Cost-Effectiveness of ECPR Versus CCPR in OHCA; a Trial-Based Economic Evaluation

Introduction: When out-of-hospital cardiac arrest (OHCA) becomes refractory, extracorporeal cardiopulmonary resuscitation (ECPR) is a potential option to restore circulation and improve the patient's outcome. However, ECPR requires specific materials and highly skilled personnel, and it is unclear whether increased survival and health-related quality of life (HRQOL) justify these costs. Methods: This cost-effectiveness study was part of the INCEPTION study, a multicenter, pragmatic randomized trial comparing hospital-based ECPR to conventional CPR (CCPR) in patients with refractory OHCA in 10 cardiosurgical centers in the Netherlands. We analyzed healthcare costs in the first year and measured HRQOL using the EQ-5D-5L at 1, 3, 6, and 12 months. Incremental cost-effectiveness ratio’s (ICER), cost-effectiveness planes, and acceptability curves were calculated. Sensitivity analyses were performed for per-protocol and as-treated subgroups as well as imputed productivity loss in deceased patients.  Results: In total 132 patients were enrolled: 62 in the CCPR and 70 in the ECPR group. The difference in mean costs after one year was €5,109 (95%CI -7,264 – 15,764). Mean QALY after one year was 0.15 in the ECPR group and 0.11 in the CCPR group, resulting in an ICER of €121.643 per additional QALY gained. The acceptability curve shows that at a willingness-to-pay threshold of €80.000, the probability of ECPR being cost-effective compared to CCPR is 36%. Sensitivity analysis showed increasing ICER in the per-protocol and as-treated groups and lower probabilities of acceptance. Conclusion: Hospital-based ECPR in refractory OHCA has a low probability of being cost-effective in a trial-based economic evaluation.' Trial Registration: It was registered at clinicaltrials.gov (NCT03101787). Funding: Supported by the Netherlands Organization for Health Research and Development (Project number 80-84300-98-71040) and Maquet Cardiopulmonary (Getinge). Declaration of Interest: Ethical Approval: The trial used deferred informed consent and was assessed and approved by the institutional review board of the Maastricht University Medical Center (METC 162039).