Cost-Effectiveness of α₂ Agonists for Intravenous Sedation in Patients With Critical Illness

Abstract

Importance: Propofol and the α2 agonists dexmedetomidine and clonidine are used for sedation in patients with critical illness receiving mechanical ventilation. Evidence about the cost-effectiveness of intravenous (IV) sedation with these medications is lacking. Objective: To investigate the cost-effectiveness of dexmedetomidine-, clonidine-, and propofol-based IV sedation in patients with critical illness receiving mechanical ventilation. Design, Setting, and Participants: This economic evaluation used within-trial cost-utility analysis with a 6-month time horizon comparing dexmedetomidine-, clonidine-, and propofol-based IV sedation from a UK National Health Service and Personal Social Services perspective, with individual-level data collected from the Alpha 2 Agonists for Sedation to Produce Better Outcomes From Critical Illness (A2B) trial. Adults with critical illness receiving mechanical ventilation, with an anticipated total requirement for mechanical ventilation of at least 2 days, from 41 intensive care units in the UK were included. Recruitment ran from December 2018 through October 2023; the last date of follow-up was December 10, 2023. Interventions: Dexmedetomidine, clonidine, or propofol IV sedation. Patients receiving α2 agonists were permitted to receive supplemental propofol to achieve the target sedation score if required. Main Outcomes and Measures: Incremental costs and quality-adjusted life years (QALYs) gained between dexmedetomidine-based vs propofol-based and clonidine-based vs propofol-based IV sedation were assessed. Mean net monetary benefits with each medication were assessed. Results: Among 1404 adults with critical illness receiving mechanical ventilation (mean [SD] age, 59.2 [14.9] years; 901 male [64.2%]), the mean (SD) Acute Physiology and Chronic Health Evaluation (APACHE) II score was 20.3 (8.2). The incremental cost for dexmedetomidine vs propofol was $1273 (95% CI, -$5000 to $7545), and for clonidine vs propofol, it was -$1328 (-$7114 to $4459). For dexmedetomidine vs propofol, there were 0.0008 QALYs (95% CI, -0.0198 to 0.0214 QALYs) gained, and for clonidine vs propofol, there were -0.0019 QALYs (95% CI, -0.0221 to 0.0181 QALYs) gained. Mean net monetary benefits for dexmedetomidine, clonidine, and propofol were -$53 278 (95% CI, -$58 063 to -$48 493), -$50 882 (95% CI, -$55 003 to -$46 762), and -$52 036 (95% CI, -$56 230 to -$47 834), respectively, at a maximum willingness to pay for a QALY of $16 250. Conclusions and Relevance: In this study, dexmedetomidine-, clonidine-, and propofol-based IV sedation in patients with critical illness receiving mechanical ventilation had similar costs and QALYs. These findings suggest that economic considerations should not affect which sedative these patients receive.