Abstracts

Rationale: To quantify the cost-effectiveness of rescue medications for pediatric status epilepticus: rectal diazepam, nasal midazolam, buccal midazolam, intramuscular midazolam, and nasal lorazepam.  Methods: Decision analysis model populated with effectiveness data from the literature and cost data from publicly available market prices. Twenty-four studies were included in the quantitative analysis of effectiveness, measured as seizure stopped (SS). The primary outcome was cost per seizure stopped ($/SS). One-way sensitivity analyses and Second Order Monte Carlo simulations evaluated the robustness of the results across wide variations of the input parameters.  Results: The most cost-effective rescue medication was buccal midazolam (incremental cost-effectiveness ratio (ICER): $13.16/SS) followed by nasal midazolam (ICER: $38.19/SS). Nasal lorazepam (ICER: -$3.8/SS), intramuscular midazolam (ICER: -$64/SS), and rectal diazepam (ICER: -$2,246.21/SS) are never more cost-effective than the other options at any willingness to pay (Figure 1). On one-way sensitivity analysis: 1) at its current effectiveness, rectal diazepam would become the most cost-effective option only if its cost was $6 or less and 2) at its current cost, rectal diazepam would become the most cost-effective option only if effectiveness was higher than 0.89 (and only with very high willingness to pay of $2,859/SS to $31,447/SS). On Second Order Monte Carlo simulations: 1) nasal midazolam and intramuscular midazolam were the most effective options; 2) the most cost-effective option was buccal midazolam for a willingness to pay from $14/SS to $41/SS and nasal midazolam for a willingness to pay above $41/SS; 3) cost-effectiveness overlapped for buccal midazolam, nasal lorazepam, intramuscular midazolam, and nasal midazolam (Figure 2); and 4) rectal diazepam was not cost-effective at any willingness to pay and this conclusion remained extremely robust to wide variations of the input parameters. In summary, rectal diazepam is not a cost-effective alternative to any of the other non-intravenous midazolam routes or to the nasal lorazepam option. An interactive version of the cost-effectiveness model is available athttps://ivansanchezfernandez-shinyapps.shinyapps.io/CErescuemedicationsSE/ for readers who wish to evaluate how modification of input parameters may influence cost-effectiveness. Conclusions: For pediatric status epilepticus, buccal midazolam and nasal midazolam are the most cost-effective non-intravenous rescue medications in the USA. Rectal diazepam is not a cost-effective alternative and this conclusion remains extremely robust to wide variations of the input parameters. Funding: None