ClinicoEconomics and Outcomes Research (Nov 2017)
Propofol or benzodiazepines for short- and long-term sedation in intensive care units? An economic evaluation based on meta-analytic results
Abstract
Lorenzo Pradelli,1 Massimiliano Povero,1 Hartmut Bürkle,2 Tim-Gerald Kampmeier,3 Giorgio Della-Rocca,4 Astrid Feuersenger,5 Jean-Francois Baron,6 Martin Westphal5 1AdRes HE&OR, Torino, Italy; 2Department of Anaesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, 3Clinic for Anesthesiology and Surgical Intensive Care Medicine, University Hospital Münster, Münster, Germany; 4Department of Anaesthesia and Intensive Care Medicine, Medical School of the University of Udine, Udine, Italy; 5Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany; 6Fresenius Kabi ELAMA, Paris Cedex, France Purpose: This evaluation compares propofol and benzodiazepine sedation for mechanically ventilated patients in intensive care units (ICUs) in order to identify the potential economic benefits from different payers’ perspectives. Methods: The patient-level simulation model incorporated efficacy estimates from a structured meta-analysis and ICU-related costs from Italy, Germany, France, UK, and the USA. Efficacy outcomes were ICU length of stay (LOS), mechanical ventilation duration, and weaning time. We calculated ICU costs from mechanical ventilation duration and ICU LOS based on national average ICU costs with and without mechanical ventilation. Three scenarios were investigated: 1) long-term sedation >24 hours based on results from randomized controlled trials (RCTs); 2) long-term sedation based on RCT plus non-RCT results; and 3) short-term sedation <24 hours based on RCT results. We tested the model’s robustness for input uncertainties by deterministic (DSA) and probabilistic sensitivity analyses (PSA).Results: In the base case, mean savings with propofol versus benzodiazepines in long-term sedation ranged from €406 (95% confidence interval [CI]: 646 to 164) in Italy to 1,632 € (95% CI: 2,362 to 880) in the USA. Inclusion of non-RCT data corroborated these results. Savings in short-term sedation ranged from €148 (95% CI: 291 to 2) in Italy to €502 (95% CI: 936 to 57) in the USA. Parameters related to ICU and mechanical ventilation had a stronger influence in the DSA than drug-related parameters. In PSA, propofol reduced costs and ICU LOS compared to benzodiazepines in 94%–100% of simulations. The largest savings may be possible in the UK and the USA due to higher ICU costs.Conclusion: Current ICU sedation guidelines recommend propofol rather than midazolam for mechanically ventilated patients. This evaluation endorses the recommendation as it may lead to better outcomes and savings for health care systems, especially in countries with higher ICU-related costs. Keywords: critically ill patients, mechanical ventilation, anesthetics, length of stay, costs, health care system
