Cost considerations in patient-controlled analgesia

Patient-controlled analgesia (PCA) is the use of a portable infusion pump activated by the patient to inject an analgesic drug intravenously, subcutaneously or epidurally. PCA permits a patient to deliver a small bolus of opioid to achieve prompt relief without over sedation. Use of PCA for pain management is increasing in hospitals and home settings, largely because it can provide equivalent or better analgesia than conventional methods, and patients are more satisfied with its use. This article reports on studies published between January 1984 and December 1995 which considered cost aspects of PCA. Most studies compared the direct costs of administering PCA with the cost of other forms of drug delivery, usually intramuscular injections. A few studies have included indirect costs such as length of stay and adverse effects associated with the use of PCA. The research on cost considerations of PCA is dominated by case reports, descriptive studies and poorly designed quasi-experimental studies. The most complete and well conducted studies usually have included only drug, equipment and labour costs. Only 6 randomised controlled trials were reported, all of which were conducted on postoperative patients. The cost effectiveness of PCA for pain management is an unresolved question because of the variability in methods used to determine costs and expenses, the different settings and patient populations in which PCA is applied, the different means to organise its management and the fact that it is a rapidly evolving technology during an era of changing reimbursement practices. There is substantial variation in the cost of drugs used in PCA and in the devices themselves, which influences the comparison of costs across studies. Also, researchers do not include the full scope of costs associated with the use of PCA in comparison with conventional drug delivery methods and some do not measure the level of pain relief achieved. Of the few complete and well designed published studies found, PCA was reported to produce superior analgesia at a higher cost than conventional intramuscular therapy in 3 studies, but to be more costly and produce less pain relief than intramuscular therapy in 1 study. There is a pressing need for cost-effectiveness, cost-utility and cost-benefit analyses to determine the appropriate clinical and cost circumstances for the use of PCA.