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Remifentanil vs conventional sedation in The Netherlands: a pharmacoeconomic model analysis

Introduction

The goal of this study was to compare the duration of mechanical ventilation (MV), the length of stay (LOS) and the direct medical costs of remifentanil-based sedation (RS) vs conventional sedation (CS) in ICU patients requiring MV.

Methods

A Markov model was developed based on UltiSAFE, a recent Dutch open-label randomized controlled study that included patients with an expected MV time of 2–3 days. Study medication was either CS (morphine or fentanyl combined with propofol, midazolam or lorazepam according to Dutch guidelines) or RS (remifentanil, combined with propofol when required). The LOS on the ICU, the time at which the patient was eligible for weaning or extubation and the actual time of weaning and extubation, plus all study drugs with all adjustments in dosage, were recorded. The model describes the patient flow on the ICU. Three states were defined: MV before weaning, MV after weaning has started before extubation, post-MV before discharge. At every hour, patients either stay at the current state, move to the next state or die. Transition probabilities and the costs of the study drugs were derived from UltiSAFE, whereas all other direct medical costs on the ICU were estimated in a separate Dutch monocenter micro-costing study. All costs were measured from the hospital perspective with 2006 as the reference year. The time horizon used in the model was 28 days.

Results

From the trial data, it was estimated that the costs of RS on MV before the start of weaning amount to €22 per hour, compared with €15 for the CS treatment. After the start of weaning, these costs decrease to €8 per hour for RS and €2 per hour for CS. The LOS on the ICU was 9.2 days in the CS group vs 8.1 days in the RS group (difference 1.1, 95% CI 0.6–1.5), whereas the length of time on MV was 6.3 days and 5.2 days, respectively, with a difference of 1.1 day (95% CI 0.6–1.6). The average total 28-day costs were €15,911 in the CS group vs €14,855 in the RS group, resulting in RS related cost-savings of €1,056 (95% CI €58–2,054).

Conclusion

Compared with CS, RS seems to be the preferred regimen for patients with an expected MV time of 2–3 days. It not only significantly decreases the length of ICU stay and the total costs but also significantly reduces the duration of MV, which is a risk factor for ventilator-associated morbidity.

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Al, M., Hakkaart, L., Tan, S. et al. Remifentanil vs conventional sedation in The Netherlands: a pharmacoeconomic model analysis. Crit Care 11, P427 (2007). https://0-doi-org.brum.beds.ac.uk/10.1186/cc5587

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Keywords

  • Morphine
  • Mechanical Ventilation
  • Fentanyl
  • Midazolam
  • Remifentanil