Are $100,000-plus ICU drugs worth the cost?

Yes – Expensive drugs may offset other costs.

As in every aspect of medicine, there is a cost-benefit balance, with the cost of care being weighed against the benefits of a favorable outcome. The debate seems to be complex, but it can really be boiled down to a single question: Is the therapy worth using when compared with alternatives or to current practice?

It is incumbent upon us as clinicians to evaluate the appropriate use of both expensive and inexpensive drugs.

Drug costs in the ICU always involve more than meets the eye. If we take the traditional silo-based perspective and focus only on the acquisition cost of a drug, we’re ignoring the reality that the less expensive drug is not always the best drug for a condition and that health system costs are affected by the total cost of care. If a less expensive drug requires more patient monitoring, it offsets at least some of the cost advantage by adding higher laboratory or imaging costs.

Another consideration for the hospital is the reimbursement climate. Hospitals that receive low scores on pain management under the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey may experience significant reductions in reimbursement. So if, say, an expensive nonopioid analgesic used as part of a multimodal therapy could significantly improve pain control and reduce opioid-related adverse events, the extra cost could be justified.

Acquisition costs are only part of a drug’s total cost, which also includes the costs of preparation, storage, administration (such as infusion devices), lab monitoring, treating adverse drug events, and, of course, failed therapy.

Costly drugs also may pay for themselves by offsetting other costs. A new, costly drug that reduces the patient’s length of ICU stay by 1 day would save $4,000 to $5,000, and a drug that reduces time spent on a mechanical ventilator could reduce costs by about $1,900 for each ventilator-free day. Ventilator-associated pneumonias cost approximately $50,000 more per case ($70,580 vs. $21,620), but prevention strategies, including the use of medications, could reduce these costs.

Our group recently did a study of ICU costs associated with acute kidney injury following coronary artery bypass grafts and found that costs were twice as high in patients with kidney injury ($25,950 vs. $13,830). If patients have even a 1.5-fold increase over baseline in serum creatinine, the associated cost is $21,775, compared with $13,830 in patients whose serum creatinine is controlled. We calculated that an effective drug, if it cost less than $12,000, would offset these costs (Textbook of Critical Care, 6th edition, 2011, pp. 1387-92).

A 2012 analysis of the cost offset of tolvaptan in patients with inappropriate antidiuretic hormone secretion indicated that the cost of treating hyponatremia was $1,694 and that tolvaptan, at a cost of $250 per day for 4 days, reduced the length of stay by an estimated 1.1 days, thereby providing a savings of $694 per patient (Hosp. Pract. 2012;40:7-14).

Similarly, recombinant factor VIIa costs $7,000 to $10,000 per dose, but when used for its approved indication – bleeding episodes in hemophilia A or B patients with inhibitors to factors VIII/IX and for prevention of bleeding during surgical intervention in these patients – costs per resolved bleeding episode were $3,000 to $17,000 lower than for patients given activated prothrombin complex concentrate (Haemophilia 2009;15:405-19).

Clinicians are excited when we have new options for therapy, but we have to figure out where a new, expensive therapy fits. Does it make sense to use it? What is the efficacy of the drug relative to its costs? The key to the appropriate use of drugs, both costly and cheap, is to develop a disease state–based protocol tailored to your institution’s specific usage patterns, case mix, economic climate, and politics.

Dr. Sandra Kane-Gill is associate professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. She also serves as associate professor for the Center for Pharmacoinformatics and Outcomes Research at the School of Pharmacy.

No – With cost evaluations, the devil is in the details.

Drug-cost evaluations look great on paper, but they often don’t work in the real world. An expensive drug may let you take a patient off a ventilator earlier, but if you can’t send the patient to the floor because there is no available bed and you can’t let that patient’s nurse go home, there may not be a true savings in cost.

As Dr. Kane-Gill points out, the problem is complex and there are many analytic approaches. We can consider whether we have therapeutically equivalent options, balance the cost-effectiveness and cost-benefit ratios of treatments with different outcomes, or consider patient preference measured in cost-utility tradeoff and expressed as quality-adjusted life years (QALYs).