The cost analysis of remifentanil and fentanyl for analgosedation in mechanically ventilated patients in intensive care: Post hoc analysis of an open-labelled pilot randomised controlled study

Objective To compare total hospital costs associated with remifentanil versus fentanyl for analgosedation in mechanically ventilated intensive care unit (ICU) patients, given increasing interest in remifentanil as a feasible alternative, but limited economic evidence. Design Cost analysis of a single-centre, prospective, randomised controlled trial (remi-fent1 RCT). Setting Nepean Hospital ICU, New South Wales, Australia. Patients Adult patients admitted between June 2020 and August 2021 requiring invasive mechanical ventilation (IMV) who were randomised to receive remifentanil or fentanyl as part of their analgosedation regimen. Main outcome measures The primary outcome was total hospital bed-day costs (Australian Dollars), estimated from a healthcare payer perspective using the Australian Independent Hospital Pricing Authority National Pricing Model for the financial year 2020–2021. Health-related quality of life (HRQoL) at 6 months was measured using the generic EuroQoL 5-dimension 5-level (EQ-5D-5L) instrument. Pre-specified subgroup analyses examined age (arbitrary cut-off 65 years) and duration of IMV (arbitrary cut-off 72 h). Results A total of 210 patients were analysed (remifentanil n = 104; fentanyl n = 106). Opioid acquisition costs were comparable between groups. Total mean hospital bed-day costs were lower in the remifentanil group compared with the fentanyl ($48,301 [$38,644-$57,958] vs. $37,012 [95% confidence interval {CI}: $27,834-$46,191]; p = 0.006). The remifentanil group was associated with lower total hospital costs in older patients (≥65 years) and in those ventilated for ≤72 h. At 6 months, 110 patients were alive, with 7 lost to follow-up, (61/103 remifentanil [59.2%] vs. 59/100 fentanyl [59.0%]; p = 0.80). Among survivors, remifentanil continued to demonstrate lower overall hospital costs, but 6-month HRQoL remained similar between groups (EQ-5D-5L index 0.83 vs. 0.87; p = 0.24). Conclusion Remifentanil was associated with lower total hospital costs than fentanyl, without differences in survival or HRQoL at 6 months, suggesting that remifentanil may be a lower-cost alternative for analgosedation. However, the results are exploratory and require confirmation in larger, adequately powered multicentre phase-2 trials.