A micro-costing study: comparing a standard intravenous patient-controlled analgesia system with a novel sublingual patient-controlled analgesia system.

BACKGROUND: Judicious spending in healthcare is of paramount importance, particularly when introducing new devices or interventions. These products or interventions need to be economically efficient both directly and indirectly. An accepted method of cost estimation is micro-costing. Micro-costing involves direct enumeration and costing of every input consumed in the treatment of a particular patient when using new device, medicine or intervention. In our study, we investigated the cost of using a novel sublingual (SL) patient-controlled analgesia (PCA) device and compared it with our conventional intravenous (IV) PCA device. METHODS: A previous study performed in our institution produced a cost per use of IV PCA device at €97. This compared with a previous European study published in this journal in 2010 which showed a similar figure of €96 per use of IV PCA device. In our comparative study, we used a case record form (CRF) to incorporate a cost to all consumables used, staff time and equipment used to both the SL PCA and the IV PCA. RESULTS: A total of 60 patients of similar demographic were included in our study. The cost of an IV PCA episode was €97.89 and €182.32 for an SL PCA episode. Standl et al. (2010) showed that the average cost of an IV PCA episode was €96.40 with 78% of this being made up of staff time. SL PCA was more efficacious in certain patient groups and in certain surgical groups. CONCLUSION: After performance of a micro-costing study, the less costly IV PCA episode was statistically significant compared with a SL PCA episode. However, the associated staff costs were less with a SL PCA episode. We performed a micro-costing study on a novel sublingual PCA device and compared it with a conventional intravenous PCA device. All resources were included and compared.

The cost-effectiveness of epidural, patient-controlled intravenous opioid analgesia, or transversus abdominis plane infiltration with liposomal bupivacaine for postoperative pain management.

STUDY OBJECTIVE: Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN: Retrospective cost effectiveness analysis. SETTING: Operating room. PATIENTS: We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS: A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS: A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS: From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of $150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of $10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS: This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.

An economic analysis of patient controlled remifentanil and epidural analgesia as pain relief in labour (RAVEL trial); a randomised controlled trial.

OBJECTIVE: To compare the costs of a strategy of patient controlled remifentanil versus epidural analgesia for pain relief in labour. DESIGN: We performed a multicentre randomised controlled trial in 15 hospitals in the Netherlands, the RAVEL trial. Costs were analysed from a health care perspective alongside the RAVEL trial. POPULATION: Pregnant women of intermediate to high risk beyond 32 weeks gestation who planned vaginal delivery. METHODS: Women were randomised before the onset of labour, to receive either patient controlled remifentanil or epidural analgesia when pain relief was requested during labour. MAIN OUTCOME MEASURES: Primary outcome for effectiveness was satisfaction with pain relief, expressed as the area under the curve (AUC). A higher AUC represents higher satisfaction with pain relief. Here, we present an economic analysis from a health care perspective including costs from the start of labour to ten days postpartum. Health-care utilization was documented in the Case Report Forms and by administering an additional questionnaire. RESULTS: The costs in the patient controlled remifentanil group (n = 687) and in the epidural group (n = 671) were €2900 versus €3185 respectively (mean difference of -€282 (95% CI -€611 to €47)). The (non-significant) higher costs in the epidural analgesia group could be mainly attributed to higher costs of neonatal admission. CONCLUSION: From an economic perspective, there is no preferential pain treatment in labouring intermediate to high risk women. Since patient controlled remifentanil is not equivalent to epidural analgesia with respect to AUC for satisfaction with pain relief we recommend epidural analgesia as the method of choice. However, if appropriately counselled on effect and side effects there is, from an economic perspective, no reason to deny women patient controlled remifentanil.

Medication, equipment, and supply costs for common interventions providing extended post-surgical analgesia following total knee arthroplasty in US hospitals.

AIMS: To estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) required to administer common interventions for post-surgical analgesia after total knee arthroplasty (TKA), including single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, intravenous patient-controlled analgesia (IV PCA), and local infiltration of bupivacaine liposome injectable suspension (BLIS). MATERIALS AND METHODS: This analysis was conducted using a mixed methods approach combining published literature, publicly available data sources, and administrative data, to first identify the materials required to administer these interventions, and then estimate the cost to the hospital of those materials. Medication costs were estimated primarily using the Wholesale Acquisition Costs (WAC), the cost of reusable equipment was obtained from published sources, and costs for disposable supplies were obtained from the US Government Services Administration (GSA) database. Where uncertainty existed about the technique used when administering these interventions, costs were calculated for multiple scenarios reflecting different assumptions. RESULTS: The total cost of materials (i.e. medications, equipment, and supplies) required to provide post-surgical analgesia was $41.88 for sPNB with bupivacaine; $756.57 for cFNB with ropivacaine; $16.38 for periarticular infiltration with bupivacaine, morphine, methylprednisolone, and cefuroxime; $453.84 for continuous epidural analgesia with fentanyl and ropivacaine; $178.94 for IV PCA with morphine; and $319.00 for BLIS. LIMITATIONS: This analysis did not consider the cost of healthcare providers required to administer these interventions. In addition, this analysis focused on the cost of materials and, therefore, did not consider aspects of relative efficacy or safety, or how the choice of intervention for post-surgical analgesia might impact outcomes such as length of stay, re-admissions, discharge status, adverse events, or total hospitalization costs. CONCLUSIONS: This study provided an estimate of the costs to hospitals for materials required to administer commonly used interventions for post-surgical analgesia after TKA.

The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital.

The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.

Minimizing pain medication use and its associated costs following robotic surgery.

INTRODUCTION: Minimally invasive surgery (MIS) has been associated with diminished postoperative pain and analgesia requirements. The objective of the current study was to evaluate the use of analgesia in the post-operative period following robotic surgery for endometrial cancer. METHODS: All consecutive patients who underwent robotic surgery for the treatment of endometrial cancer were included in this study. The timing, dose, and type of analgesics administered postoperatively were recorded from patients' electronic medical record. Data was compared to a matched historical cohort of patients who underwent laparotomy before the introduction of the robotic program. RESULTS: Only eight patients (2.4%, 5 during the first 25 cases and 3 following mini-laparotomy) received patient-controlled analgesia (PCA) following robotic surgery. Most patients' pain was alleviated by over-the-counter analgesics (acetaminophen, non-steroidal anti-inflammatories). In comparison to laparotomy, patients who underwent robotic surgery required significantly less opioids (71mg vs. 12mg IV morphine, p<0.0001) and non-opioids (4810mg vs. 2151mg acetaminophen, 1892 vs. 377mg ibuprofen, and 1470mg vs. 393mg naproxen; all p<0.0001). CONCLUSION: Patients require less analgesics (opioids and non-opioids) following robotic surgery in comparison to conventional laparotomy, including the elderly and the obese. The diminished pain medication use is associated with some cost savings.

Activity-based costing analysis of the analgesic treatments used in postoperative pain management in Italy.

BACKGROUND: The aim of this analysis is to evaluate the costs of 72-hour postoperative pain treatment in patients undergoing major abdominal, orthopedic and thoracic procedures in nine different Italian hospitals, defined as the cumulative cost of drugs, consumable materials and time required for anesthesiologists, surgeons and nurses to administer each analgesic technique. METHODS: Nine Italian hospitals have been involved in this study through the administration of a questionnaire aimed to acquire information about the Italian clinical practice in terms of analgesia. This study uses activity-based costing (ABC) analysis to identify, measure and give value to the resources required to provide the therapeutic treatment used in Italy to manage the postoperative pain patients face after surgery. A deterministic sensitivity analysis (DSA) has been performed to identify the cost determinants mainly affecting the final cost of each treatment analyzed. Costs have been reclassified according to three surgical macro-areas (abdominal, orthopedic and thoracic) with the aim to recognize the cost associated not only to the analgesic technique adopted but also to the type of surgery the patient faced before undergoing the analgesic pathway. RESULTS: Fifteen different analgesic techniques have been identified for the treatment of moderate to severe pain in patients who underwent a major abdominal, orthopedic or thoracic surgery. The cheapest treatment actually employed is the oral administration "around the clock" (€ 8.23), whilst the most expensive is continuous peripheral nerve block (€ 223.46). The intravenous patient-controlled analgesia costs € 277.63. In terms of resources absorbed, the non-continuous administration via bolus is the gold standard in terms of cost-related to the drugs used (€ 1.28), and when administered pro re nata it also absorbs the lowest amount of consumables (€0.58€) compared to all other therapies requiring a delivery device. The oral analgesic administration pro re nata is associated to the lowest cost in terms of health professionals involved (€ 6.25), whilst intravenous PCA is the most expensive one (€ 245.66), requiring a massive monitoring on the part of physicians and nurses. CONCLUSIONS: The analysis successfully collected information about costs of 72-hour postoperative pain treatment in patients undergoing major abdominal, orthopedic and thoracic procedures in all the nine different Italian hospitals. The interview showed high heterogeneity in the treatment of moderate to severe pain after major abdominal, orthopedic and thoracic surgeries among responding anesthesiologists, with 15 different analgesic modalities reported. The majority of the analgesic techniques considered in the analysis is not recommended by any guideline and their application in real life can be one of the reasons for the high incidence of uncontrolled pain, which is still reported in the postoperative period. Health care costs have become more and more important, although the choice of the best analgesic treatment should be a compromise between efficacy and economic considerations.

Epidural versus Patient-Controlled Analgesia after Pediatric Thoracotomy for Malignancy: A Preliminary Review.

Introduction The use of thoracic epidural is standard in adult thoracotomy patients facilitating earlier mobilization, deep breathing, and minimizing narcotic effects. However, a recent randomized trial in pediatric patients who undergo repair of pectus excavatum suggests patient-controlled analgesia (PCA) produces a less costly, minimally invasive postoperative course compared with epidural. Given that thoracotomy is typically less painful than pectus bar placement, we compared the outcomes of epidural to PCA for pain management after pediatric thoracotomy. Methods A retrospective review of 17 oncologic thoracotomies was performed at a children's hospital from 2004 to 2013. Data points included operative details, epidural or PCA use, urinary catheterization, days to regular diet, days to oral pain regimen, postoperative pain scores, length of stay, and anesthesia charges. Patients were excluded if they did not have epidural or PCA following thoracotomy. Results Six thoracotomies were managed with an epidural and 11 with a PCA. Three epidural patients were opiate naïve compared with two with a PCA. The most common indication for thoracotomy was metastatic osteosarcoma (n = 13). When comparing epidural to PCA, there was no significant difference in days to removal of Foley catheter, regular diet, oral pain control, length of stay, or total operating room time. Postoperative pain scores were also comparable. The mean anesthesia charges were significantly higher in patients with an epidural than with a PCA. Conclusion Epidural catheter and PCA provided comparable pain relief and objective recovery course in children who underwent thoracotomy for oncologic disease; however, epidural catheter placement was associated with increased anesthesia charges, suggesting that PCA is a noninvasive, cost-effective alternative.

[Cost minimization analysis in postoperative pain management : economic efficiency and effectiveness of two infusion pump systems]. / Kostenminimierungsanalyse in der postoperativen Schmerztherapie : Wirtschaftlichkeit und Effektivität von 2 Schmerzpumpensystemen.

BACKGROUND: Besides reliable efficacy and patient satisfaction, economic efficiency is becoming increasingly more important in postoperative pain management. AIM: The present study investigated the effectiveness of two pain pump systems and compared the running costs in treatment. MATERIAL AND METHODS: In this study 40 patients received an interscalene catheter prior to shoulder surgery. Postoperative pain management was provided via an electronic pump with patient-controlled analgesia (PCA) or a mechanical pump without PCA. Patients kept a pain log. After treatment they were interviewed about their satisfaction with the pump. In addition drug consumption, nursing material, staff time for handling and maintenance of the pumps and preparation of medications pro re nata were assessed. RESULTS: Postoperative pain levels and patient satisfaction were comparable in both groups. Economically, the electronic pump was more cost-effective than the electronic model for a duration of treatment of 1 and 2 days. With treatment duration of 2 days the costs of both pumps were equivalent; however, the PCA feature of the electronic pump allowed a reduced intake of systemic analgesics on demand. CONCLUSION: Both pain pump systems provide equally effective pain management, while the electronic model caused less costs. Both pumps offer advantages and disadvantages that should be considered based on local circumstantial demands.

Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis.

BACKGROUND/PURPOSE: The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER. METHODS: We searched MEDLINE (1946-2012) and the Cochrane Library (inception-2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively. RESULTS: Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD -1.04, 95% CI -2.11 to 0.03, p=0.06), 12 hours (WMD -1.12; 95% CI -1.61 to -0.62, p<0.001), 24 hours (WMD -0.51, 95%CI -1.05 to 0.02, p=0.06), and 48 hours (WMD -0.85, 95% CI -1.62 to -0.07, p=0.03) after surgery. We found no statistically significant differences between secondary outcomes. CONCLUSIONS: Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.

[Direct cost of connecting, maintaining and disconnecting patient-controlled analgesia pump]. / Custo direto da instalação, manutenção e desligamento da bomba de analgesia.

Quantitative research that aimed to identify the mean total cost (MTC) of connecting, maintaining and disconnecting patient-controlled analgesia pump (PCA) in the management of pain. The non-probabilistic sample corresponded to the observation of 81 procedures in 17 units of the Central Institute of the Clinics Hospital, Faculty of Medicine, University of Sao Paulo. We calculated the MTC multiplying by the time spent by nurses at a unit cost of direct labor, adding the cost of materials and medications/solutions. The MTC of connecting was R$ 107.91; maintenance R$ 110.55 and disconnecting R$ 4.94. The results found will subsidize discussions about the need to transfer money from the Unified Health System to hospitals units that perform this technique of analgesic therapy and it will contribute to the cost management aimed at making efficient and effective decision-making in the allocation of available resources.

Direct cost of connecting, maintaining and disconnecting patient-controlled analgesia pump / Custo direto da instalacao, manutencao e desligamento da bomba de analgesia / Costo directo de la instalacion, mantenimiento y detencion de la bomba de analgesia controlada por el paciente

Quantitative research that aimed to identify the mean total cost (MTC) of connecting, maintaining and disconnecting patient-controlled analgesia pump (PCA) in the management of pain. The non-probabilistic sample corresponded to the observation of 81 procedures in 17 units of the Central Institute of the Clinics Hospital, Faculty of Medicine, University of Sao Paulo. We calculated the MTC multiplying by the time spent by nurses at a unit cost of direct labor, adding the cost of materials and medications/solutions. The MTC of connecting was R$ 107.91; maintenance R$ 110.55 and disconnecting R$ 4.94. The results found will subsidize discussions about the need to transfer money from the Unified Health System to hospitals units that perform this technique of analgesic therapy and it will contribute to the cost management aimed at making efficient and effective decision-making in the allocation of available resources.

Estudio cuantitativo cuyo fue objetivo identificar el costo total promedio (CTM) de la instalación, mantenimiento y detención de la bomba de analgesia controlada por el paciente (PCA) para el manejo del dolor. La muestra no probabilística correspondió a la observación de 81 procedimientos en 17 unidades del Instituto Central del Hospital de las Clínicas de la Facultad de Medicina de la Universidad de São Paulo. Se calculó el CTM multiplicándose el tiempo dedicado por las enfermeras por el costo unitario de la mano de obra directa más el costo de los materiales y medicamentos/soluciones. El CTM de la instalación fue de R$107,91, el del mantenimiento fue de R$ 110,55 y el de la detención de la bomba fue de R$ 4,94. Los resultados pueden contribuir a las discusiones sobre la necesidad de transferir dinero del Sistema Nacional de Salud a las unidades hospitalarias que realizan esta técnica de terapia analgésica y a la gestión de los costos con el fin de favorecer la toma de decisiones eficientes y eficaces respecto al destino de los recursos disponibles.

Pesquisa quantitativa que objetivou identificar o custo total médio (CTM) da instalação, manutenção e desligamento da bomba de analgesia controlada pelo paciente (PCA) no manejo da dor. A amostra não probabilística correspondeu à observação de 81 procedimentos em 17 Unidades do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Calculou-se o CTM multiplicando-se o tempo despendido pelas enfermeiras pelo custo unitário da mão de obra direta, somando-se ao custo dos materiais e medicamentos/soluções. O CTM da instalação foi de R$ 107,91; da manutenção R$ 110,55 e do desligamento R$ 4,94. Os resultados obtidos subsidiarão discussões acerca da necessidade de repasse monetário do Sistema Único de Saúde às unidades hospitalares que realizam essa técnica de terapia antálgica e contribuirão para o gerenciamento de custos visando à tomada de decisão eficiente e eficaz na alocação dos recursos disponíveis.

Patient-controlled analgesia: therapeutic interventions using transdermal electro-activated and electro-modulated drug delivery.

Chronic pain poses a major concern to modern medicine and is frequently undertreated, causing suffering and disability. Patient-controlled analgesia, although successful, does have limitations. Transdermal delivery is the pivot to which analgesic research in drug delivery has centralized, especially with the confines of needle phobias and associated pain related to traditional injections, and the existing limitations associated with oral drug delivery. Highlighted within is the possibility of further developing transdermal drug delivery for chronic pain treatment using iontophoresis-based microneedle array patches. A concerted effort was made to review critically all available therapies designed for the treatment of chronic pain. The drug delivery systems developed for this purpose and nondrug routes are elaborated on, in a systematic manner. Recent developments and future goals in transdermal delivery as a means to overcome the individual limitations of the aforementioned delivery routes are represented as well. The approval of patch-like devices that contain both the microelectronic-processing mechanism and the active medicament in a small portable device is still awaited by the pharmaceutical industry. This anticipated platform may provide transdermal electro-activated and electro-modulated drug delivery systems a feasible attempt in chronic pain treatment. Iontophoresis has been proven an effective mode used to administer ionized drugs in physiotherapeutic, diagnostic, and dermatological applications and may be an encouraging probability for the development of devices and aids in the treatment of chronic pain.

Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a "poor man's epidural".

BACKGROUND: The epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units. Since the end of the 90 ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don't want, can't have or don't need epidural analgesia. DISCUSSION: In view of the need for conversion to central neuraxial blocks and the analgesic effect remifentanil has been demonstrated to be superior to pethidine. Despite being less effective in terms of the resulting pain scores, clinical studies suggest that the satisfaction with analgesia may be comparable to that obtained with epidural analgesia. Owing to this fact, remifentanil has gained a place in modern labour analgesia in many institutions. However, the fact that remifentanil may cause harm should not be forgotten when the use of this potent mu-agonist is considered for the use in labouring women. In the setting of one-to-one midwifery care, appropriate monitoring and providing that enough experience exists with this potent opioid and the treatment of potential complications, remifentanil PCA is a useful option in addition to epidural analgesia and other central neuraxial blocks. Already described serious consequences should remind us not refer to remifentanil PCA as a "poor man's epidural" and to safely administer remifentanil with an appropriate indication. SUMMARY: Therefore, the authors conclude that economic considerations and potential cost-savings in conjunction with remifentanil PCA may not be appropriate main endpoints when studying this valuable method for labour analgesia.

Epidural analgesia versus patient-controlled analgesia for pain relief in uterine artery embolization for uterine fibroids: a decision analysis.

PURPOSE: This study was designed to compare the costs and effects of epidural analgesia (EDA) to those of patient-controlled intravenous analgesia (PCA) for postintervention pain relief in women having uterine artery embolization (UAE) for systematic uterine fibroids. METHODS: Cost-effectiveness analysis (CEA) based on data from the literature by constructing a decision tree to model the clinical pathways for estimating the effects and costs of treatment with EDA and PCA. Literature on EDA for pain-relief after UAE was missing, and therefore, data on EDA for abdominal surgery were used. Outcome measures were compared costs to reduce one point in visual analogue score (VAS) or numeric rating scale (NRS) for pain 6 and 24 h after UAE and risk for complications. RESULTS: Six hours after the intervention, the VAS was 3.56 when using PCA and 2.0 when using EDA. The costs for pain relief in women undergoing UAE with PCA and EDA were 191 and 355, respectively. The costs for EDA to reduce the VAS score 6 h after the intervention with one point compared with PCA were 105 and 179 after 24 h. The risk of having a complication was 2.45 times higher when using EDA. CONCLUSIONS: The results of this indirect comparison of EDA for abdominal surgery with PCA for UAE show that EDA would provide superior analgesia for post UAE pain at 6 and 24 h but with higher costs and an increased risk of complications.

A cost utilization analysis of intrathecal therapy for refractory cancer pain: identifying factors associated with cost benefit.

OBJECTIVE: Intrathecal therapy (ITT) for cancer pain is characterized by high initial cost followed by low maintenance costs. Non-ITT pain management is associated with steadily increasing cumulative cost that can equal the cost of ITT over time. The intent of this modeling project is to identify factors associated with relatively rapid achievement of cost-benefit with ITT. DESIGN: A retrospective chart review was performed on 36 patients with cancer pain who underwent ITT and survived beyond 4 weeks. METHODS: Data on the cost of conventional opioid therapy prior to ITT and at 4-6 weeks were collected and projected over time. ITT costs included all intrathecal pump implantation and maintenance costs. Pre-ITT opioid regimens were stratified into high-cost conventional (HCC-high-dose, nongeneric, or use of intravenous patient-controlled analgesia, N = 12) and low-cost conventional (low-dose or generic, N = 24) regimens. RESULTS: The median daily cost of opioid medications pre-ITT was $21.26 (25th-75th percentile $10.31-78.85, range 0-$971.97) vs $0 (25th-75th percentile $0-0.70), P = 0.007, post-ITT. In the HCC group, the median daily cost was $172.47 (25th-75th percentile $67.29-406.20). The median daily cost of ITT medications was $16.01 (25th-75th percentile $9.52-23.23).When these data were used to model costs over the long term, including pump implantation costs, cost-benefit for all patients compared with conventional therapy was predicted at 344 months but at 7.4 months in the HCC group. Seven patients (19%) achieved cost equivalence within 6 months and three of these within the first 3 months. CONCLUSIONS: In selected patients on high-cost opioid regimens, ITT may become cost-beneficial within 6 months. Factors associated with earlier attainment of ITT cost-benefit include the use of parenteral therapy, high-dose opioids, and the use of nongeneric opioid products.

Patient-controlled analgesia compared with interval analgesic dosing for reducing complications in blunt thoracic trauma: a retrospective cohort study.

OBJECTIVES: To determine if complications from blunt thoracic trauma are reduced with patient-controlled analgesia (PCA) compared with interval analgesic dosing given as needed. Secondary aims were to investigate the influence of PCA on hospital length of stay (LOS) and cost. METHODS: In this retrospective cohort study, patients were identified using the hospital trauma registry and clinical information department. Data on analgesic method, outcomes and confounders were obtained from the medical record. Costing data were obtained from the case-mix department. The analysis used logistic regression for the primary outcome and a generalised linear model for the secondary outcomes to adjust for potential confounders. RESULTS: 227 patients were included. In the PCA group, 17/52 (33%) patients had a complication compared with 26/175 (15%) in the interval dosing group. The adjusted odds for a complication in patients receiving PCA was not significantly different from the adjusted odds in those receiving interval dosing (OR=1.2, 95% CI 0.3 to 4.6, p=0.83). The median LOS was 8.9 days in the PCA group and 4.6 days in the interval dosing group. The adjusted LOS for patients receiving PCA was 10% shorter than those receiving interval dosing (relative difference 0.9, 95% CI 0.6 to 1.3, p=0.52). The median hospital cost was $A11 107 in the PCA group (IQR $A7520-$A15 744) and $A4511 (IQR $A2687-$A8248) in the interval dosing group. The adjusted total hospital costs for patients receiving PCA was 10% higher than for those receiving interval dosing (relative difference 1.1, 95% CI 0.8 to 1.5, p=0.44). CONCLUSIONS: PCA did not reduce complications, hospital LOS or costs compared with interval analgesic dosing.

Remifentanil patient controlled analgesia versus epidural analgesia in labour. A multicentre randomized controlled trial.

BACKGROUND: Pain relief during labour is a topic of major interest in the Netherlands. Epidural analgesia is considered to be the most effective method of pain relief and recommended as first choice. However its uptake by pregnant women is limited compared to other western countries, partly as a result of non-availability due to logistic problems. Remifentanil, a synthetic opioid, is very suitable for patient controlled analgesia. Recent studies show that epidural analgesia is superior to remifentanil patient controlled analgesia in terms of pain intensity score; however there was no difference in satisfaction with pain relief between both treatments. METHODS/DESIGN: The proposed study is a multicentre randomized controlled study that assesses the cost-effectiveness of remifentanil patient controlled analgesia compared to epidural analgesia. We hypothesize that remifentanil patient controlled analgesia is as effective in improving pain appreciation scores as epidural analgesia, with lower costs and easier achievement of 24 hours availability of pain relief for women in labour and efficient pain relief for those with a contraindication for epidural analgesia.Eligible women will be informed about the study and randomized before active labour has started. Women will be randomly allocated to a strategy based on epidural analgesia or on remifentanil patient controlled analgesia when they request pain relief during labour. Primary outcome is the pain appreciation score, i.e. satisfaction with pain relief.Secondary outcome parameters are costs, patient satisfaction, pain scores (pain-intensity), mode of delivery and maternal and neonatal side effects.The economic analysis will be performed from a short-term healthcare perspective. For both strategies the cost of perinatal care for mother and child, starting at the onset of labour and ending ten days after delivery, will be registered and compared. DISCUSSION: This study, considering cost effectiveness of remifentanil as first choice analgesia versus epidural analgesia, could strongly improve the care for 180.000 women, giving birth in the Netherlands yearly by giving them access to pain relief during labour, 24 hours a day. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR2551, http://www.trialregister.nl.

Epidural analgesia for blunt thoracic injury--which patients benefit most?

INTRODUCTION: Epidural analgesia for blunt thoracic injury has been demonstrated to be beneficial for pulmonary function, analgesia, and subjective pain; however the optimal patient selection and timing of thoracic epidural placement have not been well studied. We hypothesised that early (<48h) epidural analgesia (EA) as compared with usual care involving oral and intravenous narcotics delivered by patient-controlled analgesia (PCA) in patients with blunt thoracic trauma (>3 ribs fractured) is associated with fewer pulmonary complications and lower resource utilisation as measured by ICU and hospital length of stay. METHODS: This is a retrospective review of all non-intubated patients suffering from blunt thoracic injury with 3 or more rib fractures requiring hospital admission for >24h over a recent 5-year period. Pulmonary complications were defined as pneumonia, empyema, hypoxia, and need for delayed intubation. Logistic regression was utilised to analyse patient and injury characteristics associated with pulmonary complications. RESULTS: 187 patients were included in the analysis; early thoracic epidural was utilised in 18% (n=34). There was no difference in age, ISS, ICU length of stay (LOS), or pulmonary complications between patients who received an epidural (EPI) compared with those who did not (NO EPI). A significantly increased incidence of pulmonary complications was noted in patients who required tube thoracostomy (p=0.017). CONCLUSION: In our experience, insertion of a thoracic epidural catheter early post-injury failed to reduce the incidence of pulmonary complications, ICU and hospital LOS. However, since pulmonary complications are more frequent in patients requiring tube thoracostomy, the cost-effectiveness of epidural analgesia in these patients warrants further investigation.

Cost-effectiveness analysis comparing epidural, patient-controlled intravenous morphine, and continuous wound infiltration for postoperative pain management after open abdominal surgery.

BACKGROUND: Continuous wound infiltration (CWI), i.v. patient-controlled analgesia (i.v.-PCA), and epidural analgesia (EDA) are analgesic techniques commonly used for pain relief after open abdominal surgery. The aim of this study was to evaluate the cost-effectiveness of these techniques. METHODS: A decision analytic model was developed, including values retrieved from clinical trials and from an observational prospective cohort of 85 patients. Efficacy criteria were based on pain at rest (VAS ≤ 30/100 mm at 24 h). Resource use and costs were evaluated from medical record measurements and published data. Probabilistic sensitivity analysis (PSA) was performed. RESULTS: When taking into account all resources consumed, the CWI arm (€ 6460) is economically dominant when compared with i.v.-PCA (€ 7273) and EDA (€ 7500). The proportion of patients successfully controlled for their postoperative pain management are 77.4%, 53.9%, and 72.9% for CWI, i.v.-PCA, and EDA, respectively, demonstrating the CWI procedure to be both economically and clinically dominant. PSA reported that CWI remains cost saving in 70.4% of cases in comparison with EDA and in 59.2% of cases when compared with PCA. CONCLUSIONS: Device-related costs of using CWI for pain management after abdominal laparotomy are partly counterbalanced by a reduction in resource consumption. The cost-effectiveness analysis suggests that CWI is the dominant treatment strategy for managing postoperative pain (i.e. more effective and less costly) in comparison with i.v.-PCA. When compared with EDA, CWI is less costly with almost equivalent efficacy. This economic evaluation may be useful for clinicians to design algorithms for pain management after major abdominal surgery.