The cost-effectiveness ratio of a managed protocol for severe sepsis ☆ , ☆☆ Murillo Santucci Cesar Assuncao, MD, MSC a, ⁎, Vanessa Teich, BSc b , Sandra Christina Pereira Lima Shiramizo, RN a , Denizart Vianna Araújo, MD c , Renato Melli Carrera, MD a , Ary Serpa Neto, MD, MSC a , Eliezer Silva, MD, PhD a, ⁎ a Department of Critically Ill Patient, Intensive Care Unit, Hospital Israelita Albert Einstein, Av Albert Einstein, 627/701, Sao Paulo (SP), Brazil 05652-000 b MedInsight, Decisions in Health Care, Rio de Janeiro, Baazil c Department of Internal Medicine, Medical Sciences School, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil abstract article info Keywords: Sepsis Severe sepsis Septic shock Cost-effectiveness analysis Outcome Protocol Purpose: Severe sepsis is a time-dependent disease, and implementation of early treatment has been associated with mortality rate reduction. However, the literature is controversial regarding cost-effectiveness analysis of this intervention. The aim was to assess the cost-effectiveness of a managed protocol for the treatment of severe sepsis. Materials and methods: This is a prospective cohort study involving a historical comparison (before and after the implementation of the protocol) of patients who had been hospitalized with severe sepsis and septic shock. The group of patients who were treated before the assistance routine was implemented was considered to be the control. The case-managed nurse involved with assistance protocol performed the data collection. This nurse received special training to ensure the quality of the data and to measure the intervention throughout the implementation process. Results: A total of 414 patients were analyzed. The mortality rates were 57% in the control group and 38% in the protocol group (P = .002). After the implementation of the protocol, the absolute risk reduction was 18%; and the relative risk reduction was 31.8%. There was a tendency for a reduction in the cost of the full hospitalization, but this trend did not reach statistical significance. Nevertheless, the cost of hospitalization in the intensive care unit was reduced significantly from US $138,237 ± $202,418 in the control group to US $85,484 ± $127,471 in the protocol group (P = .003). The managed protocol for sepsis resulted in an average gain of 3.2 life-years after being discharged from the hospital (8.8 ± 13.3 years in the control group and 12.0 ± 14.0 years in the protocol group, P = .01). Conclusions: Given that the incremental cost was lower than or equal to zero, the effectiveness of the protocol was justified by the significant increase in the life-years saved and the reduced mortality. © 2014 Elsevier Inc. All rights reserved. 1. Introduction Sepsis is a common disease that is associated with high morbidity and mortality rates, especially in developing countries. In Brazil, there are an estimated 500,000 new cases of severe sepsis every year; and the sepsis mortality rate, ranging between 40% and 60%, is one of the highest in the world [1,2]. The direct costs associated with sepsis treatment have reached approximately 17 billion dollars per year [3]. In Brazil, Sogayar et al conducted an elegant study that found that the median total cost of sepsis treatment in the intensive care unit (ICU) was US $9632 per patient, which corresponds to a daily cost of US $934. Furthermore, nonsurvivors exhibited significantly higher costs than survivors [2]. Delays in recognition and treatment onset increase mortality risk of severe sepsis patients. A recent study showed that physicians’ ability to recognize severe sepsis is unsatisfactory, which may impact the clinical outcome [4]. In addition, several studies have showed an association with lower mortality rate and implementation of the 6- and 24-hour bundles recommended by the Surviving Sepsis Campaign (SSC) [3,5–8]. Nevertheless, the expenses that are associated with these bundles and the direct costs that are related to the treatments have been only partially assessed [9–12]. Therefore, an assessment of the incremental costs and benefits of the SSC implementation is crucial, especially in developing countries such as Brazil. The primary aim of the present study was to assess the cost- effectiveness ratio of a managed protocol for severe sepsis that was Journal of Critical Care xxx (2014) xxx–xxx Abbreviations: ICU, intensive care unit; SSC, Surviving Sepsis Campaign. ☆ Competing interests: The authors declare that they have no competing interests. ☆☆ Nonfinancial competing interests: Murillo Santucci Cesar Assuncao is a member of the Latin American Institute of Sepsis; Eliezer Silva is a member of the Steering Committee of the Global Sepsis Alliance, member of the Board of Sepsis Surviving Campaign, and former President of the Latin American Sepsis Institute. ⁎ Corresponding author. Hospital Israelita Albert Einstein, Av Albert Einstein, 627/ 701, Sao Paulo (SP), Brazil 05652-000. Tel/fax: +55 11 2151 1521. E-mail addresses: santucci@einstein.br (M.S.C. Assuncao), vanessateich@medinsight.com (V. Teich), sandralima@einstein.br (S.C.P.L. Shiramizo), denizarvianna@gmail.com (D.V. Araújo), aryserpa@terra.com.br (A. Serpa Neto), eliezer@einstein.br (E. Silva). http://dx.doi.org/10.1016/j.jcrc.2014.03.008 0883-9441/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Critical Care journal homepage: www.jccjournal.org Please cite this article as: Assuncao MSC, et al, The cost-effectiveness ratio of a managed protocol for severe sepsis, J Crit Care (2014), http:// dx.doi.org/10.1016/j.jcrc.2014.03.008