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1.
Am J Respir Crit Care Med ; 205(12): 1382-1390, 2022 Jun 15.
Article in English | MEDLINE | ID: covidwho-1714499

ABSTRACT

The role of extracorporeal membrane oxygenation (ECMO) in the management of severe acute respiratory failure, including acute respiratory distress syndrome, has become better defined in recent years in light of emerging high-quality evidence and technological advances. Use of ECMO has consequently increased throughout many parts of the world. The coronavirus disease (COVID-19) pandemic, however, has highlighted deficiencies in organizational capacity, research capability, knowledge sharing, and resource use. Although governments, medical societies, hospital systems, and clinicians were collectively unprepared for the scope of this pandemic, the use of ECMO, a highly resource-intensive and specialized form of life support, presented specific logistical and ethical challenges. As the pandemic has evolved, there has been greater collaboration in the use of ECMO across centers and regions, together with more robust data reporting through international registries and observational studies. Nevertheless, centralization of ECMO capacity is lacking in many regions of the world, and equitable use of ECMO resources remains uneven. There are no widely available mechanisms to conduct large-scale, rigorous clinical trials in real time. In this critical care review, we outline lessons learned during COVID-19 and prior respiratory pandemics in which ECMO was used, and we describe how we might apply these lessons going forward, both during the ongoing COVID-19 pandemic and in the future.


Subject(s)
COVID-19 , Extracorporeal Membrane Oxygenation , Respiratory Distress Syndrome , COVID-19/therapy , Humans , Pandemics , SARS-CoV-2
2.
Crit Care Med ; 50(1): 144-147, 2022 01 01.
Article in English | MEDLINE | ID: covidwho-1591953
3.
Sci Rep ; 11(1): 17787, 2021 09 07.
Article in English | MEDLINE | ID: covidwho-1397899

ABSTRACT

Despite COVID-19's significant morbidity and mortality, considering cost-effectiveness of pharmacologic treatment strategies for hospitalized patients remains critical to support healthcare resource decisions within budgetary constraints. As such, we calculated the cost-effectiveness of using remdesivir and dexamethasone for moderate to severe COVID-19 respiratory infections using the United States health care system as a representative model. A decision analytic model modelled a base case scenario of a 60-year-old patient admitted to hospital with COVID-19. Patients requiring oxygen were considered moderate severity, and patients with severe COVID-19 required intubation with intensive care. Strategies modelled included giving remdesivir to all patients, remdesivir in only moderate and only severe infections, dexamethasone to all patients, dexamethasone in severe infections, remdesivir in moderate/dexamethasone in severe infections, and best supportive care. Data for the model came from the published literature. The time horizon was 1 year; no discounting was performed due to the short duration. The perspective was of the payer in the United States health care system. Supportive care for moderate/severe COVID-19 cost $11,112.98 with 0.7155 quality adjusted life-year (QALY) obtained. Using dexamethasone for all patients was the most-cost effective with an incremental cost-effectiveness ratio of $980.84/QALY; all remdesivir strategies were more costly and less effective. Probabilistic sensitivity analyses showed dexamethasone for all patients was most cost-effective in 98.3% of scenarios. Dexamethasone for moderate-severe COVID-19 infections was the most cost-effective strategy and would have minimal budget impact. Based on current data, remdesivir is unlikely to be a cost-effective treatment for COVID-19.


Subject(s)
COVID-19/drug therapy , COVID-19/therapy , Health Care Costs/statistics & numerical data , Health Care Rationing/economics , Adenosine Monophosphate/analogs & derivatives , Adenosine Monophosphate/economics , Adenosine Monophosphate/therapeutic use , Alanine/analogs & derivatives , Alanine/economics , Alanine/therapeutic use , COVID-19/diagnosis , COVID-19/economics , COVID-19/mortality , COVID-19/virology , Clinical Decision-Making/methods , Computer Simulation , Cost-Benefit Analysis , Dexamethasone/economics , Dexamethasone/therapeutic use , Health Care Rationing/organization & administration , Humans , Intensive Care Units/economics , Intensive Care Units/statistics & numerical data , Middle Aged , Oxygen/administration & dosage , Oxygen/economics , Quality-Adjusted Life Years , Respiration, Artificial/economics , SARS-CoV-2 , Severity of Illness Index , Treatment Outcome , United States/epidemiology
6.
Lancet Respir Med ; 9(4): 430-434, 2021 04.
Article in English | MEDLINE | ID: covidwho-1033502

ABSTRACT

The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical-circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.


Subject(s)
COVID-19/therapy , Critical Care/organization & administration , Health Care Rationing/organization & administration , Pandemics/prevention & control , Triage/organization & administration , Advisory Committees/organization & administration , Advisory Committees/standards , COVID-19/epidemiology , Critical Care/economics , Critical Care/standards , Critical Care/statistics & numerical data , Decision Making, Organizational , Global Health/economics , Global Health/standards , Health Care Rationing/economics , Health Care Rationing/standards , Health Policy , Humans , Intersectoral Collaboration , Pandemics/economics , Practice Guidelines as Topic , Standard of Care/economics , Triage/standards
7.
Am J Bioeth ; 20(7): 67-74, 2020 07.
Article in English | MEDLINE | ID: covidwho-603950

ABSTRACT

Ethics consultants and critical care clinicians reflect on Seattle's early experience as the United States' first epicenter of COVID-19. We discuss ethically salient issues confronted at UW Medicine's hospitals and provide lessons for other health care institutions that may soon face what we have faced.


Subject(s)
Betacoronavirus , Communicable Disease Control , Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , COVID-19 , Cities , Coronavirus Infections/prevention & control , Humans , Pandemics/ethics , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , SARS-CoV-2 , Washington/epidemiology
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