Cost-effectiveness of differing perioperative beta-blockade strategies in vascular surgery patients

Objectives: To determine the incremental value of different strategies of both oral and intravenous beta-blockade during the perioperative period in high-risk vascular patients in reducing costs and improving outcomes. Design: Decision analytic model incorporating costs from provider's perspective. Interventions: Five perioperative strategies in patients undergoing abdominal aortic aneurysm surgery: (1) no routine beta-blockade, (2) preoperative oral bisoprolol for 7 days followed by perioperative intravenous metoprolol and oral bisoprolol based on preoperative titration, (3) immediate preoperative atenolol with postoperative intravenous then oral atenolol, (4) intraoperative esmolol and postoperative intravenous then oral atenolol, and (5) intraoperative and 18 hours of postoperative esmolol then atenolol. Measurements and Main Results: Perioperative death was associated with a net increase of $21,909 in charges to Medicare, whereas sustaining a perioperative myocardial infarction was associated with a net increase in charges of $15,000. There is a net hospital saving of $500 using a strategy of titration of an oral beta-blocker medication for a minimum of 7 days, with a net increase in efficacy of 0.0304. All of the strategies involving acute perioperative blockade were associated with a net cost savings and increase in efficacy, although less than the strategy involving preoperative oral titration. Conclusion: Perioperative beta-blockade is both cost effective as well as efficacious from a short-term provider perspective. The optimal strategy of treatment for patients who do not present to surgery already on beta-blockers requires further study, although all strategies save money even accounting for pharmaceutical costs. (C) 2004 Elsevier Inc. All rights reserved.