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Amy Durtschi

The cost of acute episodes such as renal failure, heart failure, and delirium can be dramatic. Eight out of 10 patients on mechanical ventilation have at least one episode of delirium, noted Amy Durtschi, associate director of health economics and health outcomes research for Abbott Laboratories. Patients with delirium typically spend eight days in the ICU compared with five days for similar patients who remain adequately sedated and do not suffer delirium. A single episode of delirium boosts the typical ICU cost from $14,000 to more than $23,000.

"You have to assume that ICU costs are underestimated," Durtschi said. "These kinds of studies are not done as often as they might be. But with that kind of cost difference, we can expect to see increasing importance placed on the effectiveness of a drug, not its cost."

ICU sedation is a case in point. Sedatives account for 10% to 15% of the typical ICU drug spend, Dasta said. Excessive sedation can prolong the ICU stay and so can inadequate sedation.

Studies in Canada in the late 1990s showed that propofol is more effective than midazolam. Propofol costs twice as much, but patients spend 20% longer at the target sedation level. It was calculated that propofol's higher effectiveness saved $403 per patient for every 10 hours of sedation, despite the higher price. Similar results have been found with low molecular weight heparin (expensive) versus unfractionated heparin (cheap) to prevent postsurgical pulmonary embolism and deep vein thrombosis.

Computing cost-effectiveness in the short term of an ICU stay can be relatively straightforward, said Sandra Kane-Gill, Pharm.D., assistant professor, University of Pittsburgh School of Pharmacy Center for Pharmacoinformatics and Outcomes Research. Figuring the cost-effectiveness of a lifesaving treatment over an entire lifetime is more difficult.