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Human albumin: cost–benefits


Survival and discharge Crystalloid


In-hospital death


pDeadSep Survival and discharge Albumin


In-hospital death


pDeadAlb ICU fluid therapy in sepsis Renal


Survival at 90 days


Survival and discharge


HES


In-hospital death


pDeadHES Figure 3: Decision tree for assessing choice of fluid therapies14


a loss of 1.00 life years. The calculated cost of $9149 per life year gained with albumin is well within the range of measures considered cost effective by reimbursement agencies. Added attractions to this approach include the ability to analyse the effect of variables such as age on the outcomes. Further research on sepsis including the effect of quality of life on cost-effectiveness outcomes may also be informed by models such as these. The key issue is that these analyses are more sophisticated than 'bottle to bottle' comparisons and give payers the opportunity to assess the effect of therapeutic choice on total medical costs. The risk of developing budgets to small areas within hospitals includes the temptation to ignore global, long-term benefits to healthcare for patients and focus on the immediate need to cut costs regardless of ultimate outcomes.15


The introduction of


approaches such as the one described is therefore highly desirable.


Conclusions – albumin as the last colloid standing?


Albumin stands centre stage in the debate over fluid therapies and management costs. This natural colloid would clearly be the therapy of choice if the decision was not obscured by cost issues. Approaching such a decision has to be done in the context of assessing total


medical costs, which, in the case of the diseases treated by albumin (for example, sepsis and cirrhosis) are high, irrespective of the costs of fluids and the pharmaco- economic outcomes show that the additional cost of fluid, irrespective of its nature, has no effect on outcome.14


this level of decision making has to be taken from the purview of areas where the focus is immediate, short-term, competitive resource management. 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. l


References 1. Farrugia A. Albumin usage in clinical medicine: tradition or therapeutic? Transf Med Rev 2010;24(1):53–63.


2. Reviewers CIGA. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998;317(7153):235–40.


3. Wise J. Boldt: the great pretender. BMJ 2013;346:f1738.


4. Myburgh J, McIntyre L. New insights into fluid resuscitation. Intens Care Med 2013;39(6):998– 1001.


5. Farrugia A. Safety of plasma volume expanders. J Clin Pharmacol 2011;51(3):292–300.


6. Bansal M, Farrugia A, Balboni S, Martin G. Relative survival benefit and morbidity with fluids in severe sepsis – A network meta-analysis of alternative therapies. Curr Drug Safety (in press).


7. Palanzo DA et al. Hetastarch as a prime for cardiopulmonary bypass. Ann Thorac Surg 1982;34(6):680–3.


Hence,


8. Huang DT, Clermont G, Dremsizov TT, Angus DC. Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis. Crit Care Med 2007;35(9):2090–100.


9. Gentilini P et al. Albumin improves the response to diuretics in patients with cirrhosis and ascites: results of a randomized, controlled trial. J Hepatol 1999;30(4):639–45.


10. Evans TW. Review article: albumin as a drug-biological effects of albumin unrelated to oncotic pressure. Aliment Pharmacol Ther 2002;16 Suppl 5:6–11.


11. Burchardi H, Schneider H. Economic aspects of severe sepsis: a review of intensive care unit costs, cost of illness and cost effectiveness of therapy. Pharmacoeconomics 2004;22(12):793–813.


12. Dellinger RP et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41(1):580–637.


13. Guidet B, Mosqueda GJ, Priol G, Aegerter P. The COASST study: cost-effectiveness of albumin in severe sepsis and septic shock. J Crit Care 2007;22(3):197–203.


14. Farrugia A, Martin G, Bult M. Colloids for Sepsis: Effectiveness and Cost Issues. Ann Update Crit Care Emer Med 2013.


15. Should hospital pharmacy drug budgets be the responsibility of each individual department in an institution, or should such budgets be controlled centrally by the pharmacy department? Can J Hosp Pharm 2010;63(4):330–2.


www.hospitalpharmacyeurope.com


Death at 90 days


pDeadHES90 pRenalHES Bleeding pBleedingHES


Bleeding No bleeding


No renal


pBleedingHES No bleeding


23


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