(E-Entropy, Bispectral Index and Narcotrend): a

284 Pages·2013·2.35 MB·English

by  Shepherd J

Health technology Assessment 2013; Vol. 17: No. 34 HealtH tecHnology assessment
Report methods for synthesising evidence of cost-effectiveness
VOLUME 17 ISSUE 34 AUgUSt 2013 References
ISSN 1366-5278
Appendix 2 Literature search strategies
MEDLINE search strategy for Bispectral Index, Narcotrend and E-Entropy used
in systematic review of patient outcomes
MEDLINE search strategy for Bispectral Index, Narcotrend and E-Entropy used
in systematic review of cost-effectiveness
clinical effectiveness and cost-effectiveness of depth
of anaesthesia monitoring (e-entropy, Bispectral Index
Appendix 3 Inclusion/exclusion worksheet used in systematic review of
and narcotrend): a systematic review and
patient outcomes
economic evaluation
Appendix 4 Reasons for the exclusion of full-text publications from
J Shepherd, J Jones, GK Frampton, J Bryant, L Baxter and K Cooper systematic review of patient outcomes
Exclusion criterion = study design (five publications)
Exclusion criterion = comparator (standard practice unclear or not defined)
(four publications)
Publication retracted by journal (one publication)
Appendix 5 Data extraction and critical appraisal forms used in the
systematic review of patient outcomes
Aime et al.
Avidan et al.
Bannister et al.
Bhardwaj and Yaddanapudi
Chan et al.
Choi et al.
Ellerkmann et al.
gruenewald et al.
Kamal
Kerssens et al.
DOI 10.3310/hta17340

Clinical effectiveness and cost-
effectiveness of depth of anaesthesia
monitoring (E-Entropy, Bispectral Index
and Narcotrend): a systematic review and
economic evaluation
J Shepherd,* J Jones, GK Frampton, J Bryant,
L Baxter and K Cooper
Southampton Health Technology Assessments Centre (SHTAC), University of
Southampton, Southampton, UK
*Corresponding author
Declared competing interests of the authors: none
Published August 2013
DOI: 10.3310/hta17340
This report should be referenced as follows:
Shepherd J, Jones J, Frampton GK, Bryant J, Baxter L, Cooper K. Clinical effectiveness and cost-
effectiveness of depth of anaesthesia monitoring (E-Entropy, Bispectral Index and Narcotrend): a
systematic review and economic evaluation. Health Technol Assess 2013;17(34).
Health Technology Assessment is indexed and abstracted in Index Medicus/MEDLINE, Excerpta
Medica/EMBASE, Science Citation Index Expanded (SciSearch®) and Current Contents®/
Clinical Medicine.

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DOI: 10.3310/hta17340 HealtH tecHnOlOgy assessment 2013 VOl. 17 nO. 34
Abstract
Clinical effectiveness and cost-effectiveness of depth of
anaesthesia monitoring (E-Entropy, Bispectral Index and
Narcotrend): a systematic review and economic evaluation
J Shepherd,* J Jones, GK Frampton, J Bryant, L Baxter and K Cooper
Southampton Health Technology Assessments Centre (SHTAC), University of Southampton,
Southampton, UK
*Corresponding author
Background: It is important that the level of general anaesthesia (GA) is appropriate for the individual
patient undergoing surgery. If anaesthesia is deeper than required to keep a patient unconscious, there
might be increased risk of anaesthetic-related morbidity, such as postoperative nausea, vomiting and
cognitive dysfunction. This may also prolong recovery times, potentially increasing health-care costs. If
anaesthesia is too light, patients may not be fully unconscious and could be at risk of
intraoperative awareness.
Objective: The objective of this report is to assess the clinical effectiveness and cost-effectiveness of
Bispectral Index (BIS), E-Entropy and Narcotrend technologies, each compared with standard clinical
monitoring, to monitor the depth of anaesthesia in surgical patients undergoing GA.
Data sources: A search strategy was developed and run on a number of bibliographic electronic
databases including MEDLINE, EMBASE, The Cochrane Library and the Health Technology Assessment
(HTA) database. For the systematic review of patient outcomes, databases were searched from the
beginning of 2009 to November 2011 for studies of BIS (and then updated in February 2012), and from
1995 to November 2011 (and then updated in February 2012) for studies of E-Entropy and Narcotrend.
For the systematic review of cost-effectiveness, searches were from database inception to November 2011
(an update search was performed in February 2012).
Review methods: The systematic review of patient outcomes followed standard methodology for
evidence synthesis. A decision-analytic model was developed to assess the cost-effectiveness of depth of
anaesthesia monitoring compared with standard clinical observation. A simple decision tree was
developed, which accounted for patients’ risk of experiencing short-term anaesthetic-related complications
in addition to risk of experiencing intraoperative awareness.
Results: Twenty-two randomised controlled trials comparing BIS, E-Entropy and Narcotrend with standard
clinical monitoring were included in the systematic review of patient outcomes, alongside evidence from a
recent Cochrane review. Six trials of patients classified with risk factors for intraoperative awareness were
combined in a fixed-effect meta-analysis. The overall pooled Peto’s odds ratio was 0.45 (95% confidence
interval 0.25 to 0.81) in favour of BIS. However, there was statistically significant heterogeneity. The base-
case cost per quality-adjusted life-year (QALY) for BIS compared with standard clinical monitoring ranged
from £22,339 to £44,198 depending on patient subgroups (type of GA received; level of risk for
awareness). For E-Entropy, base-case estimates ranged from £14,421 to £31,430. For Narcotrend,
estimates varied from a cost per QALY of £8033 to Narcotrend dominating standard clinical monitoring.
© Queen’s Printer and Controller of HMSO 2013. This work was produced by Shepherd et al. under the terms of a commissioning contract issued by the Secretary of State
for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals v
provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be
addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science
Park, Southampton SO16 7NS, UK.
abstract
Limitations: The analysis was limited by lack of clinical effectiveness data, particularly for E-Entropy
and Narcotrend.
Conclusions: The available evidence on the impact of the technologies on reducing the likelihood of
intraoperative awareness is limited. However, there were reductions in general anaesthetic consumption
and anaesthetic recovery times. The cost-effectiveness of depth of anaesthesia monitoring appears to be
highly dependent on a number of factors, including probability of awareness.
Study registration: PROSPERO registration number CRD42011001834.
Funding: The National Institute for Health Research Health Technology Assessment programme.
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NIHR Journals Library www.journalslibrary.nihr.ac.uk
DOI: 10.3310/hta17340 HealtH tecHnOlOgy assessment 2013 VOl. 17 nO. 34
Contents
List of abbreviations ix
Scientific summary xi
Chapter 1 Background and definition of the decision problem 1
Condition and aetiology 1
Description of technologies under assessment 4
Comparators 7
Care pathways 7
Summary of the decision problem 7
Chapter 2 Assessment methods 9
Systematic review of patient outcomes 9
Systematic review of cost-effectiveness 11
Economic evaluation 12
Chapter 3 Assessment results 15
Results of systematic review of patient outcomes 15
Results of systematic review of cost-effectiveness 53
Model structure, model parameterisation and results of economic evaluation 56
Chapter 4 Assessment of factors relevant to the NHS and other parties 119
Chapter 5 Discussion 121
Statement of principal findings 121
Strengths and limitations of the assessment 132
Uncertainties 134
Chapter 6 Conclusions 137
Implications for service provision 137
Suggested research priorities 137
Acknowledgements 139
References 141
Appendix 1 Report methods for synthesis of evidence of clinical effectiveness and
cost-effectiveness as described in the research protocol 151
Appendix 2 Literature search strategies 155
Appendix 3 Inclusion/exclusion worksheet used in systematic review of patient
outcomes 161
Appendix 4 Reasons for the exclusion of full-text publications from systematic review
of patient outcomes 163
© Queen’s Printer and Controller of HMSO 2013. This work was produced by Shepherd et al. under the terms of a commissioning contract issued by the Secretary of State
for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals vii
provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be
addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science
Park, Southampton SO16 7NS, UK.
cOntents
Appendix 5 Data extraction and critical appraisal forms used in the systematic
review of patient outcomes 165
Appendix 6 Data extraction and critical appraisal forms used in the systematic
review of cost-effectiveness 245
Appendix 7 Studies excluded from the review of economic evaluations 251
Appendix 8 Pooled intravenous anaesthetic consumption for Narcotrend randomised
controlled trials 253
Appendix 9 Derivation of the pooled estimates of cumulative incidence of awareness
used in the model 257
Appendix 10 Survival modelling methodology 259
Appendix 11 Search strategy to identify utility values for post-traumatic stress
disorder 261
Appendix 12 Ongoing trials identified 263
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