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Abstract

Introduction: A meta-analyses of six RCTs (1,235 pts) comparing a benzodiazepine (BZ) (lorazepam or midazolam) vs. a non-BZ (dexmedetomidine or propofol) sedative regimen in non-cardiac surgery, critically ill adults found that non-BZ sedation was associated with a shorter duration of mechanical ventilation (MV) (1.9 less days (d); p < 0.00001) and ICU length of stay (1.62 less d, p=0.0007) but a similar prevalence of delirium and short-term mortality rate (CCM 2013;41:S30). Methods: A CE analysis, from both an administrator & third party payer perspective and including medical, critically ill adults requiring ≥1d MV and administered either a BZ or non-BZ sedative, cycled health states and costs daily using a Markov model that accounted for daily MV need until ICU discharge. Transition probabilities were obtained from the meta-analysis and costs were estimated as follows: 1) One ICU d (CCM 2005;33:1266) inflated to 2012 $US using medical CPI and based on continued need for MV [MV (d1 $6,848; ≥ d2 $4,797); no-MV(≥ d2 $3,585)] and 2) sedative drug cost [infusion time x mean dose/pt (from the 6 studies) and then weighted by the # of pts per study x average AWP]. Sensitivity analyses were run for all extubation and ICU discharge probabilities (0 to1) and for varying cost estimates. Results: When a non-BZ rather than BZ sedation regimen was used, the incremental CE ratio to avert 1d in the ICU (while MV) or 1d in the ICU (while either MV or non-MV) was $3,406 and $3,136, respectively. The base-case analysis revealed, over the course of an ICU stay, that use of a non-BZ sedative (vs. a BZ sedative) resulted in higher drug costs ($1,327 vs. $65) but lower total ICU costs (% accounted for MV need): $35,380 (71.0%) vs. $45,394 (70.6%). Sensitivity analysis revealed that a BZ strategy would only be less costly if the daily rate of extubation was ≥ 16% and the overall rate of successful ICU discharge without MV was ≥ 77%. Conclusions: Despite its higher acquisition cost, a non-BZ sedative strategy appears to have a more favorable CE ratio for MV, critically ill adults than a BZ sedative strategy over most cost estimates.