Pulmonary artery catheters

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Abstract
Research findings to date The best evidence comes from well designed and conducted clinical trials in the general intensive care population,4 and more selected populations of high risk or critically ill patients.5–7 None of the trials show that using a pulmonary artery catheter benefits patients. A recently published trial in patients with acute lung injury confirmed these findings.8 A meta-analysis of 13 trials reported no overall effect of using these devices on mortality or length of hospital stay.9 The HTA report includes a systematic review that reaches the same conclusion, a more detailed description of the authors' previously published PACMAN trial,4 and an economic evaluation examining the cost effectiveness of withdrawing these catheters from UK intensive care units.3 Given the pre-existing evidence that the use of these devices does not benefit patients, the report's conclusion that withdrawing pulmonary artery catheters may reduce mortality at the cost of £2985 (€4446; $5622) per quality adjusted life year deserves closer scrutiny. The authors examined cost effectiveness from a decision science perspective,10 an approach that many clinicians will be unfamiliar with. In essence, whereas traditional hypothesis testing seeks to detect differences that are not likely to have arisen by chance, decision analysis seeks to determine what is most likely to happen if a particular course of action is taken. In this case, the most likely result of withdrawing pulmonary artery catheters from UK intensive care units is a net health gain at moderate cost. We also note that the conclusions are based upon assumptions regarding the duration and quality of life of survivors of critical illness, as the authors could find no appropriate health related quality of life data for survivors of intensive care units. The assumptions on which the analysis is based are open to question, and the results may not hold true for other healthcare systems. Is the lack of benefit specific to the pulmonary artery catheter or does it extend to other devices that measure and monitor central haemodynamics? At present that question cannot be answered with certainty, but in the absence of benefit from the pulmonary artery catheter, the onus should be on the marketers of other haemodynamic monitors to demonstrate their clinical usefulness and cost effectiveness, not simply show that they are as good as a device that has no proved benefit.