Cost-effectiveness of α₂ agonists for intravenous sedation in patients with critical Illness

Abstract

IMPORTANCE Propofol and the α2 agonists dexmedetomidine and clonidine are used for sedation in patients with critical illness receiving mechanical ventilation. Evidence about thecosteffectiveness of intravenous (IV) sedation with these medications is lacking.

OBJECTIVE To investigate the cost-effectiveness of dexmedetomidine-, clonidine-, and propofolbased IV sedation in patients with critical illness receiving mechanical ventilation.

DESIGN, SETTING, AND PARTICIPANTS This economic evaluation used within-trial cost-utility analysis with a 6-month time horizon comparing dexmedetomidine-, clonidine-, and propofol-basedIV sedation from a UK National Health Service and Personal Social Services perspective, with individual-level data collected from the Alpha 2 Agonists for Sedation to Produce Better OutcomesFrom Critical Illness (A2B) trial. Adults with critical illness receiving mechanical ventilation, with ananticipated total requirement for mechanical ventilation of at least 2 days, from 41 intensive careunits in the UK were included. Recruitment ran from December 2018 through October 2023; the lastvdate of follow-up was December 10, 2023.

INTERVENTIONS Dexmedetomidine, clonidine, or propofol IV sedation. Patients receiving α2agonists were permitted to receive supplemental propofol to achieve the target sedation score ifrequired.

MAIN OUTCOMES AND MEASURES Incremental costs and quality-adjusted life years (QALYs)gained between dexmedetomidine-based vs propofol-based and clonidine-based vs propofol-basedIV sedation were assessed. Mean net monetary benefits with each medication were assessed.

RESULTS Among 1404 adults with critical illness receiving mechanical ventilation (mean [SD] age,59.2 [14.9] years; 901 male [64.2%]), the mean (SD) Acute Physiology and Chronic Health Evaluation(APACHE) II score was 20.3 (8.2). The incremental cost for dexmedetomidine vs propofol was $1273(95% CI, −$5000 to $7545), and for clonidine vs propofol, it was −$1328 (−$7114 to $4459). Fordexmedetomidine vs propofol, there were 0.0008 QALYs (95% CI, −0.0198 to 0.0214 QALYs)gained, and for clonidine vs propofol, there were −0.0019 QALYs (95% CI, −0.0221 to 0.0181 QALYs)gained. Mean net monetary benefits for dexmedetomidine, clonidine, and propofol were −$53 278(95% CI, −$58 063 to −$48 493), −$50 882 (95% CI, −$55 003 to −$46 762), and −$52 036 (95% CI,−$56 230 to −$47 834), respectively, at a maximum willingness to pay for a QALY of $16 250.

CONCLUSIONS AND RELEVANCE In this study, dexmedetomidine-, clonidine-, and propofol-basedIV sedation in patients with critical illness receiving mechanical ventilation had similar costs andQALYs. These findings suggest that economic considerations should not affect which sedative thesepatients receive.

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Identifiers

ORCID for Cathrine McKenzie: orcid.org/0000-0002-5190-9711

ORCID for Ahilanandan Dushianthan: orcid.org/0000-0002-0165-3359

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