Question 4

College Answer

Any component of care could be assessed (eg. staffing levels, equipment, new techniques or drugs).
•    Strength of evidence supporting the new component of care (eg. more than one adequately powered prospective randomised clinical trial). Internal validity of trials (adequacy of methodology).
•    External validity of trials or other supporting information (ie. ability to extrapolate to the patients that you are managing).
•    Ability to accurately identify those patients who would benefit from new component of care.
Accurate identification of patients prospectively decreases costs by decreasing the number of patients who will need to be treated but who will not benefit (or may even be harmed).
•    Magnitude of outcome benefit found (eg. number needed to treat to achieve specific outcome). Consider survival to hospital versus 30 day survival versus 12 month survival.
•    Additional costs that may be generated by achieving that outcome (eg. costs of hospitalisation or other care, incurred after survival). Comparison with costs generated (or saved) by alternative strategy.
•    Source of funding for costs should be considered. Special grant (above and beyond current budget) or would any additional costs be paid from existing budget (requiring cost cutting in other areas).

Discussion

Of the vague questions from the early papers of the CICM fellowship, this one is a peach. The poor candidate would have to guess what was meant by "new component of care". Do they mean the puchase of new equipment? The implementation of a new hand-washing protocol? The hiring of new cleaners? A modification of the departmental toast-buttering policy? These things are unclear.

Let us consider the question in generic terms.

Evidence in support of the new component

• Is there robust evidence to support the use of this component
• Is this evidence generaliseable to the relevant population
• What is the expected benefit (eg. expressed as OR or RRR)
• What is the magnitude of its impact (eg. expressed in NNT)

Cost-benefit analysis of new component

• What is the cost of the new component
• How does this cost compare to the cost of existing practice
• Does the cost-benefit ratio favour this new component over the existing practice (eg. if the new component is more expensive but also more effective, how much extra QALY does each extra dollar buy?)
• How does this specific new component compare to an alternative in terms of cost-benefit ratio? A comparison of several alternatives would be required.

Logistics of implementation

• Where will the funding come from
• Is the incremental cost of the component covered by the funding
• What savings or costs will be generated by the abandonment of the existing practice
• What costs are involved in the training and education of staff
• What costs are involved in the processes of quality assurance audit and follow-up for this new component
• What degree of acceptance is there for this new component among the staff
• How will the satisfaction of staff with this new component be assessed?

Valentin, Andreas, and Patrick Ferdinande. "Recommendations on basic requirements for intensive care units: structural and organizational aspects."Intensive care medicine 37.10 (2011): 1575-1587.

Laupacis, A., et al. "How attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations." CMAJ: Canadian Medical Association Journal 146.4 (1992): 473.