Economic evaluation of propofol and lorazepam for critically ill patients undergoing mechanical ventilation*

Abstract

Objective-The economic implications of sedative choice in the management of patients receiving mechanical ventilation are unclear because of differences in costs and clinical outcomes associated with specific sedatives. Therefore, we aimed to determine the cost-effectiveness of the most commonly used sedatives prescribed for mechanically ventilated critically ill patients.Design, Setting, and Patients-Adopting the perspective of a hospital, we developed a probabilistic decision model to determine if continuous propofol or intermittent lorazepam was associated with greater value when combined with daily awakenings. We also evaluated the comparative value of continuous midazolam in secondary analyses. We assumed that patients were managed in a medical intensive care unit and expected to require ventilation for at least 48 hours. Author contributions:Christopher Cox: Final approval, concept and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript, statistical analysis, obtaining funding, administrative support, and supervision. Shelby Reed: Final approval, concept and design, analysis and interpretation of data, critical revision of the manuscript, and administrative, technical, or material support. Joseph Govert: Final approval, concept and design, analysis and interpretation of data, critical revision of the manuscript, administrative support, and supervision. Jo Ellen Rodgers: Final approval, conception and design, acquisition of data, analysis and interpretation of data, critical revision of the manuscript, obtaining funding, and supervision. Stacy Campbell-Bright: Final approval, acquisition of data, analysis and interpretation of data, critical revision of the manuscript, and administrative support. John Kress: Final approval, concept and design, acquisition of data, drafting of the manuscript, obtaining funding, administrative support, critical revision of the manuscript, and supervision. Shannon Carson: Final approval, concept and design, acquisition of data, analysis and interpretation of data, obtaining funding, critical revision of the manuscript, and supervision. NIH Public AccessAuthor Manuscript Crit Care Med. Author manuscript; available in PMC 2009 October 19. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptModel inputs were derived from primary analysis of randomized controlled trial data, medical literature, Medicare reimbursement rates, pharmacy databases, and institutional data.Main Results-We measured cost-effectiveness as costs per mechanical ventilator-free day within the first 28 days after intubation. Our base-case probabilistic analysis demonstrated that propofol dominated lorazepam in 91% of simulations and, on average, was both $6,378 less costly per patient and associated with over three additional mechanical ventilator-free days. The model did not reveal clinically meaningful differences between propofol and midazolam on costs or measures of effectiveness.Conclusion-Propofol ...

The pharmacology of oversedation in mechanically ventilated adults

“…For example, although both propofol and dexmedetomidine have acquisition costs far higher than that of the benzodiazepines, recent pharmacoeconomic analyses have demonstrated that propofol and dexmedetomidine therapy is actually cheaper when each is compared with benzodiazepine therapy [39 ,40]. In fact, one recent cost-effectiveness analysis demonstrated that propofol dominated scheduled intermittent lorazepam in 91% of simulations and, on average, was $6378 less costly per patient [39 ]. In the MENDS trial, despite the higher acquisition cost of dexmedetomidine compared to lorazepam, the overall pharmacy, respiratory, ICU, and hospital costs were approximately equal between groups [7 ].…”

Sedation in the intensive care setting

“…When compared with benzodiazepines, propofol has been shown to increase duration at target arousal level, reduce cost per patient, and decrease time spent on mechanical ventilation 60–62,68. A meta-analysis comparing propofol to alternate sedation regimens for medium to long-term sedation demonstrated a decreased ICU length of stay that was significant when compared with the long-acting benzodiazepines (diazepam, lorazepam) but not when compared with the shorter- acting midazolam 69.…”

Understanding health economic analysis in critical care

“…In a study by Dasta et al [38 ], a comparison of dexmedetomidine to propofol or remifentanil may also have been informative, as both propofol and remifentanil are rapidly cleared and may shorten duration of mechanical ventilation, and both are less costly than dexmedetomidine [44,45].…”