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Ventilator-Associated Events Cost in ICU Patients Receiving Mechanical Ventilation: A Multi-State Model Cover

Ventilator-Associated Events Cost in ICU Patients Receiving Mechanical Ventilation: A Multi-State Model

The Journal of Critical Care Medicine
Volume 10 (2024): Issue 2 (April 2024)
By: ,  ,  ,  ,   and    
Open Access
|Apr 2024
Figures & tables

Figures & Tables

Fig. 1.

Multi-state model with 4 states: 0, ICU admission without a VAE; 1, VAE (exposed); 2, discharge; and 3, death. All patients entered into the initial state 0. Then the patient may acquire a VAE, moving to intermediate state 1, be discharged without a VAE, moving to state 2, or die without a VAE. Once acquired a VAE, the patient can move from state 1 to 2 or from 1 to 3. Hazard rates are denoted by k. with indices i and j indicating the states which they connect. VAE, Ventilator-Associated Event.

Table 1.

Multi-state analysis of Ventilator-Associated Events

Constant hazards from MSM
VAE hazardλ01
Discharge hazard without VAEλ02
Death hazard without VAEλ03
Discharge hazard with VAEλ12
Death hazard with VAEλ13
Occurrence of VAE
Incidence rate of VAE per patient dayλ01
Mortality due to VAE
ICU mortality(λ01λ13 / λ01λ02λ03) + λ03 / λ01λ02λ03
Hazard ratio of VAE (death)λ13 / λ03
Hazard ratio of VAE (discharge)λ12 / λ02
Attributable mortality of VAE(λ02λ13 − λ03λ12) / (λ12 + λ13) (λ02 + λ03)
Population attributable fraction for mortality[λ01 (λ02λ13 − λ03λ12)] / (λ02 + λ03) (λ03λ1 + λ01λ13), λ1 = λ12 + λ13

[i] MSM, multi-state model; VAE, ventilator-associated event; ICU, intensive care unit.

Table 2.

The characteristics of patients with and without ventilator-associated events

VAEP Value
Yes
N = 143, %		No
N= 235, %
Gender0.451
Male88 (61.5)134 (57)
Age, years (Median, Interquartile range)59 (46–73)61 (45–74)0.649
Type of patient
  Medical74 (51.7)115 (48.9)0.671
  Surgical69 (48.3)120 (51.1)
McCabe score
  Non-fatal disease49 (34.3)114 (48.5)0.007
  Ultimately fatal disease16 (11.2)20 (8.5)0.470
  Rapidly fatal disease78 (54.5)101 (43)0.034
Admission diagnosis
  Trauma42 (29.4)43 (18.3)0.016
  Neurological disease30 (21)42 (17.9)0.500
  Pulmonary disease33 (23.1)35 (14.9)0.053
  Post-operative observation18 (12.6)66 (28.1)0.000
  Cardiovascular disease11 (7.7)26 (11.1)0.372
  Malignancy5 (3.5)17 (7.2)0.175
  Other (burn, poisoning)4 (2.8)6 (2.6)1.000
Death63 (44.1)55 (23.4)0.000

[i] VAE, ventilator-associated event.

Table 3.

Multi-state model constant hazards

Constant hazards (95% CI)VAEVACIVACPVAP
λ01 VAE hazard0.026 (0.022–0.030)0.011 (0.009–0.014)0.005 (0.003–0.007)0.001 (0.001–0.002)
λ02 Discharge hazard without VAE0.033 (0.028–0.038)0.029 (0.026–0.034)0.028 (0.025–0.032)0.028 (0.025–0.032)
λ03 Death hazard without VAE0.010 (0.007–0.013)0.011 (0.009–0.014)0.012 (0.010–0.014)0.012 (0.010–0.014)
λ12 Discharge hazard with VAE0.020 (0.016–0.025)0.021 (0.015–0.027)0.021 (0.014–0.031)0.014 (0.006–0.027)
λ13 Death hazard with VAE0.016 (0.012–0.020)0.016 (0.011–0.022)0.014 (0.091–0.023)0.018 (0.008–0.033)

[i] CI, confidence interval; VAE, ventilator-associated event; VAC, ventilator-associated condition; IVAC, infection-related ventilator-associated complication; PVAP, possible ventilator-associated pneumonia.

Table 4.

Death and discharge hazard ratio for patients with VAE

Types of VAEDeath hazard ratio (95% CI)Discharge hazard ratio (95% CI)
VAC1.401 (0.938–2.063)0.704 (0.509–0.960)
IVAC1.223 (0.721–1.984)0.755 (0.494–1.116)
PVAP1.471 (0.701–2.788)0.493 (0.233–1.044)
VAEs1.582 (1.101–2.278)0.614 (0.470–0.797)

[i] CI, confidence interval; VAE, ventilator-associated event; VAC, ventilator-associated condition; IVAC, infection-related ventilator-associated complication; PVAP, possible ventilator-associated pneumonia.

Fig. 2.

Plot of the expected LOS in ICU. The black line shows that a VAE has occurred, and the red line indicates a lack of VAE up to 30 days after ICU hospitalization. The weights (distribution of the time to VAE) are illustrated in the upper plot. VAE, ventilator-associated event; LOS, length of stay.

Table 5.

Mean additional length of stay associated with VAEs

Additional ICU days regarding discharge ± SE95% BCa CIAdditional ICU days regarding death ± SE95% BCa CITotal additional ICU days ± SE95% BCa CI
VAC4.50 ± 1.931.14–8.872.43 ± 1.220.21–4.816.93 ± 2.382.45–11.83
IVAC1.92 ± 1.81−0.93–6.185.35 ± 2.450.85–10.487.27 ± 2.941.68–13.08
PVAP3.99 ± 2.65−0.25–10.307.09 ± 5.38−1.21–18.5711.08 ± 5.650.60–22.05
All VAEs3.25 ± 1.370.71–6.083.30 ± 1.171.10–5.646.55 ± 1.782.76–9.73

[i] BCa CI, Bias-corrected and accelerated confidence interval; SE, standard error; VAE, ventilator-associated event; VAC, ventilator-associated condition; IVAC, infection-related ventilator-associated complication; PVAP, possible ventilator-associated pneumonia.

Table 6.

The direct additional cost per VAE episode

Direct additional cost per VAE episode, €
Additional cost regarding deathAdditional cost regarding dischargeTotal additional cost
VAC1,197.502,217.603,415.10
IVAC2,636.48946,173,582.65
PVAP3,493.951,966.275,460.22
All VAEs1,626.241,601.603,227.84

[i] VAE, ventilator-associated event; VAC, ventilator-associated condition; IVAC, infection-related ventilator-associated complication; PVAP, possible ventilator-associated pneumonia.

DOI: https://doi.org/10.2478/jccm-2024-0016 | Journal eISSN: 2393-1817 | Journal ISSN: 2393-1809
Journal RSS Feed
Language: English
Page range: 168 - 176
Submitted on: Oct 30, 2023
Accepted on: Mar 28, 2024
Published on: Apr 30, 2024
Published by: University of Medicine, Pharmacy, Science and Technology of Targu Mures
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
ventilator-associated events,
cost,
intensive care units,
multi-state model,
mechanical ventilation
Related subjects:
Medicine,
Clinical medicine,
Internal medicine,
Internal medicine, other,
Surgery,
Surgery, other,
Anaesthesiology,
Emergency medicine and intensive-care medicine

© 2024 Alkmena Kafazi, Eleni Apostolopoulou, Vasiliki Benetou, Georgia Kourlaba, Christos Stylianou, Ioanna D Pavlopoulou, published by University of Medicine, Pharmacy, Science and Technology of Targu Mures
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 10 (2024): Issue 2 (April 2024)
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