Medical Inspection – Health Blog

As shown in Table 6, the three predictors of the increasing LOS in the recovery room, in decreasing order of importance, were:

• a longer duration of the procedure.
• older age of the patient.
• the antiemetic drug administered (the use of granisetron or dolasetron versus ondansetron drug).

Therefore, the variables that were not significant predictors of LOS (both univariately and multivariately) were as follows:

• the need for a rescue medication
• the patient’s sex
• the number of anesthetic induction agents used
• perioperative or postoperative administration of the antiemetic drug

From the regression analysis (data not shown), the use of ondansetron, compared with dolasetron and granisetron, reduced the length of recovery by almost 19%.

Table 6 Multivariate Analysis of Predictors of Increasing Length of Stay in the Recovery Room

Table 7 summarizes the multivariate analysis of predictors of the need for a rescue drug. The variables that were most predictive of patients requiring a rescue drug, in order of decreasing importance, were:

• female sex.
• administration of dolasetron or granisetron, compared with ondansetron canadian.
• the increasing number of induction agents used in the procedure.

With regard to the odds ratio, women were 2.7 times more likely than men to need a rescue drug. This finding is consistent with the current literature. Patients receiving dolasetron or granisetron for the prevention of PONV were 2.5 times more likely to require a rescue agent than those receiving ondansetron.

The number of anesthetic induction agents used in the procedure was also a significant factor in predicting the need for a rescue agent. As the number of induction agents increased by one agent, there was an increase of 42% in the probability of needing a rescue drug (odds ratio, 1.42).

Table 7 Multivariate Analysis of Predictors of the Need for a Rescue Medication

Again, the type of procedure, the age of the patient, peri-operative or postoperative administration of the antiemetic drug, and the duration of the procedure were not significant predictors of the need for a rescue drug, either univariately or multivariately. cheap cialis canadian pharmacy

DISCUSSION

Cost

Hill et al. noted that the hospital cost of each emetic episode was approximately $400. Many components accounted for this expense, including:

• antiemetic agents, only 3% of the total expense.
• personnel charges, 83%.
• the patient’s hospital admission, 10%.
• an extended stay in the recovery room, 4%.
• hospital materials, 0.2%.

The cost-effectiveness of using ondansetron rather than granisetron and dolasetron for preventing (and treating, if necessary) PONV was further investigated. The costs per dosage of the three medications were as follows:

• granisetron, $9.25
• dolasetron, $10.75
• ondansetron, $16.75.

All of the patients received one of the three medications during or after the surgical procedure to prevent PONV. Rescue medications were needed as follows:

• canadian granisetron: 24 of 100 patients, or 24%
• dolasetron: 21 of 89 patients, or 23.6%
• ondansetron: 11 of 93 patients, or 11.8%

Even though granisetron is the least expensive drug, its rescue rate is the highest (24%). Ondansetron is the most expensive drug, but its rescue rate was the lowest (11.8%). The rescue rates for granisetron and dolasetron were similar (23.6% vs. 24%), but granisetron is 14% less expensive than dolasetron. Therefore, dolasetron was not considered in this analysis.

Ondansetron appears to be a more effective antiemetic agent because it has the lowest rescue rate. Consequently, clinicians generally use it for rescue purposes in PONV to increase the chances that nausea will be resolved after the rescue drug is taken. Therefore, this cost-effectiveness analysis assumes that ondansetron is the only drug used as a rescue medication.

The following two strategies were used to compute the total costs of prevention (and treatment, if necessary) of PONV:

1. Giving granisetron to prevent PONV, followed by ondan­setron for rescue, if necessary): For 100 patients, it would cost

100 x $9.25, or $925, to prevent PONV with the use of granisetron. We would expect 24% (24 patients) to require ondansetron as the rescue drug. This would cost patients 24 x $16.75, or $402. The total cost of preventing PONV in 100 patients and treating it (with rescue medication) in 24 patients is $402 + $925, or $1,327. Therefore, the total cost per patient is $1,327 -f 100, or $13.27.
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2. Giving ondansetron to prevent PONV and as rescue medication, if necessary): For 100 patients, it would cost 100 x $16.75, or $1,675 to prevent PONV with the use of ondansetron. We would expect 11.8% (11.8 patients) to require ondansetron as a rescue drug. This would cost 11.8 x $16.75, or $197.65. The total cost of preventing PONV in 100 patients and treating it in 11.8 patients is $1,675 + $197.65, or $1,872.65. Therefore, the total cost per patient is $1,872.65 f 100, or $18.73.

The difference in cost per patient for the two strategies would be $18.73 – $13.27, or $5.46 ($5.50). Thus, for an additional cost of $5.50 per patient, we could reduce the chances of that patient’s needing a rescue drug from 24% to 11.8% (a 50% reduction). Alternatively, the cost per 1% reduction in the percentage use of a rescue drug would be $5.46/(24 – 11.8), or $0.45. Considering the difference in cost per patient for the two strategies ($5.50), it is understood that—even though the total cost of preventing PONV and using a rescue medication is higher for ondansetron than for granisetron—ondansetron has the ability to lower the probability of a patient who would require a rescue drug by about 50% for a nominal additional amount of $5.50 per patient.

As mentioned earlier, each event of breakthrough nausea and vomiting can cost the hospital up to $400. The results from the LOS multivariate analysis confirm that even though the cost per dosage of ondansetron is higher than that of dolasetron and granisetron, the LOS in the recovery room is reduced by about 19%, compared with a combination of the other two agents. This reduction is significant for a hospital because this suggests a decrease in expenses on other direct and indirect medical and nonmedical costs that are associated with caring for the patient. Consequently, the potential result is more efficient utilization of resources because space is created for a new patient after a bed is vacated.

Study Limitations

One limitation of our study was our inability to establish a correlation between the duration and the type of procedure to the use of a rescue drug because the sample size was not large enough. Because this was a retrospective study, there was no control over the quality and type of data that were available. Therefore, a randomized, controlled, prospective clinical trial should be conducted with these agents to further validate our findings.
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Finally, the cost-effectiveness analysis considered only the cost of the antiemetic drugs for preventing and treating PONV. The analysis did not include other direct and indirect medical or nonmedical expenses, such as those for personnel, admissions, and hospital materials, all of which are associated with each emetic episode.

CONCLUSION

The incidence of PONV is reported to be in the range of 20% to 30%. The complications of PONV can cost up to $400 per episode for a hospital.

After observing 282 patients who received dolasetron, ondansetron, or granisetron for the prevention of PONV, we found that significantly fewer patients receiving ondansetron needed a rescue medication, compared with patients receiving dolasetron (11.8% vs. 23.6%, P = .05), generic granisetron (11.8% vs. 24%, P < 0.04), or a combination of the two (11.8% vs. 23.8%, P < .02). We also noted a significant reduction in the LOS in the recovery room for patients receiving ondansetron (2 hours), compared with dolasetron (3.3 hours), or granisetron (3 hours) (P < .0001 by the Kruskal-Wallis test; P < .05 by Tukey’s test).

On the basis of these findings, we suggest that it is more cost-effective to use ondansetron as a first-line therapy to prevent and treat PONV because it appears to be the most efficacious agent among the three, secondary to its reduced need for a rescue drug and its significant reduction of recovery-room time.

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