TY - JOUR
T1 - Preoperative paravertebral blocks for the management of acute pain following mastectomy
T2 - a cost-effectiveness analysis
AU - Offodile, Anaeze C.
AU - Sheckter, Clifford C.
AU - Tucker, Austin
AU - Watzker, Anna
AU - Ottino, Kevin
AU - Zammert, Martin
AU - Padula, William
PY - 2017/7/4
Y1 - 2017/7/4
N2 - Purpose: Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds. Methods: A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control. Results: The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40–$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71–$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds. Conclusion: Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.
AB - Purpose: Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds. Methods: A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control. Results: The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40–$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71–$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds. Conclusion: Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.
KW - Cost-effectiveness analysis
KW - Mastectomy
KW - Pain
KW - Paravertebral block
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U2 - 10.1007/s10549-017-4371-9
DO - 10.1007/s10549-017-4371-9
M3 - Article
C2 - 28677010
AN - SCOPUS:85021832373
SN - 0167-6806
SP - 1
EP - 8
JO - Breast Cancer Research and Treatment
JF - Breast Cancer Research and Treatment
ER -