Prehospital thawed plasma (TP) transfusion was both cost-effective and lifesaving when used during resuscitation of trauma patients in hemorrhagic shock during air transport, suggest results from a cost-utility analysis.
There is significant evidence backing a transfusion strategy approximating whole blood, “with a 1:1:1 ratio of plasma to platelets to packed red blood cells both in hospital and in the prehospital environment; however, prehospital volume resuscitation strategies for patients with active hemorrhage are limited by the feasibility and availability of blood products,” Jason L. Sperry, MD, MPH, of the Department of Surgery at University of Pittsburgh Medical Center in Pittsburgh, and colleagues wrote in JAMA Surgery.
Recently, the Prehospital Plasma in Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial showed that use of prehospital TP improved 30-day mortality among trauma patients, but concerns regarding costs have prevented widespread use, with another study estimating that the cost of maintaining TP stores may exceed $24,000 per helicopter base per year.
For this study, Sperry and colleagues set out to assess the cost-effectiveness of implementing a prehospital TP program using patient-level data from the PAMPer trial.
“In this study, prehospital TP was cost-effective across a range of patient and center-level variables,” Sperry and colleagues found. “The cost of a prehospital TP program was small when distributed across patients and QALYs. The bulk of the observed incremental cost was attributable to in-hospital and lifetime care associated with improved survivorship after prehospital TP.”
Compared to standard care, TP transfusion was cost-effective, with an incremental cost-effectiveness ratio (ICER) of $50,467 per quality-adjusted life-year compared with standard care.
“Plasma should be a standard component of prehospital resuscitation during the air medical transport of trauma patients in hemorrhagic shock,” they concluded.
In an editorial accompanying the study, Elliott R. Haut, MD, PhD, of The John Hopkins University School of Medicine and The Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues called the study “a beautifully executed, clearly reported cost-effectiveness trial.”
But the editorialists noted that the question of who actually pays for prehospital plasma programs is not settled—Sperry and colleagues make the assumption that helicopter bases are associated with trauma centers. “However, there are other possible payers for this type of intervention, they wrote, “including insurers, hospitals, private aeromedical transport companies, or states (i.e., Maryland with its single-payer trauma helicopter system).”
And the logistics of implementing such a plasma program remain, they noted, though they added that it “should not be hard to answer questions regarding refrigerated storage, transport mechanisms, replenishment, and how much plasma to keep at each base. Several aeromedical programs across the United States have been using plasma for over a decade without notable waste or increased costs. Low-titer A plasma protocols make implementation even more achievable.
“The evidence (including cost-effectiveness) is compelling,” they concluded. “We challenge all trauma centers and systems to integrate a plasma transfusion program into their prehospital air transport resuscitation protocols.”
For their analysis, Sperry and colleagues used published and unpublished patient-level data from the PAMPer trial, health care and trauma-specific databases, and the published literature to create a decision tree and Markov model in order to compare standard care against prehospital TP transfusion. Inclusion criteria included at least one episode of hypotension and tachycardia or any severe hypotension during air transport for traumatic injury.
The intervention consisted of transfusion of two units of TP during transport; the control group received crystalloid and up to two units of universal donor packed red blood cells, as dictated by local protocols.
“Each month, air medical bases were randomized to deliver the intervention or standard care (SC) resuscitation to eligible patients, and intraclass correlation was used to account for this cluster design,” the study authors explained. “The primary outcome, 30-day mortality, was assessed by a modified intention-to-treat analysis. Multiple imputation was used for patients with unknown 30-day vital status.”
The study authors estimated the total annual cost of a prehospital TP program; attributable costs for plasma distribution, recovery, waste, and recycling were obtained from site-level accounting data. They also used data from the Healthcare Cost and Utilization Project and published literature to estimate the daily average cost of hospitalization following traumatic injury, and post-discharge costs for the first post-trauma year were estimated by inflating costs obtained from the Centers for Medicare and Medicaid Services mean annual health expenditures report.
The study’s main outcome was the ICER, which represents the cost of obtaining an additional unit of benefit—in this case, quality-adjusted life-years (QALYs)—at a standard willingness-to-pay threshold of $100,000 per QALY. The secondary outcome was the cost of obtaining an additional unadjusted life-year.
The final analysis included 501 patients (median [interquartile range] age: 44 (31-59) in the TP group; 46 (28-60) in the standard care group), of whom 364 (72.7%) were male.
“Thawed plasma transfusion was cost-effective with an incremental cost-effectiveness ratio of $50,467.44 per QALY compared with standard care,” the study authors found. “The preference for thawed plasma was robust across all 1- and 2-way sensitivity analyses. When considering only patients injured by a blunt mechanism, the incremental cost-effectiveness ratio decreased to $37,735.19 per QALY. Thawed plasma was preferred in 8,140 of 10,000 iterations (81.4%) on probabilistic sensitivity analysis. A detailed analysis of incremental costs between strategies revealed most were attributable to the in-hospital and postdischarge lifetime care of critically ill patients surviving severe trauma.”
Sperry and colleagues noted that the cost-effectiveness of prehospital TP will vary based on center-level characteristics, including the number of air bases supplied, annual volume of trauma patients who meet the criteria for TP, and the proportion of blunt trauma injuries.
“However, 1- and 2-way sensitivity analyses failed to reveal clinically meaningful scenarios wherein prehospital TP was not cost-effective,” they wrote. “A 2-way sensitivity analysis of annual patient volume and number of bases per trauma center showed that [standard care] became the preferred strategy when the number of bases exceeded the annual volume of eligible patients, a highly improbable scenario.”
Study limitations include that model inputs were derived from multicenter data with variations across trial sites; annual eligibility was estimated from single-site internal data and multisite enrollment data, which may not reflect actual trauma volume; hospital charges used to estimate costs may not reflect actual payment by the health care system; the impact of variations in regional regulations and emergency protocols on total costs was not considered; there was limited data on long-term cost projections for patients with a history of severe trauma; and, “although this analysis shows prehospital TP to be cost-effective, it does not answer the question of who should pay for this service or provide a model of how this cost could be passed on to various stakeholders, such as states, trauma centers, patients, or society.”
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Results from a cost-utility analysis suggest prehospital thawed plasma (TP) transfusion was both cost-effective and lifesaving when used during resuscitation of trauma patients in hemorrhagic shock during air transport.
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The study authors concluded that plasma should be a standard component of prehospital resuscitation during the air medical transport of trauma patients in hemorrhagic shock.
John McKenna, Associate Editor, BreakingMED™
Sperry and coauthors Guyette, Claridge, and Phelan reported grants from the Department of Defense during the conduct of the study.
Haut reported research funding from the Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, the National Institutes of Health/National Heart, Lung, and Blood Institute, the Department of Defense/Army Medical Research Acquisition Activity, and the Henry M. Jackson Foundation for the Advancement of Military Medicine; royalties from Lippincott Williams & Wilkins for the book “Avoiding Common ICU Errors”; and was a paid speaker for the Vizient Hospital Improvement Innovation Network VTE Prevention Acceleration Network. Coauthor Cotton is on the Scientific Advisory Board for Haemonetics.
Cat ID: 254
Topic ID: 253,254,254,570,730,192,925
