COST-EFFECTIVENESS
Pharmacoeconomic perspectives on fluid therapy
In the era when other colloids have been shown to be unsafe , albumin has come into its own as a safe , effective therapy with demonstrable cost effectiveness
Albert Farrugia BSc PhD ( Edin ) Adjunct Professor , School of Surgery , Faculty of Medicine and Surgery , The University of Western Australia , Perth , Australia
The development of albumin ’ s role as a blood substitute and plasma-expanding agent has been reviewed . 1 This role appeared unquestioned until the publication of a rapidly discredited Cochrane review in 1998 , 2 which threw doubts on the safety of albumin . It is probable that this contributed to the consideration of other fluids and to the rapid ascendancy of hydroxyethyl starch solutions ( HES ) as the predominant colloid fluid therapy in the 2000s , despite the already established adverse events associated with these compounds . The obviation of much of the evidence base for HES through the Boldt scandal , 3 coupled with the increasing body of evidence that all types of HES were associated with serious adverse effects , 4 has led the regulatory agencies of the US and Europe to severely restrict or disallow totally the use of these products in critical illness . It seems unlikely that
FIGURE 1
Relative ranking of survival with different fluid therapies in sepsis 6
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0 Albumin Crystalloid HES
HES will regain a significant position in fluid replacement therapy and the position of albumin as the colloid least associated with adverse events 5 has undergone a remarkable evolution since the questions raised by the Cochrane review . The body of evidence demonstrating the efficacy of albumin in areas of critical care and hepatology is impressive , and a recently published meta-analysis 6 demonstrates its superiority relative to other treatments in conferring a survival benefit to patients with sepsis ( Figure 1 ).
Pharmacoeconomic perspectives on fluid therapy Despite these developments , it is likely that the controversy around the choice of fluid therapy in clinical care will continue , as it is essentially reflective of economic concerns , which , if anything , are increasingly acute in the current healthcare landscape worldwide . It is intriguing that even supposedly objective and clinical evidence-based processes such as the Cochrane Collaboration cannot help including comments on costs in their reports , irrespective of the relevance of such comments to the issue of best evidence care . Pharmacoeconomic analysis is one area of health technology assessment ( HTA ) which is increasingly used by healthcare agencies and payers to assist decision making . This kind of decision making is being rapidly devolved to individual hospital departments , particularly pharmacies in the case of drug purchasing . The pressure on these individual areas , each fighting to retain their budgets and provide services , makes them particularly vulnerable to commercial claims regarding the relative costs of treatments . Such claims have included material from the manufacturers of HES , drawing attention to the higher cost of albumin versus HES , and are reflective of earlier analyses comparing the costs of different fluids in areas such as cardiac surgery , where simple ‘ bottle to bottle ’ costs were compared as a basis for suggested choices . 7 A rigorous costeffectiveness analysis is needed in making such comparisons , in which all costs and outcomes such as morbidity , mortality and length of intensive care stay , for example , can be factored into the final outcome . Some areas of fluid treatment have been subjected to such an exercise , for example , in the area of goal-directed therapy . 8 The role of albumin in cirrhosis has also been examined for its cost – benefit 9 in a study demonstrating the usefulness of using such analyses in identifying sub-groups of patients where clinical and cost benefits may be targeted . Given the evolving perspective of albumin as a drug with specific pharmacological effects in
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