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

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58 Results of the adult economic evaluation 600 500 400 300 200 100 0 Willingness to pay (£) < 250 250–500 501–1000 1001–2000 > 2000 Monthly household income (£) FIGURE 7 Willingness to pay for induction anaesthesia versus monthly household income (limit 5% and 95% percentiles) in the adult study TABLE 36 ICERs with respect to propofol/isoflurane in the adult study Sevoflurane/sevoflurane was dominated. As the cost increases, so does effectiveness, although it must be noted that these differences in effectiveness are not statistically significant. No statistically significant differences were found in the rate of PONV between propofol/propofol, propofol/sevoflurane and propofol/isoflurane. If this is because the regimens were equivalent, then the least costly of these alternatives is likely to be the most cost-effective. In this analysis, that would be propofol induction followed by isoflurane maintenance anaesthesia. 600 500 400 300 200 100 0 Willingness to pay (£) < 250 250–500 501–1000 1001–2000 > 2000 Monthly household income (£) FIGURE 8 Willingness to pay for maintenance anaesthesia versus monthly household income (limit 5% and 95% percentiles) in the adult study Anaesthetic regimen Total variable cost for No. of patients ICER per PONV instance the group (mean cost with PONV avoided (£) per patient) (£) Propofol/propofol 5591.5 (21.1) 37 (14.0%) 296 Propofol/sevoflurane 3864.0 (13.8) 46 (16.4%) 333 Propofol/isoflurane 1975.8 (7.4) 49 (18.4%) – Sevoflurane/sevoflurane 3840.3 (15.3) 75 (29.9%) Dominated Sensitivity analysis Uncertainty: CESA RCT data Incremental cost-effectiveness ratios Table 37 shows the results of a deterministic sensitivity analysis on the observed rate of PONV. The modelled baseline values for the ICERs closely match the values from the empirical study. The two sets of values do not match exactly due to arithmetic rounding. This sensitivity analysis shows that the rank order of the ICERS is robust in terms of the observed rate of PONV. However, given that the low rate of PONV for each arm was used
TABLE 37 Deterministic sensitivity analysis on the rate of PONV in the adult study Parameter of interest Anaesthetic regimen simultaneously this is not surprising. The bootstrapping approach reported in the next section further explored the volatility in the rank ordering of the ICERs. Bootstrapped distributions of ICERs Bootstrapped distributions of ICERs were generated for all combinations, excluding sevoflurane/ sevoflurane (Figures 9 to 11). The cost-effectiveness planes generated for propofol/propofol versus propofol/isoflurane (2.5% percentile, –£2683; 97.5% percentile, £1904) and versus propofol/ sevoflurane (2.5% percentile, –£6878; 97.5% percentile, £2192) and for propofol/sevoflurane versus propofol/isoflurane (2.5% percentile, –£11441; 97.5% percentile, £1844) confirm that the rank order of these ICERs is not robust. Validity of the use of the Dion approximation of volatile consumption A substudy showed that the Dion algebraic approximation consistently underestimated the amount of volatile anaesthetic used (see appendix 18). Results from this study suggested that the actual amounts of isoflurane and sevoflurane were between 6% and 27% higher than estimated. The variable costs were therefore recalculated using these inflation factors (Table 38). © Queen’s Printer and Controller of HMSO 2002. All rights reserved. Health Technology Assessment 2002; Vol. 6: No. 30 Propofol/ Propofol/ Propofol/ Sevoflurane/ propofol isoflurane sevoflurane sevoflurane (n = 265) (n = 267) (n = 280) (n = 251) Mean cost per patient with PONV (£) 21.55 9.60 16.34 18.21 Mean cost per patient with no PONV (£) 21.07 6.91 13.24 14.10 Probability of PONV (low and 0.14 0.18 0.17 0.30 high values) (low 0.10; (low 0.13; (low 0.13; (low 0.24; high 0.18) high 0.23) high 0.21) high 0.36) Probability of no PONV 0.86 0.82 0.83 0.70 (= 1 – probability of PONV) Expected variable cost per patient 21.14 7.39 13.77 15.33 (low and high values) (£) (low 21.12; (low 7.26; (low 13.64; (low 15.09; high 21.16) high 7.53) high 13.89) high 15.58) Incidence of PONV from empirical 37 (14.0%) 49 (18.4%) 46 (16.4%) 75 (29.9%) study Baseline ICER (best and worse cases) 307 * – 319 † (£/PONV case avoided) (best case 374; (best case 638; worst case 242) worst case 318) * Calculated with respect to the propofol/sevoflurane regimen † Calculated with respect to the propofol/isoflurane regimen Dominated It can be seen that the arms most affected are those containing sevoflurane, due to the high relative acquisition cost of this agent. However, the rank order of the alternatives does not change, and so the conclusions regarding cost-effectiveness do not change from those for the base case. Uncertainty: differences between the CESA RCT and routine practice Simulation of the use of prophylactic anti-emetics The cost variables of the decision-analytic model were assigned the beta-subjective distribution (minimum value, mode, mean, maximum value), which makes limited assumptions regarding the shape of the distribution of the stochastic data from the empirical study. Table 39 reports the distributions and RRRs for the simulation. Figures 12 to 15 show the completed decision trees for the simulation. The branch of the tree for no anti-emetic prophylaxis models the results of the empirical study accurately. The mean and standard deviation of the simulation (Table 40) mirror the empirical study results (see Table 29). Table 41 shows the expected costs and predicted outcome (with the 95% CIs) for the study 59
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Which anaesthetic agents are costef
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Which anaesthetic agents are costef
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NHS R&D HTA Programme The NHS R&D H
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Contents Appendix 6 Adult patient-b
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Background The aim of the project w
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• The incidence of PONV was low d
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2 Introduction dizziness or disorie
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4 Introduction a reduced incidence
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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
Page 63 and 64: Clinical outcome data PONV by anaes
Page 65 and 66: The findings from the logistic regr
Page 67 and 68: TABLE 29 The length of stay and pri
Page 69 and 70: 140 120 100 80 60 40 20 0 No. of pa
Page 71: 250 200 150 100 50 0 No. of patient
Page 75 and 76: 20 15 10 5 0 -5 Difference in varia
Page 77 and 78: Patient admitted for day surgery an
Page 79 and 80: 500 400 300 200 100 0 -100 -200 -30
Page 81 and 82: Recruitment to the CESA RCT The stu
Page 83 and 84: TABLE 49 The occurrence of any PONV
Page 85 and 86: 60 50 40 30 20 10 0 No. of patients
Page 87 and 88: a scale effect for scenario A, but
Page 89 and 90: The mean CVs for avoidance of PONV
Page 91 and 92: 1.80 The new variable cost and tota
Page 93 and 94: 100 90 80 70 60 50 40 30 20 10 0 Su
Page 95 and 96: The structure and content of this d
Page 97 and 98: nurses to have an in-depth knowledg
Page 99 and 100: agent used (see appendix 18). It wa
Page 101 and 102: Furthermore, anaesthetists operate
Page 103 and 104: The CESA project was designed to as
Page 105: practice, such as the use of midazo
Page 109 and 110: 1. Royal College of Surgeons of Eng
Page 111 and 112: 60. Cheng KI, Chu KS, Fang YR, Su K
Page 113 and 114: 112. Raeder J, Gupta A, Pedersen FM
Page 115 and 116: 162. Viitanen H, Baer G, Annila P.
Page 117 and 118: 220. Rosenberg KM, Bridge P, Brown
Page 119 and 120: The range of databases interrogated
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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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