Aanesthetic Agents for Day Surgery - NIHR Health Technology ...

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iv Executive summary Outcome measures Postoperative nausea and vomiting (PONV) was the primary clinical outcome measure. The contingent valuation (CV) method was used to determine patient preferences for different anaesthetic agents at day 7. Prospective patient-based resource-use data were collected up to day 7 postdischarge, from the perspective of the NHS and the patients. Results Adult study • More adults experienced PONV with sevoflurane/sevoflurane (29.9%) than with propofol/propofol (14.0%) (p < 0.0001), propofol/sevoflurane (16.6%) (p < 0.001) and propofol/isoflurane (18.2%) (p < 0.003). • The length of hospital stay and total costs were not statistically different between the four study arms, but variable costs were higher in the TIVA arm and lower in the propofol/ isoflurane arm. • Of those who received intravenous induction, 79% would prefer that method in the future to inhalational induction. Of those patients who received inhalational induction, 64% would prefer that method in the future. There were no differences in the CVs for induction or maintenance between the randomisation arms. • Propofol/propofol was the most effective and most costly. Sevoflurane/sevoflurane was the least effective, and was more costly than the mixed arms. The incremental cost-effectiveness ratio (ICER) for propofol/propofol compared with propofol/sevoflurane is £296 to avoid one PONV incident. The ICER for propofol/ sevoflurane compared with propofol/isoflurane is £333 to avoid one PONV incident. • The use of the Dion algebraic approximation for volatile anaesthetic use resulted in a 6–27% underestimation. The impact of this was strongest in the sevoflurane/sevoflurane and propofol/sevoflurane arms due to the high acquisition costs of sevoflurane. • Investigating the use of prophylactic intravenous ondansetron 4 mg suggested that propofol/ propofol would remain the most costly and effective arm. However, if this agent was used in all arms except the propofol/propofol arm, propofol/sevoflurane became the most costly and effective regimen. • The net benefit (= total cost – (CV[induction] + CV[maintenance]) was positive in all arms and was positive for over 90% of patients. Sevoflurane/sevoflurane had a lower net benefit than did the other three arms. Paediatric study • More children experienced PONV with sevoflurane/sevoflurane (14.7%) than with propofol/halothane (5.7%) (p < 0.01). • The length of hospital stay was not different between the randomisation arms, but variable and total costs were higher in the sevoflurane/ sevoflurane arm. • Parents whose children had not had the mask (sevoflurane) before did not want it in the future. Parents whose children had not had the injection (propofol) before did not want it in the future. The CVs for PONV avoidance were not affected by the experience of PONV. • Propofol/halothane was more effective and less costly than the sevoflurane/sevoflurane regimen. • In a sensitivity analysis, when isoflurane was substituted for halothane, propofol/isoflurane was more effective and less costly than sevoflurane/sevoflurane. When sevoflurane was substituted for halothane, propofol/sevoflurane was more effective and more costly than sevoflurane/sevoflurane. • Both arms had an overall positive net benefit, and these benefits were not statistically different. The net benefit was positive for over 90% of patients in both arms. Conclusions The main conclusions are: • Sevoflurane/sevoflurane is not a cost-effective regimen for day surgery in adults or children. It is associated with higher rates of PONV than propofol followed by propofol, isoflurane or sevoflurane. It is more expensive than mixed anaesthesia regimens. • In the adult study, there were no statistically significant differences in the incidence of PONV between the regimens that used propofol for induction. However, there were statistically significant differences in the variable costs of the regimens. The propofol/isoflurane regimen was associated with the lowest cost per episode of PONV avoided. Implications for practice • In both adults and children a propofolcontaining regimen appears to confer antiemetic protection over a sevoflurane/ sevoflurane anaesthetic regimen, without increased costs, unless TIVA is used. In children, sevoflurane/sevoflurane is also associated with agitation in recovery.
• The incidence of PONV was low despite the withholding of prophylactic anti-emetics, possibly due to the low opioid use in this study. • The reluctance to have an inhalation induction was reduced by experience of this technique. • Decisions around clinical practice in day surgery should not be based on inpatient evidence. • The current development of patient information on anaesthetics needs to incorporate patients’ views and preferences. © Queen’s Printer and Controller of HMSO 2002. All rights reserved. Health Technology Assessment 2002; Vol. 6: No. 30 Recommendations for further research Further research is needed in the following areas: • the optimisation of perioperative analgesia • routine perioperative PONV prophylaxis should be reviewed • the risk factors for PONV • the cost of volatile anaesthetics • the role of patient preferences in anaesthesia. v
Page 1 and 2: Which anaesthetic agents are costef
Page 3: Which anaesthetic agents are costef
Page 6 and 7: NHS R&D HTA Programme The NHS R&D H
Page 8 and 9: Contents Appendix 6 Adult patient-b
Page 11: Background The aim of the project w
Page 16 and 17: 2 Introduction dizziness or disorie
Page 18 and 19: 4 Introduction a reduced incidence
Page 20 and 21: 6 Introduction willingness to pay f
Page 22 and 23: 8 Literature review included in the
Page 24 and 25: 10 Literature review TABLE 1 Compar
Page 26 and 27: 12 Literature review intermediate a
Page 32 and 33: 18 Literature review Patient-based
Page 34 and 35: 20 Literature review TABLE 5 contd
Page 36 and 37: 22 Literature review No studies fol
Page 38 and 39: 24 Literature review (30%) and meth
Page 40 and 41: 26 Literature review • There are
Page 42 and 43: 28 National survey of anaesthetic p
Page 50 and 51: 36 Economic evaluation methods (inc
Page 52 and 53: 38 Economic evaluation methods The
Page 54 and 55: 40 Economic evaluation methods Tabl
Page 56 and 57: 42 Economic evaluation methods simi
Page 58 and 59: 44 Economic evaluation methods Prob
Page 61 and 62: Recruitment to the CESA RCT The stu
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Clinical outcome data PONV by anaes
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The findings from the logistic regr
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TABLE 29 The length of stay and pri
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140 120 100 80 60 40 20 0 No. of pa
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250 200 150 100 50 0 No. of patient
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TABLE 37 Deterministic sensitivity
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20 15 10 5 0 -5 Difference in varia
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Patient admitted for day surgery an
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500 400 300 200 100 0 -100 -200 -30
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Recruitment to the CESA RCT The stu
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TABLE 49 The occurrence of any PONV
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60 50 40 30 20 10 0 No. of patients
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a scale effect for scenario A, but
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The mean CVs for avoidance of PONV
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1.80 The new variable cost and tota
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100 90 80 70 60 50 40 30 20 10 0 Su
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The structure and content of this d
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nurses to have an in-depth knowledg
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agent used (see appendix 18). It wa
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Furthermore, anaesthetists operate
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The CESA project was designed to as
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practice, such as the use of midazo
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1. Royal College of Surgeons of Eng
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60. Cheng KI, Chu KS, Fang YR, Su K
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112. Raeder J, Gupta A, Pedersen FM
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162. Viitanen H, Baer G, Annila P.
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220. Rosenberg KM, Bridge P, Brown
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The range of databases interrogated
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24. preferen$.mp. [mp=title, abstra
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110 Appendix 2 TABLE 65 contd Summa
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112 Appendix 3 Quality assessment o
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TABLE 69 Summary of paediatric pati
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TABLE 69 contd Summary of paediatri
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TABLE 70 Characteristics of cost or
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TABLE 71 Quality of cost or economi
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TABLE 71 contd Quality of cost or e
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Abbott J, Abbott P. Psychological a
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Hall JE, Stewart JIM, Harmer M. Sin
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Struys M, Versichelen L, Thas O, He
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182 Appendix 11
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184 Appendix 11
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186 Appendix 11
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188 Appendix 11
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The aim of this study was to develo
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anaesthetics in day surgery, using
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© Queen’s Printer and Controller
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Background The empirical study quan
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Satisfaction with care Nearly all (
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TABLE 76 Reason given for preferenc
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TABLE 79 Comparisons with previous
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TABLE 80 Reason given for preferenc
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TABLE 81 Reason given for willingne
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Background Variable costs account f
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TABLE 85 Unit costs for the purchas
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Background The empirical study requ
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Ethical approval This was covered b
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20 15 10 5 0 -5 -10 -15 True weight
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15 10 5 0 -5 -10 True weight - Dion
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224 Appendix 19 • patients aged o
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All staff unit costs were for the y
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Background Fixed costs account for
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232 Appendix 22 March, Tuesday 15 A
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234 Appendix 23 TABLE 96 Reasons fo
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Patients were coded using the OPCS
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Q03.4 punch biopsy of cervix Q03.5
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This section displays the associati
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given in Table 103 confirm the age
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TABLE 107 Occurrence of PONV by dur
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248 Appendix 27 TABLE 113 Frequency
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This section displays the associati
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The adverse events observed in the
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262 Health Technology Assessment Pr
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264 Health Technology Assessment Pr
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