Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery

Paediatr Anaesth. 2018 Mar;28(3):237-248. doi: 10.1111/pan.13329. Epub 2018 Jan 29.

Abstract

Background: Enhanced recovery after surgery protocols increasingly use multimodal analgesia after major surgeries with intravenous acetaminophen and ketorolac, despite no documented cost-effectiveness of these strategies.

Aims: The goal of this prospective cohort study was to model cost-effectiveness of adding acetaminophen or acetaminophen + ketorolac to opioids for postoperative outcomes in children having scoliosis surgery.

Methods: Of 106 postsurgical children, 36 received only opioids, 26 received intravenous acetaminophen, and 44 received acetaminophen + ketorolac as analgesia adjuncts. Costs were calculated in 2015 US $. Decision analytic model was constructed with Decision Maker® software. Base-case and sensitivity analyses were performed with effectiveness defined as avoidance of opioid adverse effects.

Results: The groups were comparable demographically. Compared with opioids-only strategy, subjects in the intravenous acetaminophen + ketorolac strategy consumed less opioids (P = .002; difference in mean morphine consumption on postoperative days 1 and 2 was -0.44 mg/kg (95% CI -0.72 to -0.16); tolerated meals earlier (P < .001; RR 0.250 (0.112-0.556)) and had less constipation (P < .001; RR 0.226 (0.094-0.546)). Base-case analysis showed that of the 3 strategies, use of opioids alone is both most costly and least effective, opioids + intravenous acetaminophen is intermediate in both cost and effectiveness; and opioids + intravenous acetaminophen and ketorolac is the least expensive and most effective strategy. The addition of intravenous acetaminophen with or without ketorolac to an opioid-only strategy saves $510-$947 per patient undergoing spine surgery and decreases opioid side effects.

Conclusion: Intravenous acetaminophen with or without ketorolac reduced opioid consumption, opioid-related adverse effects, length of stay, and thereby cost of care following idiopathic scoliosis in adolescents compared with opioids-alone postoperative analgesia strategy.

Keywords: cost-effectiveness; intravenous acetaminophen; ketorolac; multimodal analgesia; pain; spine fusion.

MeSH terms

  • Acetaminophen / administration & dosage
  • Acetaminophen / economics*
  • Acetaminophen / therapeutic use*
  • Adolescent
  • Analgesics, Non-Narcotic / administration & dosage
  • Analgesics, Non-Narcotic / economics*
  • Analgesics, Non-Narcotic / therapeutic use*
  • Analgesics, Opioid / adverse effects
  • Analgesics, Opioid / therapeutic use
  • Anti-Inflammatory Agents, Non-Steroidal / administration & dosage
  • Anti-Inflammatory Agents, Non-Steroidal / economics*
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use*
  • Child
  • Cohort Studies
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Drug Therapy, Combination / economics
  • Female
  • Humans
  • Injections, Intravenous
  • Ketorolac Tromethamine / administration & dosage
  • Ketorolac Tromethamine / economics*
  • Ketorolac Tromethamine / therapeutic use*
  • Male
  • Pain, Postoperative / drug therapy
  • Postoperative Complications / epidemiology
  • Prospective Studies
  • Scoliosis / surgery*
  • Treatment Outcome

Substances

  • Analgesics, Non-Narcotic
  • Analgesics, Opioid
  • Anti-Inflammatory Agents, Non-Steroidal
  • Acetaminophen
  • Ketorolac Tromethamine