Modeling the costs and benefits of capnography monitoring during procedural sedation for gastrointestinal endoscopy

Rhodri Saunders, Mary Erslon, John Vargo, Rhodri Saunders, Mary Erslon, John Vargo

Abstract

Background and study aims: The addition of capnography to procedural sedation/analgesia (PSA) guidelines has been controversial due to limited evidence of clinical utility in moderate PSA and cost concerns.

Patients and methods: A comprehensive model of PSA during gastrointestinal endoscopy was developed to capture adverse events (AEs), guideline interventions, outcomes, and costs. Randomized, controlled trials and large-scale studies were used to inform the model. The model compared outcomes using pulse oximetry alone with pulse oximetry plus capnography. Pulse oximetry was assumed at no cost, whereas capnography cost USD 4,000 per monitor. AE costs were obtained from literature review and Premier database analysis. The model population (n = 8,000) had mean characteristics of age 55.5 years, body mass index 26.2 kg/m(2), and 45.3 % male.

Results: The addition of capnography resulted in a 27.2 % and 18.0 % reduction in the proportion of patients experiencing an AE during deep and moderate PSA, respectively. Sensitivity analyses demonstrated significant reductions in apnea and desaturation with capnography. The median (95 % credible interval) number needed to treat to avoid any adverse event was 8 (2; 72) for deep and 6 (-59; 92) for moderate. Reduced AEs resulted in cost savings that accounted for the additional upfront purchase cost. Capnography was estimated to reduce the cost per procedure by USD 85 (deep) or USD 35 (moderate).

Conclusions: Capnography is estimated to be cost-effective if not cost saving during PSA for gastrointestinal endoscopy. Savings were driven by improved patient safety, suggesting that capnography may have an important role in the safe provision of PSA.

Conflict of interest statement

Competing interests: Rhodri Saunders was a full-time employee of Ossian Health Economics and Communications (Basel, Switzerland), which received consultancy fees for work developing the health econnomic model. Rhodri is now director of Coreva Scientific GmbH & Co. KG. (Freiburg, Germany), which has consultancy contracts with Medtronic Inc. Mary Erslon is a full-time employee of Medtronic Inc. John Vargo is a physician who has consulted for multiple medical devices and pharmaceutical companies. Dr Vargo received no payment for work on this research project or manuscript.

Figures

Fig. 1
Fig. 1
Overview of the model structure. The model runs on a cohort basis. Based on study data, a proportion of patients will experience a model outcome. The likelihood of events is provided for the standard-of-care arm, with an odds ratio used to estimate the likelihood of events in the capnography arm. Adverse events, rescue medication, and death are all assumed to take place during the procedure and can impact on the procedure time, while presence of events can influence recovery time.
Fig. 2
Fig. 2
Assessing outcomes in the cohort using a decision tree. p[N] is the probability of the outcome, where N is the number of the transition in question. In this example, not all possible transitions and trees are shown.
Fig. 3
Fig. 3
Median (95 % credible interval) cost saving associated with capnography monitoring under different scenarios, n = 5,000 simulations for each. Negative cost savings reflect a cost increase.Abbreviations: AE, adverse event; ASA, American Society for Anesthesia; BMI, body mass index; USD, United States Dollar.
Figure S1
Figure S1
Cost items that influence the cost saving with capnography by ≥ 10 %.

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