Intensive care is not expensive compared with other treatments

Editor—The article by Bennett and Bion in the ABC of Intensive Care contains one statement that should not go unchallenged—that “intensive care is expensive.”¹ This is true only at the most simple level unless comparisons are made with other treatments.

The internal evidence of Bennett and Bion’s review is that an absolute risk reduction of 50% is possible, at least in polio, when comparing intensive care with isolated “iron lung” treatment. Such an absolute risk reduction means that only two patients had to be treated to get a survivor who would otherwise have died.

No randomised controlled trials have been done to show the advantage of intensive care versus non-intensive care treatment in the United Kingdom for severe illness.² There seems to be a consensus that it does work and that such trials would be unethical.

If we guess that modern intensive care can produce only a 20% absolute risk reduction, use the higher figure of £1800 a day in intensive care, and take an average stay of five days rather than the median of two given in the article then the cost per extra survivor is £45 000.

A trial of the prevention of coronary heart disease with pravastatin in men with hypercholesterolaemia showed that 200 men would have to take the drug for five years for one additional life to be saved.³ Taking the price of a typical statin at its lowest dose as advertised in the BMJ, this would cost £226 560 per additional survivor. Proof of effect of controlling hypertension on mortality is also rare. One five year trial showed a number needed to treat for five years of 774⁴; if enalapril is chosen as the treatment the cost per life saved is £36 300, not very different from that for intensive care.

Thus intensive care compares well with other treatments in the United Kingdom.