Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation

Abstract

Introduction: Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation.

Methods: The total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only.

Results: Based on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs-€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)-and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam).

Conclusions: From an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation.

Trial registration: ClinicalTrials.gov NCT00479661 (PRODEX), NCT00481312 (MIDEX).

Figures

Figure 1

The likelihood of dexmedetomidine (D) to result in lower total intensive care unit costs than pooled standard care sedatives (SC), assessed by bootstrapping. As indicated by the black circle, the likelihood that dexmedetomidine results in lower total intensive care unit costs than the standard sedatives is 91.0%.

Figure 2

Impact of the underlying mean intensive care unit (ICU) daily cost level on the total ICU cost difference between dexmedetomidine (D) and standard care (SC). The three ICU period-specific daily costs were varied up or down from the base case values that reflected an overall mean cost of €1,702 per ICU day (triangle). Alternative period-specific unit costs reflecting a mean cost range between €500 and €3,100 per ICU day were tested. Negative values indicate lower costs on dexmedetomidine. For a conservative approach, the standard sedative acquisition costs were set to zero.