Cost-Benefit Analysis of Maintaining a Fully Stocked Malignant Hyperthermia Cart Versus an Initial Dantrolene Treatment Dose for Maternity Units

Abstract

Background: The Malignant Hyperthermia Association of the United States recommends that dantrolene be available for administration within 10 minutes. One approach to dantrolene availability is a malignant hyperthermia cart, stocked with dantrolene, other drugs and supplies. However, this may not be of cost-benefit for maternity units, where triggering agents are rarely used. Methods: We performed a cost-benefit analysis of maintaining a malignant hyperthermia cart vs an initial dantrolene dose of 250 mg on every maternity unit in the United States. We used a decision tree model to estimate the expected number of lives saved and compared this benefit against the expected costs of the policy. Results: We found that maintaining a malignant hyperthermia cart in every maternity unit in the United States would reduce morbidity and mortality costs by $3,304,641 per year nationally but would cost $5,927,040 annually. Sensitivity analyses showed that our results were largely driven by the extremely low incidence of general anesthesia. If cesarean delivery rates in the United States remained at 32% of all births, the general anesthetic rate would have to be greater than 11% to achieve cost-benefit. The only cost effective strategy is to keep a 250 mg dose of dantrolene on the unit for starting therapy. Conclusions: It is not of cost-benefit to maintain a fully stocked malignant hyperthermia cart with a full supply of dantrolene within 10 minutes of maternity units. We recommend that hospitals institute alternative strategies (e.g. maintain a small supply of dantrolene on the maternity unit for starting treatment).

Prevalence of malignant hyperthermia diagnosis in obstetric patients in the United States, 2003 to 2014

“…This recommendation also applies to facilities where volatile agents are not available or administered, and succinylcholine is only stocked on site for emergency purposes [3]. The cost of an MH cart in maternity unit for responding to MH crisis has been estimated at about $2000 per year, including cost for the dantrolene itself, cost for the cart and non-dantrolene items, and cost for MH cart maintenance [10]. Ho et al have recently questioned this recommendation based on cost-benefit analysis of stocking dantrolene in maternity units [10].…”

“…The cost of an MH cart in maternity unit for responding to MH crisis has been estimated at about $2000 per year, including cost for the dantrolene itself, cost for the cart and non-dantrolene items, and cost for MH cart maintenance [10]. Ho et al have recently questioned this recommendation based on cost-benefit analysis of stocking dantrolene in maternity units [10]. The low incidence of MH crisis and the low utilization of general anesthesia and triggering agents in obstetrics would not make stocking dantrolene policy cost-beneficial.…”

“…Reported prevalence of MH diagnosis in studies using hospital discharge records from administrative data ranges from 0.18 per 100,000 (95% confidence interval (CI), 0.12-0.25) in ambulatory surgery center patients to 0.96 (95% CI, 0.75-1.41) in surgical inpatients [8,9]. The low frequency of MH crises and the cost of stocking dantrolene have given rise to concern about the cost-benefit of the recommendation of the Malignant Hyperthermia Association of the United States (MHAUS) that dantrolene be made immediately available (for administration within 10 min) in operating room areas, especially in facilities with a low utilization of general anesthesia and triggering agents such as maternity units [10,11]. MHAUS is a patient safety and advocacy organization and its recommendations are used by accrediting agencies, such as the Joint Commission, to assess preparedness for an MH event during survey visits.…”