Reduced length of stay and hospitalization costs among inpatient hysterectomy patients with postoperative pain management including IV versus oral acetaminophen

OBJECTIVE

To compare the outcomes of hysterectomy patients who received standard pain management including IV acetaminophen (IV APAP) versus oral APAP.

METHODS

We performed a retrospective analysis of the Premier Database (January 2012 to September 2015) comparing hysterectomy patients who received postoperative pain management including IV APAP to those who received oral APAP starting on the day of surgery and continuing up to the third post-operative day, with no exclusions based on additional pain management. We compared the groups on length of stay (LOS), hospitalization costs, and average daily morphine equivalent dose (MED). The quarterly rate of IV APAP use for all hospitalizations by hospital was used as an instrumental variable in two-stage least squares regressions also adjusting for patient demographics, clinical risk factors, and hospital characteristics.

RESULTS

We identified 22,828 hysterectomy patients including 14,811 (65%) who had received IV APAP. Study subjects averaged 50 and 52 years of age, respectively in the IV APAP and oral APAP cohorts and were predominantly non-Hispanic Caucasians (≥60% in both cohorts). Instrumental variable models found IV APAP associated with 0.8 days shorter hospitalization (95% CI: -0.92 to -0.68, p<0.0001) and $2,449 lower hospitalization costs (95% CI: -$2,902 to -$1,996, p<0.0001). Average daily MED trended lower without statistical significance (-1.41 mg, 95% CI: -3.43 mg to 0.61 mg, p = 0.17).

CONCLUSIONS

Compared to oral APAP, managing post-hysterectomy pain with IV APAP is associated with shorter LOS and lower total hospitalization costs.

Hospitalization costs and resource allocation in cholecystectomy with use of intravenous versus oral acetaminophen

OBJECTIVE

To evaluate intravenous (IV) acetaminophen (APAP) vs oral APAP use as adjunctive analgesics in cholecystectomy patients by comparing associated hospital length of stay (LOS), hospital costs, opioid use, and rates of nausea/vomiting, respiratory depression, and bowel obstruction.

METHODS

We conducted a retrospective analysis of the Premier Database (January 2012 to September 2015) including cholecystectomy patients who received either IV APAP or oral APAP. Differences in LOS, hospitalization costs, mean daily morphine equivalent dose (MED), and potential opioid-related adverse events were estimated. Multivariable logistic regression was performed for the binary outcomes and instrumental variable regressions, using the quarterly rate of IV APAP use for all hospitalizations by hospital as the instrument in two-stage least squares regressions for continuous outcomes. Models were adjusted for patient demographics, clinical risk factors, and hospital characteristics.

RESULTS

Among 61,017 cholecystectomy patients, 31,133 (51%) received IV APAP. Subjects averaged 51 and 57 years of age, respectively, in the IV and oral APAP cohorts. In the adjusted models, IV APAP was associated with 0.42 days shorter LOS (95% CI = -0.58 to -0.27; p < .0001), $1,045 lower hospitalization costs (95% CI = -$1,521 to -$569; p < .0001), 2 mg lower average daily MED (95% CI = -3 mg to -0.9 mg; p = .0005), and lower rates of respiratory depression (odds ratio [OR] = 0.89, 95% CI = 0.82-0.97; p = .006), and nausea and vomiting (OR = 0.86, 95% CI = 0.86-0.86; p < .0001).

CONCLUSIONS

In patients having cholecystectomy, the addition of IV APAP to perioperative pain management is associated with shorter LOS, lower costs, reduced opioid use, and less frequent nausea/vomiting and respiratory depression compared to oral APAP. These findings should be confirmed in a prospective study comparing IV and oral APAP.

Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain

INTRODUCTION

To assess the impact on hospitalization costs of multimodal analgesia (MMA), including intravenous acetaminophen (IV-APAP), versus IV opioid monotherapy for postoperative pain management in patients undergoing orthopedic surgery.

METHODS

Utilizing the Truven Health MarketScan® Hospital Drug Database (HDD), patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or surgical repair of hip fracture between 1/1/2011 and 8/31/2014 were separated into postoperative pain management groups: MMA with IV-APAP plus other IV analgesics (IV-APAP group) or an IV opioid monotherapy group. All patients could have received oral analgesics. Baseline characteristics and total hospitalization costs were compared. Additionally, an inverse probability treatment weighting [IPTW] with propensity scores analysis further assessed hospitalization cost differences.

RESULTS

The IV-APAP group (n = 33,954) and IV opioid monotherapy group (n = 110,300) differed significantly (P < 0.0001) across baseline characteristics, though the differences may not have been clinically meaningful. Total hospitalization costs (mean ± standard deviation) were significantly lower for the IV-APAP group than the IV opioid monotherapy group (US$12,540 ± $9564 vs. $13,242 ± $35,825; P < 0.0001). Medical costs accounted for $701 of the $702 between-group difference. Pharmacy costs were similar between groups. Results of the IPTW-adjusted analysis further supported the statistically significant cost difference.

CONCLUSIONS

Patients undergoing orthopedic surgery who received MMA for postoperative pain management, including IV-APAP, had significantly lower total costs than patients who received IV opioid monotherapy. This difference was driven by medical costs; importantly, there was no difference in pharmacy costs. Generalizability of the results may be limited to patients admitted to hospitals similar to those included in HDD. Dosing could not be determined, so it was not possible to quantify utilization of IV-APAP or ascertain differences in opioid consumption between the 2 groups. This study did not account for healthcare utilization post-discharge.

Estimating the Effect of Intravenous Acetaminophen for Postoperative Pain Management on Length of Stay and Inpatient Hospital Costs

Introduction

The provision of safe, effective, cost-efficient perioperative inpatient acute pain management is an important concern among clinicians and administrators within healthcare institutions. Overreliance on opioid monotherapy in this setting continues to present health risks for patients and increase healthcare costs resulting from preventable adverse events. The goal of this study was to model length of stay (LOS), potential opioid-related complications, and costs for patients reducing opioid use and adding intravenous acetaminophen (IV APAP) for management of postoperative pain.

Methods

Data for this study were de-identified inpatient encounters from The Advisory Board Company across 297 hospitals from 2012–2014, containing 2,238,433 encounters (IV APAP used in 12.1%). Encounters for adults ≥18 years of age admitted for cardiovascular, colorectal, general, obstetrics and gynecology, orthopedics, or spine surgery were included. The effects of reducing opioids and adding IV APAP were estimated using hierarchical statistical models. Costs were estimated by multiplying modeled reductions in LOS or complication rates by observed average volumes for medium-sized facilities, and by average cost per day or per complication (LOS: US$2383/day; complications: derived from observed charges).

Results

Across all surgery types, LOS showed an average reduction of 18.5% (10.7–32.0%) for the modeled scenario of reducing opioids by one level (high to medium, medium to low, or low to none) and adding IV APAP, with an associated total LOS-related cost savings of $4.5 M. Modeled opioid-related complication rates showed similar improvements, averaging a reduction of 28.7% (5.4–44.0%) with associated cost savings of $0.2 M. In aggregate, costs decreased by an estimated $4.7 M for a medium-sized hospital. The study design demonstrates associations only and cannot establish causal relationships. The cost impact of LOS is modeled based on observed data.

Conclusions

This investigation indicates that reducing opioid use and including IV APAP for postoperative pain management has the potential to decrease LOS, opioid-related complication rates, and costs from a hospital perspective.

Funding

Mallinckrodt Pharmaceuticals.

Comparative Analysis of Length of Stay and Inpatient Costs for Orthopedic Surgery Patients Treated with IV Acetaminophen and IV Opioids vs. IV Opioids Alone for Post-Operative Pain

Introduction

Recovery from orthopedic surgery is oriented towards restoring functional health outcomes while reducing hospital length of stay (LOS) and medical expenditures. Optimal pain management is a key to reaching these objectives. We sought to compare orthopedic surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia to those who received IV opioids alone and compared the two groups on LOS and hospitalization costs.

Methods

We performed a retrospective analysis of the Premier Database (Premier, Inc.; between January 2009 and June 2015) comparing orthopedic surgery patients who received post-operative pain management with combination IV acetaminophen and IV opioids to those who received only IV opioids starting on the day of surgery and continuing up to the second post-operative day. The quarterly rate of IV acetaminophen use for all hospitalizations by hospital served as the instrumental variable in two-stage least squares regressions controlling for patient and hospital covariates to compare the LOS and hospitalization costs of IV acetaminophen recipients to opioid monotherapy patients.

Results

We identified 4,85,895 orthopedic surgery patients with 1,74,805 (36%) who had received IV acetaminophen. Study subjects averaged 64 years of age and were predominantly non-Hispanic Caucasians (78%) and female (58%). The mean unadjusted LOS for IV acetaminophen patients was 3.2 days [standard deviation (SD) 2.6] compared to 3.9 days (SD 3.9) with only IV opioids (P < 0.0001). Average unadjusted hospitalization costs were $19,024.9 (SD $13,113.7) for IV acetaminophen patients and $19,927.6 (SD $19,578.8) for IV opioid patients (P < 0.0001). These differences remained statistically significant in our instrumental variable models, with IV acetaminophen associated with 0.51 days shorter hospitalization [95% confidence interval (CI) −0.58 to −0.44, P < 0.0001] and $634.8 lower hospitalization costs (95% CI −$1032.5 to −$237.1, P = 0.0018).

Conclusion

Compared to opioids alone, managing post-orthopedic surgery pain with the addition of IV acetaminophen is associated with shorter LOS and decreased hospitalization costs.

Funding

Mallinckrodt Pharmaceuticals.

Care versus convenience: Examining paracetamol overdose in New Zealand and harm reduction strategies through sale and supply

AIM

To examine statistics on paracetamol overdose in New Zealand and investigate options to reduce paracetamol overdose rates, through supply reduction strategies.

METHOD

Data was gathered from the Ministry of Health's National Minimum Dataset and Wellington Hospital Emergency Department attendances. Twenty articles on supply reduction strategies were sourced through article database searches. A survey on paracetamol availability from online pharmacies within New Zealand was conducted by searching for New Zealand online pharmacies through Google.

RESULTS

A five-year audit of data (2007-2012) from the Wellington Hospital Emergency Department revealed that paracetamol was the most common medication used for overdose (23%). National data on aminophenol derivatives accounted for 22.4% of poisonings in New Zealand's public hospitals. An online search found that 25 out of 27 online pharmacies sold packets containing 50 grams of paracetamol. However, the literature supported restricting packets to the minimum threshold for an acute exposure (10 g).

CONCLUSION

Paracetamol poisoning is the most common form of drug overdose in many developed countries. Tightening restrictions on the quantity of paracetamol sold per packet, in all outlets in New Zealand, may be an effective strategy to reduce overdose rates. This includes online pharmacies where large quantities of paracetamol per packet are available for sale.

Interchangeability between paracetamol tablets marketed in Palestine. Is there a quality reason for a higher price?

The objective of this study was to evaluate the quality of 10 commercial paracetamol products available on the Palestinian market. We carried out a survey on the price of all paracetamol tablet products and assessed their quality. To assess quality, all products were examined visually for their organoleptic properties, tested for weight uniformity, friability, disintegration, and dissolution profile, and assayed for paracetamol content. All imported products were 2 to 3 times more expensive than the locally produced generic products. Based on our testing procedure, all paracetamol products were equivalent to the innovator product except for 1 imported product which fell below the approved specifications developed for the innovator product. Although the majority of generic products met the dissolution specification requirement that 80% of the drug must dissolve in 30 minutes, 1 generic product failed. These results demonstrate that generic paracetamol tablets produced by local manufacturers are often comparable in vitro to the innovator product and have lower costs.

Cost-effectiveness analysis of pharmacologic treatment of fibromyalgia in Mexico

OBJECTIVE

To identify, from the Mexican Public Health System perspective, which would be the most cost-effective treatment for patients with Fibromyalgia (FM).

MATERIAL AND METHODS

A Markov model including three health states, divided by pain intensity (absence or presence of mild, moderate or severe pain) and considering three-month cycles; costs and effectiveness were estimated for amitriptyline (50mg/day), fluoxetine (80 mg/day), duloxetine (120 mg/day), gabapentin (900 mg/day), pregabalin (450 mg/day), tramadol/acetaminophen (150 mg/1300 mg/día) and amitriptyline/fluoxetine (50mg/80 mg/día) for the treatment of FM. The clinical outcome considered was the annual rate of pain control. Probabilities assigned to the model were collected from published literature. Direct medical costs for FM treatment were retrieved from the 2006 data of the Mexican Institute of Social Security (IMSS) databases and were expressed in 2010 Mexican Pesos. Probabilistic Sensitivity Analyses were conducted.

RESULTS

The best pain control rate was obtained with pregabalin (44.8%), followed by gabapentin (38.1%) and duloxetine (34.2%). The lowest treatment costs was for amitriptyline ($ 9047.01), followed by fluoxetine ($ 10,183.89) and amitriptyline/fluoxetine ($ 10,866.01). By comparing pregabalin vs amitriptyline, additional annual cost per patient for pain control would be around $ 50.000 and $ 75.000 and would result cost-effective in 70% and 80% of all cases.

CONCLUSIONS

Among all treatment options for FM, pregabalin achieved the highest pain control and was cost-effective in 80% of patients of the Mexican Public Health System.

Economic evaluation of the photo-Fenton process. Mineralization level and reaction time: the keys for increasing plant efficiency

The use of the solar photo-Fenton process is proposed to degrade Paracetamol in water in order to form biodegradable reaction intermediates which can be finally removed with a downstream biological treatment. Firstly, biodegradability enhancement with photo-Fenton treatment time has been evaluated; the minimum mineralization level should be at least 18.6% where Paracetamol has been degraded and biodegradability efficiency is higher than 40%. 20 mg L(-1) of Fe(2+) and 200 mg L(-1) of H(2)O(2) were selected in a lab-scale study looking at Paracetamol's degradation rate and organic carbon mineralization rate. As a result of scaling up the process at a pilot plant, 157.5 mg L(-1) of Paracetamol (∼1 mM) was treated in 25 min of photo-Fenton treatment achieving the desired biodegradability. A further economic evaluation shows how the proposed treatment strategy markedly increases plant efficiency, resulting in an 83.33% reduction in reagent cost and a 79.11% reduction in costs associated with reaction time. Total cost is reduced from 3.4502 €/m(3) to 0.7392 €/m(3).

Intravenous paracetamol in patients with renal colic

Non-steroidal anti-inflammatory drugs and opioids have been the mainstay of pain relief in patients with renal colic, but both have side effects. Research on the efficacy of intravenous (IV) paracetamol shows that it is comparable to morphine, diclofenac and ketoralac. This article discusses the role of IV paracetamol for patients with this condition. It examines the effectiveness, mechanism of action and pharmacokinetics of IV paracetamol, and suggests that non-clinical prescribers can use the method to relieve patients' pain quickly.

Glucosamine sulphate in the treatment of knee osteoarthritis: cost-effectiveness comparison with paracetamol

INTRODUCTION

The aim of this study was to explore the cost-effectiveness of glucosamine sulphate (GS) compared with paracetamol and placebo (PBO) in the treatment of knee osteoarthritis. For this purpose, a 6-month time horizon and a health care perspective was used.

MATERIAL AND METHODS

The cost and effectiveness data were derived from Western Ontario and McMaster Universities Osteoarthritis Index data of the Glucosamine Unum In Die (once-a-day) Efficacy trial study by Herrero-Beaumont et al. Clinical effectiveness was converted into utility scores to allow for the computation of cost per quality-adjusted life year (QALY) For the three treatment arms Incremental Cost-Effectiveness Ratio were calculated and statistical uncertainty was explored using a bootstrap simulation.

RESULTS

In terms of mean utility score at baseline, 3 and 6 months, no statistically significant difference was observed between the three groups. When considering the mean utility score changes from baseline to 3 and 6 months, no difference was observed in the first case but there was a statistically significant difference from baseline to 6 months with a p-value of 0.047. When comparing GS with paracetamol, the mean baseline incremental cost-effectiveness ratio (ICER) was dominant and the mean ICER after bootstrapping was -1376 euro/QALY indicating dominance (with 79% probability). When comparing GS with PBO, the mean baseline and after bootstrapping ICER were 3617.47 and 4285 euro/QALY, respectively.

CONCLUSION

The results of the present cost-effectiveness analysis suggested that GS is a highly cost-effective therapy alternative compared with paracetamol and PBO to treat patients diagnosed with primary knee OA.

Managing acute acetaminophen poisoning with oral versus intravenous N-acetylcysteine: a provider-perspective cost analysis

BACKGROUND

Acetaminophen (APAP) overdose, which can lead to hepatotoxicity, is the most commonly reported poisoning in the United States and has the highest rate of mortality, with more than 100,000 exposures and 300 deaths reported annually (1) . The treatment of choice, N-acetylcysteine (NAC), is effective in both oral (PO) and intravenous (IV) formulations. The main difference in therapies, other than administration route, is time to complete delivery--72 hours for PO NAC versus 21 hours for IV NAC, according to full prescribing information. This distinction is the primary basis for variation in management costs for hospitalized patients receiving these products.

OBJECTIVES

To quantify and compare full treatment costs from the provider perspective to manage acute APAP poisoning with either PO or IV NAC in a standard treatment regimen.

METHODS

A cost model was developed and populated with published data comprising probabilities of potential clinical outcomes and the costs of resources consumed during patient care.

RESULTS

For patients who present <10 hours post-ingestion, the estimated total cost of care with PO NAC in the treatment regimen is $5,817 (ICU patients) or $3,850, (ward patients) compared with $3,765 and $2,768 for similar care with IV NAC. Potential cost savings equal - $2,052 (-35%) or -$1,083 (-28%), respectively, in favor of IV NAC. Similar potential savings were estimated for patients presenting 10-24 hours post-ingestion.

CONCLUSION

IV NAC is the less costly therapeutic option for APAP poisonings, based on simulation modeling and retrospective data. The current economic evaluation is restricted by the absence of comparative data from head-to-head, matched-cohort studies and the limitations common to retrospective APAP toxicology datasets. Additional research could refine these results.

Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): economic evaluation of a randomised controlled trial

OBJECTIVE

To estimate the cost to the NHS and to parents and carers of treating febrile preschool children with paracetamol, ibuprofen, or both, and to compare these costs with the benefits of each treatment regimen.

DESIGN

Cost consequences analysis and cost effectiveness analysis conducted as part of a three arm, randomised controlled trial.

PARTICIPANTS

Children between the ages of 6 months and 6 years recruited from primary care and the community with axillary temperatures >or=37.8 degrees C and <or=41 degrees C.

INTERVENTIONS

Paracetamol, ibuprofen, or both drugs.

MAIN OUTCOME MEASURES

Costs to the NHS and to parents and carers. Cost consequences analysis at 48 hours and 5 days comparing cost with children's temperature, discomfort, activity, appetite, and sleep; cost effectiveness analysis at 48 hours comparing cost with percentage of children "recovered."

RESULTS

Difficulties in recruiting children to the trial lowered the precision of the estimates of cost and some outcomes. At 48 hours, cost to the NHS was pound11.33 for paracetamol, pound8.49 for ibuprofen, and pound8.16 for both drugs. By day 5 these costs rose to pound19.63, pound18.36, and pound13.92 respectively. For parents and carers, the 48 hour costs were pound23.86 for paracetamol, pound20.60 for ibuprofen, and pound25.07 for both, and the day 5 costs were pound26.35, pound29.90, and pound24.02 respectively. Outcomes measured at 48 hours and 5 days were inconclusive because of lack of power; the cost effectiveness analysis at 48 hours provided little evidence that one treatment choice was significantly more cost effective than another. At 4 hours ibuprofen and the combined treatment were superior to paracetamol in terms of the trial primary outcome of time without fever; at 24 hours the combined treatment performed best on this outcome.

CONCLUSIONS

There is no strong evidence of a difference in cost between the treatments, but clinical and cost data together indicate that using both drugs together may be most cost effective over the course of the illness. This treatment option performs best and is no more expensive because of less use of healthcare resources, resulting in lower costs to the NHS and to parents.

Are N-of-1 trials an economically viable option to improve access to selected high cost medications? The Australian experience

OBJECTIVE

To explore the economic viability of N-of-1 trials for improving access to selected high cost medications in Australia.

METHODS

Cost and effectiveness estimates were derived from two N-of-1 trials conducted by The University of Queensland from 2003 to 2005-celecoxib versus sustained-release paracetamol for osteoarthritis in a general practice setting and gabapentin versus placebo for chronic neuropathic pain in a hospital setting. Effectiveness was determined by the proportion of responders to each medication. The costs of trials were offset against the savings generated by subsequent changes in prescribing. Decision analysis models with semi-Markov processes were used to compare different scenarios of N-of-1 trials versus usual care.

RESULTS

The fixed cost of performing N-of-1 trials was approximately AUS$23,000 for each trial and the variable cost was approximately AUS$1300 per participant. Clinical outcomes favored celecoxib over paracetamol in 17% of participants and gabapentin over placebo in 24% of participants. Modeling these results showed that the cost-offsets from efficient use of medications were less than the cost of running a trial; however, the incremental costs per quality-adjusted life-year gained were AUS$6,896 and AUS$29,550 for the gabapentin/placebo and celecoxib/paracetamol trials, respectively, over a 5-year horizon. Key factors affecting the viability were the time horizon modeled, the variable cost per participant, the probability of response to the intervention medication, and rates of use in nonresponders and the usual care alternative.

CONCLUSIONS

The N-of-1 strategy offers a realistic and viable option for increasing access to selected high cost medications where the medications are used for the symptomatic treatment of chronic disease, have rapid onset of action, and clinical response is unpredictable without a trial.

Acetaminophen and diphenhydramine premedication for allergic and febrile nonhemolytic transfusion reactions: good prophylaxis or bad practice?

Febrile nonhemolytic and allergic reactions are the most common transfusion reactions, but usually do not cause significant morbidity. In an attempt to prevent these reactions, US physicians prescribe acetaminophen or diphenhydramine premedication before more than 50% of blood component transfusions. Acetaminophen and diphenhydramine are effective therapies for fever and allergy, respectively, so their use in transfusion has some biologic rationale. However, these medications also have potential toxicity, particularly in ill patients, and in the studies performed to date, they have failed to prevent transfusion reactions. Whether the benefits of routine prophylaxis with acetaminophen and diphenhydramine outweigh their risks and cost requires reexamination, particularly in light of the low reaction rates reported at many institutions even when premedication is not prescribed.

Cost analysis applied to postoperative analgesia regimens: a comparison between parecoxib and propacetamol

BACKGROUND

Postoperative pain management represents a significant part of perioperative costs. Non-opioid analgesics are often used in combination with opiates to improve pain relief and reduce opioid-related side effects.

OBJECTIVE

To assess the costs and cost efficacy of intravenous (i.v.) parecoxib versus i.v. propacetamol in postoperative pain.

METHODS

A prospective, randomised, double-blind, clinical evaluation was performed to compare the efficacy of a single bolus injection of 40 mg parecoxib and 2 g propacetamol, administered twice within 12 h following surgical repair of inguinal hernia. Resources for each arm of treatment were collected, and total costs were determined, including costs of drug acquisition, devices and labour for preparation of the two analgesic drugs. Cost-efficacy analysis was performed as the cost to achieve complete satisfaction with analgesia. Incremental cost efficacy was determined as the ratio between the differential costs and the differential patient satisfaction. The analysis was performed from an institutional perspective over a 12 h time frame.

RESULTS

A total of 182 patients was evaluated. Pain at rest and morphine consumption were observed to be reduced in the parecoxib group. The percentages of patients totally satisfied with their pain management 12 h after surgery were 87% in the parecoxib-treated group and 70% in the propacetamol-treated group (P < 0.01). The average cost per patient was higher in the parecoxib group, 6.65 euros vs 5.28 euros in the propacetamol group). Cost per patient satisfied was calculated at a mean value of 7.64 euros for parecoxib and 7.54 euros for propacetamol. Incremental cost per additional patient satisfied was 8.02 euros in the parecoxib-treated group when preparation costs were included. Sensitivity analysis (+/-15%), including a bootstrap method applied to costs and efficacy, did not modify these conclusions.

CONCLUSION

Parecoxib exhibits higher cost and greater patient satisfaction than does propacetamol. From a cost-efficacy approach, incremental cost per additional patient satisfied for parecoxib treatment must be analysed in light of overall perioperative pharmaceutical cost.

Economic evaluation of controlled-release oxycodone vs oxycodone-acetaminophen for osteoarthritis pain of the hip or knee

OBJECTIVE

To examine, in routine practice, the effectiveness and cost-effectiveness of oxycodone (OxyContin) compared with standard therapy for osteoarthritis pain.

STUDY DESIGN

Open-label active-controlled randomized naturalistic 4-month study of oxycodone vs a combination of oxycodone-acetaminophen (Percocet).

METHODS

Outcomes and health resource utilization data were collected by telephone interview. Effectiveness was measured among 485 patients as the proportion having at least 20% improvement from baseline in the Western Ontario and McMaster Universities Osteoarthritis Index pain score. Quality-adjusted life-years (QALYs) were calculated from the Health Utilities Index 3 score. Cost-effectiveness was measured as cost per patient improved and the QALYs gained, using generic oxycodone-acetaminophen in the base case for the healthcare and societal perspectives. Uncertainty was evaluated using multiple 1-way sensitivity analyses and cost-effectiveness acceptability curves.

RESULTS

Improvement occurred in 62.2% of patients with oxycodone and in 45.9% of patients with oxycodone-acetaminophen (P < .001). After adjustment for baseline differences, 0.0105 QALYs were gained with oxycodone compared with oxycodone-acetaminophen (P = .17). The mean societal costs per patient during 4 months were 7379 US dollars and 7528 US dollars for oxycodone and oxycodone-acetaminophen, respectively (P = .33). Oxycodone was more effective and less costly than oxycodone-acetaminophen based on the societal perspective (including costs associated with time lost). Based on the healthcare perspective (excluding costs associated with time lost), the cost-effectiveness of oxycodone was 4883 US dollars per patient improved and 75,810 US dollars per QALY gained. The base-case results were robust.

CONCLUSIONS

From the societal perspective, oxycodone was more effective and less costly than oxycodone-acetaminophen. From the healthcare perspective, oxycodone (compared with generic oxycodone-acetaminophen) fell within the acceptable range of cost-effectiveness between 50,000 US dollars and 100,000 US dollars per QALY gained.

Impact of a general practitioner educational intervention on osteoarthritis treatment in an elderly population

PURPOSE

We examined whether a continuing medical education intervention increased general practitioners' ability to select the proper pharmacological treatment for patients with osteoarthritis.

SUBJECTS AND METHODS

Eight towns in Quebec, Canada were randomly allocated to one of four intervention options, workshop and decision tree, workshop, decision tree, or no intervention. All general practitioners practicing in each town were eligible to participate. We evaluated all dispensed prescriptions for either a cyclooxygenase (COX)-2 inhibitor, nonselective nonsteroidal anti-inflammatory drug or acetaminophen written by eligible general practitioners between May 2000 and June 2001 to elderly patients suffering from osteoarthritis. We used a multi-level Bayesian hierarchical model to assess the impact of the interventions on prescription adequacy.

RESULTS

We analyzed 5318 dispensed prescriptions written by 249 general practitioners in the five-month preintervention period and 4610 dispensed prescriptions written by the same physicians in the five-month postintervention period. A score of zero or one was given to every prescription, with one indicating prescription adequacy according to guidelines provided during the interventions. Bayesian hierarchical models showed some improvement in scores in the post- versus preintervention periods in all four groups. The probability of an improvement in the towns allocated the workshop and decision tree over the control was 94%, compared with 74% in the workshop group and 55% in the decision tree group.

CONCLUSION

An interactive approach offered by peers and complemented by easy to use guidelines may enhance the general practitioner's ability to manage osteoarthritis patients.

The role of paracetamol in chronic pain: an evidence-based approach

Chronic pain is a significant public health burden. Several international guidelines and influential reviews recommend the use of paracetamol (acetaminophen) as the first-line analgesic of choice for the management of chronic pain. These recommendations are based largely on the balance of evidence, which favorably demonstrates the efficacy, safety, and low cost of paracetamol relative to other analgesics.A decade ago, March et al suggested that because of the dangers associated with conventional nonsteroidal antiinflammatory (NSAID) use, particularly in the elderly, they should ideally not be used without an individual n-of-1 trial to show that they are more effective than paracetamol. Today, the results of our investigations into the individualization of pain management options continue to support this suggestion. Based on the data available to date, it still seems prudent to use NSAIDs only in those patients in whom there is good evidence of improved efficacy over paracetamol. In patients with chronic pain, paracetamol can play an important role as an NSAID sparer, with resultant benefits in terms of reduced adverse effects and cost savings.

Febrile nonhemolytic transfusion reactions. Management by premedication and cost implications in adult patients

CONTEXT

Febrile nonhemolytic transfusion reactions (FNHTRs) cause unwelcome interruptions during the course of blood product transfusions and necessitate measures to verify the nature of the reaction and to exclude certain dangerous reactions, such as hemolytic and septic phenomena.

OBJECTIVE

To examine transfusion medicine data to determine the clinical implications of the routine administration of antipyretic medication to adult patients before transfusion for the prevention of FNHTRs.

DESIGN

A retrospective review was conducted of FNHTR data during 5 years (1998-2002), and a determination was made of the cost of a transfusion complicated by an FNHTR. In addition, a comparative cost analysis was performed using our data and published data on the incidence of FNHTRs. The clinical implications of medication with respect to possible drug-induced adverse effects were assessed, as well as the potential interference with diagnosing other forms of transfusion reactions and the mitigation of the clinical effect of an FNHTR.

RESULTS

For nearly 120,000 U of transfused blood components, approximately 80% of which were preceded by antipyretic medication during the study period, the overall incidence of FNHTR was found to be 0.09%. Furthermore, there was no evidence of antipyretic-associated complications, nor any evidence that antipyretics prevented the recognition of other more dangerous complications of transfusions.

CONCLUSION

Our findings indicate that this practice provides significant advantages to the recipient of a transfusion, but does not appear to yield significant cost benefits for the health care provider.

NSAID alternatives

Patients taking celecoxib (Celebrex) because they cannot tolerate the GI effects of nonspecific NSAIDs could continue to do so, but should not exceed recommended dosage. For analgesia and osteoarthritis, acetaminophen (Tylenol, and others) or tramadol (Ultram, and others) are reasonable alternatives to NSAIDS. For rheumatoid arthritis, disease-modifying drugs (DMARDs) can be used.

[Analysis of cost-minimization treatment with paracetamol or COX-2 inhibitors (rofecoxib) for pain from arthrosis of the knee or hip]

OBJECTIVE

To assess the efficiency of paracetamol, indicated in first instance for light-to-moderate pain from hip and knee arthrosis, against rofecoxib, the COX-2 inhibitor most commonly used in Spain.

DESIGN

Pharmaco-economic model: cost-minimisation analysis based on the information provided by a systematic review of the literature.

SETTING

Spain: statewide.

PARTICIPANTS

Patients with a diagnosis of knee or hip arthrosis, who demand health-care for light-to-moderate pain in the primary care services and present no counter-indication to the treatments under evaluation.

MAIN MEASUREMENTS

Given the supposition of the equivalent efficacy of paracetamol and rofecoxib, the cost-minimisation model focused on the cost arising from the adverse side effects caused by the 2 drugs. A correction factor allowed for the number of subjects in the studies reviewed and the number of adverse side effects found.

RESULTS

Paracetamol was cheaper than rofecoxib at both 3 months and 1 year. The average cost of paracetamol per year was 307.95 Euros (301.57-315.12) versus 574.59 Euros (566.74-580.40) for rofecoxib treatment. The main cause of costs after the sensitivity analysis was the cost of acquiring the drugs, rather than the rate of incidence of adverse side effects.

CONCLUSIONS

In terms of economic analysis based on cost minimisation, paracetamol was the first-preference treatment over rofecoxib for light-to-moderate arthrosis pain. This confirmed the recommendations which, under efficacy and safety criteria, are indicated in various clinical practice guidelines in force.

Barbiturate Withdrawal Following Internet Purchase of Fioricet

BACKGROUND

The Internet enables businesses to advertise their pharmaceutical products and services without medical supervision. The Internet also allows for the unsupervised purchase of medications that may have neurologic consequences.

OBJECTIVE

To describe acute withdrawal delirium following the abrupt discontinuation of Fioricet.

PATIENT

The patient was a 37-year-old woman with a history of depression and migraine headaches but not drug abuse. She developed a florid withdrawal delirium following the discontinuation of a drug she purchased online. The medication, which contained butalbital, was self-administered in escalating doses for the treatment of chronic headaches. Daily doses of up to 750 mg to 1000 mg were reported.

RESULTS

The patient was admitted to the hospital for the treatment of unexplained seizures that were followed by several days of an intense withdrawal syndrome. Little improvement was noted after the administration of benzodiazepines and phenothiazine. After parenteral phenobarbital administration, her symptoms resolved.

CONCLUSIONS

The withdrawal state from barbiturates is similar to that from ethanol. Tolerance can develop with prolonged abuse, leading to escalating drug doses to achieve the desired effect. The suggested management of both types of withdrawal syndromes is similar, but the relative resistance of the behavioral and autonomic features in patients was remarkable. Physicians should be aware of the ease with which medications can be purchased without supervision from Internet pharmacies. The magnitude of the number of drugs that are made available through this means creates a proclivity to withdrawal states.

Costs and effectiveness of rofecoxib, celecoxib, and acetaminophen for preventing pain after ambulatory otolaryngologic surgery

We designed this randomized, double-blinded, placebo-controlled study to compare the analgesic effect of the cyclooxygenase-2 inhibitors rofecoxib and celecoxib with acetaminophen when administered before outpatient otolaryngologic surgery in 240 healthy subjects. Patients were assigned to one of four study groups: Group 1, control (vitamin C 500 mg); Group 2, acetaminophen 2 g; Group 3, celecoxib 200 mg; or Group 4, rofecoxib 50 mg. The first oral dose of the study medication was administered 15-45 min before surgery, and a second dose of the same medication was given on the morning after surgery. Recovery times, side effects, pain scores, and the use of rescue analgesics were recorded. Follow-up evaluations were performed at 24 and 48 h after surgery to assess postdischarge pain, analgesic requirements, nausea, and patient satisfaction with their postoperative pain management and quality of recovery. The need for rescue analgesia and peak pain scores were used as the primary end points for estimating efficacy, and the costs to achieve complete satisfaction with analgesia were used for the cost-efficacy comparisons. Premedication with oral rofecoxib (50 mg) or celecoxib (200 mg) was more effective than placebo in reducing postoperative pain scores and analgesic requirements in the postoperative care unit and after discharge. The analgesic efficacy of oral acetaminophen (2 g) was limited to the postdischarge period. Patient satisfaction with pain management was improved in all three treatment groups compared with placebo but was higher with celecoxib and rofecoxib compared with acetaminophen. Rofecoxib was also more effective than celecoxib in reducing pain and improving patient satisfaction after otolaryngologic surgery. Rofecoxib achieved complete satisfaction with pain control in one additional patient, who would not have otherwise been satisfied, at lower incremental costs to the institution compared with celecoxib. We conclude that rofecoxib 50 mg orally is more cost-effective for reducing postoperative pain and improving patient satisfaction with their postoperative pain management than celecoxib (200 mg) or acetaminophen (2 g) in the ambulatory setting.

IMPLICATIONS

Oral premedication with rofecoxib (50 mg) was more effective than celecoxib (200 mg) and acetaminophen (2 g) in reducing postoperative pain and in improving the quality of recovery and patient satisfaction with pain management after outpatient otolaryngologic surgery with only a small increase in cost of care.

The cost-effectiveness of acetaminophen, NSAIDs, and selective COX-2 inhibitors in the treatment of symptomatic knee osteoarthritis

OBJECTIVE

The objective of this study was to conduct an economic evaluation of rofecoxib and celecoxib compared with high-dose acetaminophen or ibuprofen with and without misoprostol for patients with symptomatic knee osteoarthritis (OA).

METHODS

A decision analysis model was designed over 6 months using two measures of effectiveness: 1) number of upper gastrointestinal (GI) adverse events averted; and 2) number of patients who achieved perceptible pain relief. Separate analyses were conducted for all patients and for those who did not respond to acetaminophen. Outcome probabilities were obtained from a comprehensive review of randomized controlled trials and observational studies. Costs were derived from actual resource utilization of OA patients.

RESULTS

In terms of averting GI events, acetaminophen dominates the other options for an average risk patient population. For patients who did not respond to acetaminophen, rofecoxib had the lowest incremental cost-effectiveness ratio (ICER) per GI event avoided (32,000 US dollars) relative to ibuprofen. In terms of pain control, ibuprofen had an ICER of 610.77 US dollars per additional patient achieving minimal perceptible clinical improvement (MPCI) relative to acetaminophen, while rofecoxib had an ICER of 12,000 US dollars relative to ibuprofen. For patients who did not respond to acetaminophen and who are at high risk of developing an adverse GI event, rofecoxib dominates ibuprofen as the preferred alternative for both measures of effectiveness. One-way, two-way, and probabilistic sensitivity analyses established that these results were generally robust.

CONCLUSIONS

Our results suggest that for average-risk knee OA patients, acetaminophen dominates the other therapies in terms of cost per GI event averted. In terms of pain relief, cost-effectiveness acceptability curves indicate that if one values pain relief below 275 US dollars per patient achieving MPCI, acetaminophen is the therapy most likely to be optimal; between 275 US dollars and 14,150 US dollars, ibuprofen is most likely to be optimal; and above 14,150 US dollars, rofecoxib is most likely to be optimal.

Evidence on the use of paracetamol in febrile children

Antipyretics, including acetaminophen (paracetamol), are prescribed commonly in children with pyrexia, despite minimal evidence of a clinical benefit. A literature review was performed by searching Medline and the Cochrane databases for research papers on the efficacy of paracetamol in febrile illnesses in children and adverse outcomes related to the use of paracetamol. No studies showed any clear benefit for the use of paracetamol in therapeutic doses in febrile children with viral or bacterial infections or with malaria. Some studies suggested that fever may have a beneficial role in infection, although no definitive prospective studies in children have been done to prove this. The use of paracetamol in therapeutic doses generally is safe, although hepatotoxicity has occurred with recommended dosages in children. In developing countries where malnutrition is common, data on the safety of paracetamol are lacking. The cost of paracetamol for poor families is substantial. No evidence shows that it is beneficial to treat febrile children with paracetamol. Treatment should be given only to children who are in obvious discomfort and those with conditions known to be painful. The role of paracetamol in children with severe malaria or sepsis and in malnourished, febrile children needs to be clarified.

[Pain management: health economics and quality of life considerations]

Pain represents a major clinical, social and economic problem, with estimates of its prevalence ranging from 8% to more than 60%, depending on the population. The impact of pain on economies is enormous, with the cost of back pain alone equivalent to more than one-fifth of one country's total health expenditure and 1.5% of its annual gross domestic product, while in another it represents three times the total cost of all types of cancer. However, decision makers have tended to concentrate their attention on one very minor component of the cost burden, namely prescription costs, which, in the case of back pain, represent 1% of the total cost burden. In addition to its economic impact, chronic pain is probably one of the diseases with the greatest negative impact on quality of life. For example, the quality of life for those with migraine had been shown to be at best equal to that for people with arthritis, asthma, diabetes mellitus or depression. The burden that pain imposes on individuals and the enormous costs that society has to bear as a result clearly demonstrate the need for collective thinking in the decision-making process. A broad, strategic perspective--based on evidence relating to effectiveness (including tolerability), efficiency and equity--is required in determining issues relating to the provision of services and resource allocation. In this regard, it is clear that paracetamol (acetaminophen) is effective in securing an analgesic effect; it has a good tolerability profile and is relatively cheap, in terms of both drug acquisition costs and its overall cost profile. Pain management strategies based on collective thinking should therefore place great reliance on paracetamol as an initial therapy in maximising pain relief and minimising cost and the impact of adverse effects.

Cost-efficacy of rofecoxib versus acetaminophen for preventing pain after ambulatory surgery

BACKGROUND

Nonsteroidal antiinflammatory drugs are commonly administered as part of a multimodal regimen for pain management in the ambulatory setting. This randomized, double-blinded, placebo-controlled study was designed to compare the analgesic effect of oral rofecoxib, a cyclooxygenase-2 inhibitor, and acetaminophen when administered alone or in combination prior to outpatient otolaryngologic surgery.

METHODS

A total of 143 healthy outpatients undergoing elective otolaryngologic surgery were assigned to one of four study groups: group 1 = control (500 mg vitamin C); group 2 = 2 g acetaminophen; group 3 = 50 mg rofecoxib; or group 4 = 2 g acetaminophen and 50 mg rofecoxib. The first oral dose of the study medication was taken 15-45 min before surgery, and a second dose of the same medication was administered on the morning after surgery. Recovery times, side effects, and the need for rescue analgesics were recorded. Follow-up evaluations were performed at 24 and 48 h after surgery to assess postdischarge pain, analgesic requirements, nausea, and patient satisfaction with their postoperative pain management and quality of recovery. Peak pain scores and the need for rescue analgesic medication were used as the endpoints for estimating efficacy of the study drugs, while cost to achieve complete satisfaction with analgesia was used in the cost-effectiveness analysis.

RESULTS

Premedication with rofecoxib (50 mg) was significantly more effective than either placebo or acetaminophen (2 g) in reducing the peak postoperative pain, the need for analgesic medication, and improving the quality of recovery and patient satisfaction. Moreover, the addition of acetaminophen failed to improve its analgesic efficacy. An expenditure for rofecoxib of 16.76 US dollars (95% confidence interval, 7.89 to 21.03 US dollars) and 30.24 US dollars (95% confidence interval, 5.25 to 54.20 US dollars) would obtain complete satisfaction with pain control in one additional patient who would not have been satisfied if placebo or acetaminophen, respectively, had been administered prior to surgery.

CONCLUSIONS

Rofecoxib, 50 mg administered orally, decreased postoperative pain and the need for analgesic rescue medication after otolaryngologic surgery. The addition of 2 g oral acetaminophen failed to improve its analgesic efficacy.

Paracetamol toxicity: epidemiology, prevention and costs to the health-care system

Paracetamol has been used as an analgesic and antipyretic for many years, with toxicity first noted in the 1960s. Since then the incidence of poisoning has increased, and paracetamol is now the most common drug in self-poisoning, with a high rate of morbidity and mortality. The use, abuse and ways of reducing paracetamol toxicity are reviewed, but in view of the potential for harm, serious consideration should be given to changing the legal status of paracetamol, possibly to a prescription-only medicine.

The role of acetaminophen in the management of patients with osteoarthritis

Both the incidence and prevalence of osteoarthritis increase with advancing age. Management of osteoarthritis in older adults focuses on reducing pain and other symptoms, minimizing functional limitation and disability from the disease, and avoiding the side effects associated with pharmacologic therapy. This article first briefly reviews the clinical pharmacology of acetaminophen and then summarizes the evidence supporting the use of acetaminophen in the management of patients with osteoarthritis. We conclude that acetaminophen, when given at full doses of 4,000 mg/day, is more efficacious than placebo and has comparable efficacy to ibuprofen in the management of patients with osteoarthritis of the knee who have mild to moderate pain. Thus, acetaminophen merits a trial as initial therapy based on its cost-effectiveness and safety profile relative to NSAIDs.

Economic evaluation alongside n-of-1 trials: getting closer to the margin

The n-of-1 trial is a particularly flexible form of randomized controlled trial that involves a single patient receiving multiple episodes of alternative therapies. Although n-of-1 trials are only applicable in certain treatment areas, the collection of economic data within such trials may provide unique advantages. This paper illustrates the issues around the use of economic n-of-1 trials with a hypothetical example, and discusses their potential for the estimation of individualized cost-effectiveness.

Impact of prepackaging antimalarial drugs on cost to patients and compliance with treatment

OBJECTIVE

To examine the extent to which district health teams could reduce the burden of malaria, a continuing major cause of mortality and morbidity, in a situation where severe resource constraints existed and integrated care was provided.

METHODS

Antimalarial drugs were prepackaged into unit doses in an attempt to improve compliance with full courses of chemotherapy.

FINDINGS

Compliance improved by approximately 20% in both adults and children. There were 50% reductions in cost to patients, waiting time at dispensaries and drug wastage at facilities. The intervention, which tended to improve both case and drug management at facilities, was well accepted by health staff and did not involve them in additional working time.

CONCLUSION

The prepackaging of antimalarials at the district level offers the prospect of improved compliance and a reduction in the spread of resistance.

Gastrointestinal health care resource use and costs associated with nonsteroidal antiinflammatory drugs versus acetaminophen: retrospective cohort study of an elderly population

OBJECTIVE

To estimate gastrointestinal (GI) health care resource use and direct costs associated with prescription nonsteroidal antiinflammatory drugs (NSAIDs) in an elderly population.

METHODS

Using the Government of Quebec's health insurance database, we obtained the medical, pharmaceutical, and demographic records of 73,850 senior citizens who, between 1993 and 1997, had either an NSAID or an acetaminophen prescription dispensed. The date of their first dispensed prescription for an NSAID or acetaminophen was termed their index date. Patients who were not taking oral corticosteroids or anticoagulants at their index date, were not diagnosed with cancer at their index date, and were not hospitalized and did not have any GI events during the year prior to their index date were included in the study. Patients who had a dispensed NSAID prescription at their index date formed the NSAID cohort; the others formed the acetaminophen cohort. All patients were followed up for 2 years. The daily direct costs of GI events incurred during NSAID therapy by the NSAID cohort were compared with those incurred during a similar followup period by the acetaminophen cohort. The difference in these average daily costs was attributed to NSAID use.

RESULTS

The NSAID cohort included 5,268 senior citizens and the acetaminophen cohort 2,245. More GI adverse events were observed in the NSAID cohort (odds ratio 2.48, 95% confidence interval 2.06, 3.00). The average daily direct cost of GI events for a day of NSAID therapy attributed to the NSAIDs was $0.84 (Canadian). On average, for each Canadian dollar spent on NSAIDs, an additional $0.66 was spent on their side effects.

CONCLUSION

Safer alternatives to NSAIDs would significantly reduce medical care costs for patients in need of NSAID therapy.

Comparison of a fixed combination of domperidone and paracetamol (Domperamol) with sumatriptan 50 mg in moderate to severe migraine: a randomised UK primary care study

Migraine is a common and debilitating condition routinely managed in primary care. A number of treatment options--both acute and prophylactic--are currently available but may differ in terms of efficacy, tolerability and cost. The aim of this study was to compare the effectiveness and tolerability of a fixed combination of domperidone and paracetamol (Domperamol; Servier), which has anti-nauseant and anti-emetic activity, with sumatriptan 50 mg in moderate to severe migraine. To do this, 120 patients were recruited from 23 primary care practices throughout the UK and were enrolled into the six-month trial. Patients were randomised at entry to one of the comparator regimens (used to treat their first migraine attack) and then crossed over to the alternative treatment for their second attack. Detailed diary cards were completed for each attack using a scale of pain severity. At two hours and four hours post-dose, the two treatments showed comparable efficacy (< or = 15% difference) in relieving headache and reducing nausea and vomiting. Both were well tolerated and there were no serious adverse effects. In the management of migraine patients typically seen in routine general practice, this trial showed that the effects of Domperamol and sumatriptan 50 mg were broadly comparable. Since Domperamol is considerably less expensive than sumatriptan (and other triptans), a first-line role for this agent appears appropriate.

[Chronic pain during dialysis. Pharmacologic therapy and its costs]

BACKGROUND

There is very little research into the problem of chronic pain in dialysed patients, despite the fact that pain is a widely diffused phenomena amongst these patients. This work proposes to evaluate the intensity of pain, supply a scale of levels of intervention, with an indication of the consumption and relative costs of pharmacological therapies.

METHODS

37 out of 100 patients undergoing haemodialysis suffer chronic pain. Aetiological research has shown that osteoarticular pain (24 cases), is the most common, peripheral vascular pain (3 cases), is subjectively and indirectly considered to be the most serious form. Nine cases have presented pain of a neuromuscular origin, whilst one case of a neoplastic origin. The degree of personal invalidism shows serious invalidism in 11 cases.

RESULTS

The therapeutic file that forsaw four levels of pharmacological intervention (1st levels: FANS, 2nd level: Codeine+paracetamol, 3rd level: Buprenorphine, 4th level: Morphine for os), accompanied by instrumental and pharmacological support intervention, has proved to be indispensable in confronting the problem. Through pharmacy data, we have noticed a progressive increase over the year in the use of analgesic medicines, of which we can confirm the effectiveness, tolerability, low level of side-effects, at low costs.

CONCLUSIONS

In our opinion chronic pain in dialysed patients should not be neglected. The perfection of diagnostic techniques, the discovery of pain-killers with reduced side-effects, the multidisciplinary approach, and reduced costs of treatment, are all valid arguments in favour of an intervention that improves the quality of life of these patients, already so compromised by the nature of the illness itself.

Comparison of postoperative emesis, recovery profile, and analgesia in pediatric strabismus repair. Rectal acetaminophen versus intravenous fentanyl-droperidol

BACKGROUND

Postoperative nausea and vomiting comprise significant morbidity in pediatric patients undergoing strabismus repair and can prolong hospitalization. Many authors recommend routine intraoperative opiate analgesia and prophylactic antiemetics.

METHODS

A prospective, comparative, randomized study to assess rectal acetaminophen (n = 45) to intravenous fentanyl-droperidol (n = 45) to resolve recovery profile, emesis rate, and adequacy of analgesia in a pediatric strabismus repair population was performed, with standardization of the anesthetic technique. Data on pharmacoeconomic cost-effectiveness analysis, willingness to pay, and willingness to repeat were elucidated.

RESULTS

Emesis rate in the acetaminophen group was 9%, and the fentanyl-droperidol group was 13% (not statistically significant). There was a statistically significant shorter wake-up time, time in postanesthesia recovery, time in ambulatory surgery unit, time to first verbal command, time to first oral intake, time to ambulation, and time to return to normal activity in the acetaminophen group (P < 0.05). Postoperative analgesic potency of rectal acetaminophen was adequate and equivalent by Observer Pain Scale. Parental satisfaction was similar by willingness-to-pay and willingness-to-repeat postoperative survey. Cost-effectiveness ratio (i.e., cost per treatment success) for acetaminophen and fentanyl-droperidol groups was $0.33 and $87.91, respectively.

CONCLUSIONS

Prophylactic fentanyl-droperidol prolongs the length-to-stay and recovery time and provides no discrete identifiable benefit over acetaminophen alone in this population. Cost-effectiveness analysis strongly favors use of acetaminophen over fentanyl-droperidol prophylaxis in children undergoing primary strabismus surgery.

Acetaminophen ingestion in childhood--cost and relative risk of alternative referral strategies

Acetaminophen is the pharmaceutical most frequently ingested by small children. Although past research has allowed the safe management of 90% of these ingestions at home, several thousand are still referred to emergency departments annually. With the goal of further reducing the number of unnecessary referrals, the risk/benefit considerations of alternate referral strategies were analyzed. In a retrospective poison center chart review study from 11 centers, the records of children between the ages 1 and 6 years who acutely ingested acetaminophen and were referred to a hospital for determination of serum acetaminophen concentration in 1986 and 1987 were identified using the database of the American Association of Poison Control Centers. Risk of hepatic injury was assigned on the basis of the Rumack-Matthew acetaminophen toxicity nomogram. The cohort was stratified in terms of the amount ingested and whether a pediatric or adult preparation was ingested. The direct cost of an evaluation was estimated from four centers. Sensitivity, specificity and direct cost of each risk identification strategy were calculated. Eight hundred sixty six of 2091 patients had a timed serum acetaminophen concentration recorded. Of these, three patients had results in the "probable risk" area of the nomogram. A referral reduction strategy which would refer only children who ingest 200 mg/kg or more of an adult preparation could eliminate 82% of referrals without missing any of these "probable risk" patients. Six other children were determined to have serum acetaminophen concentrations in an area of the nomogram labeled "possible risk". No referral reduction strategy explored identified all of these patients. The average charge for an emergency department evaluation in 1992 was $272.00. These data suggest that children less than six years of age who ingest pediatric acetaminophen products other than those from packages containing greater than 30 tablets or who ingest less than 200 mg/kg of an adult preparation may be safely managed at home without referral to a hospital. This strategy would result in significant cost savings and prevent unnecessary inconvenience to many patients and families.

Should osteoarthritis be treated with nonsteroidal anti-inflammatory drugs?

Numerous studies have demonstrated the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) and their superiority to placebo as symptomatic treatment for osteoarthritis (OA). Unquestionably, use of NSAIDs has reduced joint pain and improved mobility for millions of patients with OA. This article explores the uncertainty that exists regarding the use of NSAIDs in the treatment of OA.