Economic analysis of high-flow nasal oxygen compared with noninvasive ventilation in patients with acute respiratory failure: results from the RENOVATE randomized clinical trial.

CONTEXT: High-flow nasal oxygen (HFNO) and noninvasive ventilation (NIV) are commonly used for patients with acute respiratory failure (ARF). The RENOVATE trial previously established its clinical noninferiority.

OBJECTIVE

To assess the incremental cost of HFNO compared to NIV across four ARF groups: nonimmunocompromised with hypoxemia, chronic obstructive pulmonary disease exacerbation, acute cardiogenic pulmonary edema, and hypoxemic COVID-19.

METHODS

A cost-minimization analysis was conducted using primary outcome data, probabilities, and cost inputs from the RENOVATE trial. Direct costs were estimated using a combination of macro- and micro-costing approaches. The clinical outcome was progression to mechanical ventilation or death within 7 days. A 90-day decision-tree model compared intervention costs across disease categories. Sensitivity analyses evaluated the influence of individual parameters on outcomes.

RESULTS

Among 1800 patients enrolled across 33 Brazilian sites, 1716 were included in the primary analysis (883 in each arm). HFNO was associated with estimated cost savings in three groups: nonimmunocompromised hypoxemic patients (-$5105; 95 % CI -51,257 to 41,378), COPD (-$1267; 95 % CI -49,088 to 76,636), and cardiogenic pulmonary edema (-$2493; 95 % CI 28,682 to 21,596). However, for hypoxemic COVID-19 patients, HFNO incurred higher costs (+$4388; 95 % CI -56,174 to 69,640). Sensitivity analyses identified intubation rate, mortality, and ICU stay as key cost drivers.

CONCLUSION

HFNO demonstrated economic neutrality in non-COVID-19 ARF groups compared to NIV. No economic advantage was seen for COVID-19 patients. Cost-effectiveness should be considered alongside patient-specific clinical factors for optimal treatment decisions.