Cost-effectiveness of HFNC therapy versus continuous positive airway pressure for non-invasive respiratory support in paediatric critical care

Sadique, Z., Zapata, S.M., Grieve, R. et al. Cost-effectiveness of high flow nasal cannula therapy versus continuous positive airway pressure for non-invasive respiratory support in paediatric critical care. Crit Care 28, 386 (2024). https://doi.org/10.1186/s13054-024-05148-y

Summary of "Cost-effectiveness of high-flow nasal cannula therapy versus continuous positive airway pressure for non-invasive respiratory support in paediatric critical care"

Summary:

This study evaluates the cost-effectiveness of high-flow nasal cannula (HFNC) therapy versus continuous positive airway pressure (CPAP) for non-invasive respiratory support in paediatric critical care. Using data from two randomized controlled trials (FIRST-ABC), researchers assessed costs, quality-adjusted life years (QALYs), and incremental net benefits (INBs) at six months post-randomization. HFNC was found to be cost-saving in both step-up (acutely ill children) and step-down (extubated children) scenarios but showed no significant difference in QALYs or clinical outcomes compared to CPAP. Uncertainty around the cost-effectiveness results was noted.

Key Points:

1. Study Design: Data from two FIRST-ABC RCTs, including acutely ill (step-up) and extubated (step-down) children, formed the basis of the cost-effectiveness analysis.
2. QALYs and Costs: HFNC reduced mean costs compared to CPAP but achieved similar QALYs and life-years at six months post-randomization.
3. Incremental Cost-Effectiveness: INBs favored HFNC in both trials, with INBs of ￡5628 (step-up) and ￡4388 (step-down), though results were surrounded by significant uncertainty.
4. Mortality Rates: Both interventions demonstrated low mortality rates, but slightly higher rates were observed in HFNC groups.
5. Hospital Resource Utilization: HFNC had shorter PICU/HDU stays and lower overall hospital costs in both scenarios, particularly in the step-up RCT.
6. Subgroup Analysis: Variability in cost-effectiveness was observed in certain subgroups, such as children with cardiac comorbidities.
7. Sensitivity Analysis: Results were robust across various assumptions, but uncertainties remained due to wide confidence intervals.
8. Patient Comfort and Practicality: HFNC is perceived as more comfortable and easier to manage than CPAP, potentially influencing its increasing adoption in clinical practice.
9. Limitations: Differences in baseline characteristics, missing data, and reliance on modeled HrQoL outcomes introduced potential biases.
10. Policy Implications: Findings support the cost-saving potential of HFNC in paediatric critical care, but further research is needed to clarify its impact on long-term outcomes.

Conclusion:

HFNC therapy reduces costs compared to CPAP in paediatric critical care while providing equivalent QALYs and clinical outcomes. Despite significant uncertainties, HFNC appears to be a cost-effective option for non-invasive respiratory support. The study underscores the need for further research to address limitations and explore subgroup-specific impacts.

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Discussion Questions:

1. How can the cost-effectiveness of HFNC be improved in subgroups where it shows lower INBs, such as children with specific comorbidities?
2. What additional metrics could be included in future studies to better capture the clinical and economic impact of HFNC and CPAP?
3. How can healthcare systems address uncertainties in cost-effectiveness results to guide clinical decision-making for paediatric respiratory support?

Javier Amador-Casta?eda, BHS, RRT, FCCM

Interprofessional Critical Care Network (ICCN)

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