial for acutely ill children.
- High-flow nasal cannula (HFNC) and continuous positive airway pressure (CPAP) are common treatment options.
- Understanding the cost-effectiveness of these therapies is vital for resource allocation.
Purpose of the Study:
- To investigate heterogeneity in the cost-effectiveness of HFNC versus CPAP for pediatric noninvasive respiratory support.
- To identify patient subgroups where HFNC demonstrates superior economic value.
Main Methods:
- Utilized data from the 'First-line Support for Assistance in Breathing in Children' randomized controlled trial.
- Employed causal forest and seemingly unrelated regression approaches to analyze patient-level and subgroup heterogeneity.
- Assessed incremental net monetary benefit (INB) at a willingness-to-pay threshold of £20,000 per quality-adjusted life year.
Main Results:
- Overall INB of HFNC compared to CPAP showed significant heterogeneity.
- Subgroups including male children, infants under 12 months, and those without severe initial respiratory distress had more favorable INB.
- Heterogeneity was primarily driven by cost differences, with increased uncertainty for higher INB estimates.
Conclusions:
- The cost-effectiveness of HFNC is not uniform across all pediatric patients requiring respiratory support.
- Specific patient characteristics, such as age and severity of illness, are key determinants of HFNC's economic advantage.
- Clinical decision-making regarding HFNC should consider individual patient profiles for optimal resource utilization.
Objectives:
To investigate heterogeneity in the cost-effectiveness of high-flow nasal cannula (HFNC) therapy compared with continuous positive airway pressure (CPAP) for acutely ill children requiring noninvasive respiratory support.
Methods:
Using data from the First-line Support for Assistance in Breathing in Children trial, we explore heterogeneity at the patient and subgroup levels using 2 causal forest approaches and a seemingly unrelated regression approach for comparison. First-line Support for Assistance in Breathing in Children is a noninferiority randomized controlled trial (ISRCTN60048867) involving 24 UK pediatric intensive care units. The Step-up trial focuses on acutely ill children aged 0 to 15 years, requiring noninvasive respiratory support. A total of 600 children were randomly assigned to HFNC and CPAP groups in a 1:1 allocation ratio, with 94 patients excluded because of data unavailability.
Results:
The primary outcome is the incremental net monetary benefit (INB) of HFNC compared with CPAP, using a willingness-to-pay threshold of £20 000 per quality-adjusted life year gain. INB is derived from total costs and quality-adjusted life years at 6 months. Subgroup analysis showed that some subgroups, such as male children, those aged less than 12 months, and those without severe respiratory distress at randomization, had more favorable INB results. Patient-level analysis revealed heterogeneity in INB estimates, particularly driven by the cost component, with greater uncertainty for those with higher INBs.
Conclusions:
The estimated overall INB of HFNC is significantly larger for specific patient subgroups, suggesting that the cost-effectiveness of HFNC can be heterogeneous, which highlights the importance of considering patient characteristics in evaluating the cost-effectiveness of HFNC.
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