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Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care

Mascia, Michael F. MD, MPH; Koch, Manfred MD; Medicis, Joseph J. PharmD, BCPS

Clinical Investigations

Objective: To determine the cost-effectiveness and safety of a set of rational use guidelines for analgesia, sedation, and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in standard prescribing.

Design: Prospective cost-benefit analysis.

Setting: Medical and surgical intensive care units (ICU) of a 350-bed tertiary care university hospital.

Patients: Patients admitted to our ICUs who required mechanical ventilation and continuous analgesics, sedatives, and/or neuromuscular junction blockers (NMJBs). There were 72 patients in the baseline and 84 patients in the follow-up groups.

Interventions: Prospective tracking of eligible baseline patients was followed by the development and introduction of guidelines and an academic detailing process to promote the use of guidelines. Several months after the introduction of guidelines, a second group of eligible follow-up patients was tracked. The use and effectiveness of analgesics, sedatives, and NMJBs, as well as cost and outcomes, were followed in both groups. Data were subsequently reviewed and analyzed.

Measurements and Main Results: We recorded data by means of Paradox and Excel databases and included demographics, costs, outcomes (including adverse drug reactions, functional status, ventilator time in hours, lengths of stay), and mortality rates. Data were subsequently analyzed via the Winks statistical data analysis program. Both groups were similar with regard to demographics. There was a statistically significant increase in severity of illness in the follow-up group without a statistically significant increase in mortality. Direct drug costs, ventilator time, and lengths of stay were reduced in the follow-up group. In addition, the use of NMJBs was reduced from 30% in the baseline group to 5% in the follow-up group.

Conclusions: Rational use guidelines resulted in safe, cost-effective improvements in the provision of continuous analgesia, sedation, and neuromuscular blockade to critically ill patients requiring ventilator management when compared with similar factors in baseline prescribing strategies.

Increased use of technology in the management of critical illness has resulted in the provision of complex pharmacotherapeutic regimens to enhance patient care (1–4). To this end, critical care physicians are often called on to prescribe analgesics, sedatives, and neuromuscular junction blockers (NMJBs). Indications for these drugs include pain control, anxiolysis, management of drug withdrawal syndromes, treatment of seizures, and facilitation of mechanical ventilation. Most patients admitted to the intensive care unit (ICU) and virtually all mechanically ventilated patients will require some form of this pharmacotherapy. Proper use can enhance patient comfort and safety, but misuse, side effects, and adverse reactions to these drugs are common and costly (5–9). The challenge for critical care physicians regarding the use of analgesics, sedatives, and NMJBs is to provide comfort and safety without increased cost, morbidity, and mortality. Because of the potential high cost of these drugs and the frequency and cost of associated complications, physicians have been forced to reexamine their use and to search for optimal prescribing patterns that improve patient outcome (8, 10–13). The potential for misuse and adverse outcomes is so great that detailed reports of complications are common in the literature (14). Reports include use patterns, costs of use, and adverse outcomes (15, 16). In these reports, inappropriate use (17), high costs (6, 7, 12, 18–20), and adverse outcomes (5, 21–23) have been well documented. However, the documentation of the frequency and severity of adverse events and improved use and outcome has been limited (24, 25). Our goal was to document reduced cost without adverse outcome.

Assessments of appropriate use to date include literature on surveys (26–28), data on the adverse effects (21–23), and the impact of guidelines on cost reduction (18, 29–31). Few studies have prospectively examined the pharmacoeconomic impact of guidelines on cost and outcome (32–34). Although some authors have attempted to quantify the impact of guidelines (18), none has done so in a comprehensive, systematic manner. We hypothesized that proper use of these drugs can result in enhanced patient comfort and safety, as well as reduced cost and improved outcome. Our objective was to prospectively determine the cost effectiveness and safety of instituting rational use guidelines for analgesia, sedation, and NMJBs as compared with those factors in standard prescribing.

From the Departments of Anesthesiology (Drs. Mascia and Koch) and the Pharmacy Services, Division of Clinical Pharmacology (Dr. Medicis), State University of New York, Upstate Medical University, Syracuse, NY.

Supported, in part, by the Department of Anesthesiology, the Department of Pharmacy, and the Small Grants Projects of University Hospital through the Office of Clinical Practice Analysis, Upstate Medical University, Syracuse, NY.

Address requests for reprints to: Michael F. Mascia, MD, Tulane University School of Medicine, Department of Anesthesiology SL4, 1430 Tulane Avenue, New Orleans, LA 70112. E-mail:

© 2000 Lippincott Williams & Wilkins, Inc.