To conduct a cost-effectiveness analysis, from a hospital's perspective, of 4 procedural sedation and analgesia (PSA) regimens to facilitate forearm fracture manipulation in the pediatric emergency department (ED): deep sedation with ketamine/midazolam (K/M) administration, propofol/fentanyl administration, fentanyl/midazolam (F/M) administration, and axillary block.
We constructed a decision analytic model using relevant probabilities from published studies of pediatric patients who underwent fracture manipulation in the EDs. Total costs were calculated by assessing ED resource utilization associated with uncomplicated PSA and with PSA complicated by adverse events. Costs of consumable equipment were considered to be fixed. Total sedation time, personnel time, and drug costs were considered variable. We assumed that all PSA regimens provided effective relief from procedural distress. Failure rates for axillary block were estimated based on reports in the literature. When patients experienced emesis, recovery agitation, respiratory depression, lidocaine toxicity, or regional block failure, we assumed that the patients would require 1 additional hour of ED stay. Sensitivity analyses of all key variables in the model were performed to identify those that may result in a change in the preferred option. Monte Carlo simulations were performed to assess model robustness.
Under baseline assumptions, the propofol/fentanyl regimen was the most cost-effective choice (expected cost, US $84.06), followed by axillary block (US $88.18), K/M (US $105.32), and F/M (US $159.79), respectively. Varying the fixed and variable costs by 50% to 200% of their baseline values did not alter the ranking. When ketamine and propofol were administered without adjunctive midazolam and fentanyl, respectively, propofol remained the optimum choice. With total PSA time as the outcome measure, the incremental cost-effectiveness ratios were US $8.1 and US $24.9 per hour of ED time saved, for propofol/fentanyl versus axillary block and for axillary block versus K/M, respectively.
Among PSA regimens during forearm fracture manipulation in the pediatric ED, propofol/fentanyl is the most cost-effective regimen followed by axillary block, K/M, and F/M.