COST-EFFECTIVENESS OF PROPOFOL VS DEXMEDETOMIDINE FOR MILD TO MODERATE SEDATION DURING MECHANICAL VENTILATION

Purpose:

   This study addresses the cost-effectiveness of propofol versus dexmedetomidine for sedation during mechanical ventilation, and identifies the delirium reduction threshold required by dexmedetomidine to impact its cost-effectiveness.

   Sedation is often required for patients receiving mechanical ventilation (MV). Current evidence supports lighter sedation for patient comfort without negatively impacting recovery. Psychometric scales, such as the Richmond Agitation-Sedation Scale (RASS), are used for titration of sedatives; with time at target RASS (TAT-RASS) representing a measure of patient comfort and sedation effectiveness.

   Propofol and dexmedetomidine are effective in terms of maintaining TAT-RASS during MV. Dexmedetomidine also reduces time to extubation when compared to propofol. However, despite the recent introduction of generic formulations, dexmedtomidine is more expensive. This raises the question of which sedative is most cost-effective for mild to moderate sedation during MV. Additionally the emerging distinction between transient and persistent delirium (seemingly minor clinical impact versus costly and severe, respectively), further compounds the debate on the effect (if any), of dexmedetomidine on delirium. Expectedly, a proven reduction in delirium could impact its cost-effectiveness.

Method:

   A decision analytic model was used from the hospital perspective to compare the relative cost-effectiveness using propofol versus dexmedetomidine for sedation in terms of TAT-RASS. Costs and effects for each drug, including adverse events, were abstracted from primary and secondary data sources. Deterministic and probabilistic sensitivity analysis was performed to test robustness of the model to variability in population and parameter values, including delirium reduction thresholds. 

Result:

   At base case estimates, propofol is cost-effective at $783.66/day TAT-RASS. Dexmedetomidine was dominated at $925.80/day TAT-RASS. Results were sensitive to drug cost, patient weight, duration of sedation, and rate of ineffectiveness. Assuming transient delirium results in 12 additional hours of MV, dexmedetomidine would have to yield a reduction of >2% in baseline transient delirium rate for it to be considered cost-effective.

Conclusion:

   Propofol is a cost-effective sedative for mild to moderate sedation during MV. Despite the price reduction with generic dexmedetomidine, the reported clinical advantage of reduced intubation time is insufficient to impact its cost-effectiveness. As demonstrated by the sensitivity analysis, dexmedetomidine would become a cost-effective option if its price was to further decrease or if research delineated a role in reducing delirium.