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Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis

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Abstract

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.

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Acknowledgements and Funding Information

The present study was not supported by a pharmaceutical company and no persons or entity had input into the design or analysis of the cost-effective analysis besides the listed authors. Additionally, the authors have no acknowledgements, conflicts of interest, or any financial disclosures to report regarding the content of this manuscript.

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Authors and Affiliations

  1. Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA

    Anaeze C. Offodile II

  2. Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA

    Clifford C. Sheckter

  3. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA

    Austin Tucker, Anna Watzker & Kevin Ottino

  4. Department of Anesthesia, Brigham and Women’s Hospital, Boston, MA, 02115, USA

    Martin Zammert

  5. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA

    William V. Padula

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  1. Anaeze C. Offodile II
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  2. Clifford C. Sheckter
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  3. Austin Tucker
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  4. Anna Watzker
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  7. William V. Padula
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Correspondence to Anaeze C. Offodile II.

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Offodile, A.C., Sheckter, C.C., Tucker, A. et al. Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis. Breast Cancer Res Treat 165, 477–484 (2017). https://doi.org/10.1007/s10549-017-4371-9

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  • DOI: https://doi.org/10.1007/s10549-017-4371-9

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