Cost-effectiveness of Paravertebral versus EPidural analgesia in Minimally invasive Esophageal resectioN (PEPMEN): an economic evaluation alongside a randomized clinical trial

Abstract

BACKGROUND: Epidural analgesia has been the gold standard for pain management in minimally invasive esophagectomy (MIE), with paravertebral analgesia as a safe alternative. This cost-effectiveness analysis, conducted alongside a randomized controlled trial, evaluates the cost-effectiveness of paravertebral analgesia compared to epidural analgesia. METHODS: This multicenter randomized controlled trial across four Dutch hospitals, including 192 patients, compared epidural and paravertebral analgesia in patients undergoing MIE. Cost-effectiveness was evaluated from a healthcare perspective, including in-hospital costs only, with time horizons from initial hospital stay and 90 days postoperatively. Procedural costs were calculated with a bottom-up approach, and analgesia costs with data from the electronic case report form (eCRF). Other hospital costs were calculated using insurance claim data from hospital registries. Effectiveness was displayed as Quality of Recovery (QoR-40) scores. Bootstrapping was used to estimate uncertainty. RESULTS: Mean initial surgery costs were €10,469 for the epidural and €10,051 for the paravertebral group, primarily due to a shorter mean operating room time (mean difference 19 min; 95% CI - 7 to 45). Mean postoperative (day 1-3) medication costs were €116 and €125, respectively. During the initial hospital stay, mean total in-hospital costs for uncomplicated patients were €8557 and €8646, and for complicated patients €28,244 and €28,387, respectively. When excluding complications, bootstrapping showed that 47.9% of iterations had lower costs and lower effectiveness for paravertebral analgesia, with the other iterations across all other quadrants. CONCLUSIONS: Cost differences between paravertebral and epidural analgesia were minimal, with cost-effectiveness primarily influenced by the slightly lower effectiveness of paravertebral analgesia.