COST-EFFECTIVENESS OF PROPHYLACTIC PERIOPERATIVE BETA-BLOCKERS USE IN PATIENTS UNDERGOING CARDIAC OR HIGH-RISK NON-CARDIAC SURGERY

Purpose: Prevention of early postoperative cardiovascular complications is a major issue for patients undergoing cardiac and high-risk non-cardiac surgery. The administration of perioperative beta-blockers in those patients could prevent those cardiovascular complications, however the recommendation remains controversial especially for non-cardiac surgery where the larger positive trials are now discredited. Here we evaluate the cost-effectiveness of perioperative beta-blockers (PBB) use in cardiac and high-risk non-cardiac surgery (defined as extensive abdominal surgery, neurosurgery, organ transplantation or abdominal aorta surgery)

   Methods: A decision tree was modeled in TreeAge Pro^®. Effectiveness was calculated as the likelihood of complications and deaths avoided. Complication outcomes were evaluated during hospitalization; death was evaluated up to 30 days postoperatively. Effectiveness data were obtained from peer-reviewed publications (excluding all discredited studies). Costs were calculated using a third payer perspective, including hospital costs and physician reimbursement, using Healthcare Cost and Utilization Project (HCUP) and Centers for Medicare and Medicaid Services (CMS) data. The incremental cost-effectiveness ratio (ICER) was calculated, and the variables impacting the ICER were ranked through one-way sensitivity analysis. A Monte Carlo simulation was used to model the uncertainty surrounding the variables with 5000 samples. Deterministic sensitivity analysis was performed challenging the probability assumptions in the beta-blockers group.

   Results: In the base-case, PBB dominated the no-PBB strategy for patients undergoing cardiac surgery and patients undergoing high-risk non-cardiac surgery, with lesser costs (-$2404.69 and -$1633.39) and higher effectiveness (0.18 and 0.08 less overall event rate), respectively. In one-way sensitivity analyses, PBB dominated no-PBB across all parameter values except when the probability of having ventricular arrhythmias in the PBB group was greater than 17.9% (base case 11%) in patients undergoing high-risk non-cardiac surgery. In the Monte Carlo simulation the use of PBB was cost saving in 91% patients with high-risk non-cardiac surgery and in of 100% patients with cardiac surgery. The use of PBB would be no longer dominant in patients with high-risk non-cardiac surgery if the probability of death increased to 12.6% (base case 2.4%), supraventricular arrhythmias to 23.4% (base case 6.5%), cerebrovascular events to 13.1% (base case 1.9%) or myocardial infarction to 15.1% (base case 6.6%)

   Conclusion: Perioperative beta-blocker use appears to be a cost saving strategy for prevention of surgery-related cardiovascular adverse events in patients undergoing cardiac and high-risk non-cardiac surgery.