RESEARCH ARTICLE Open Access
Economic impac o imp o ing pa ien
sa e y using Sugammadex o ou ine
e e sal o neu omuscula blockade in
Spain
J. Ma inez-Ubie o
1
, C. A agón- Benedí
2
, J. de Ped o
3
, L. Cea-Cal o
3
, A. Mo ell
4
, Y. Jiang
5
, S. Cedillo
6
,
P. Ramí ez-Boix
3*
and A. M. Pascual-Bellos a
1
Abs ac
Backg ound: Neu omuscula blocking (NMB) agen s a e o en adminis e ed o acili a e acheal in uba ion and
p e en pa ien mo emen du ing su gical p ocedu es equi ing he use o gene al anes he ics. Incomple e e e sal
o NMB, can lead o esidual NMB, which can inc ease he isk o pos -ope a i e pulmona y complica ions.
Sugammadex is indica ed o e e se neu omuscula blockade induced by ocu onium o ecu onium in adul s. The
aim o his s udy is o es ima e he clinical and economic impac o in oducing sugammadex o ou ine e e sal o
neu omuscula blockade (NMB) wi h ocu onium in Spain.
Me hods: A decision analy ic model was cons uc ed e lec ing a se o p ocedu es using ocu onium ha esul ed
in mode a e o deep NMB a he end o he p ocedu e. Two scena ios we e conside ed o 537,931 p ocedu es
using NMB agen s in Spain in 2015: a scena io wi hou sugammadex e sus a scena io wi h sugammadex.
Compa a o s included neos igmine (plus glycopy ola e) and no e e sal agen . The o al cos s o he heal hca e
sys em we e es ima ed om he ne o cos s o e e sal agen s and o e all cos o se s ia educ ion in
pos ope a i e pneumonias and a elec asis o which incidence a es we e based on a Spanish eal-wo ld e idence
(RWE) s udy. The model ime ho izon was assumed o be one yea . Cos s we e exp essed in 2019 eu os (€) and
es ima ed om he pe spec i e o a heal hca e sys em. One-way sensi i i y analysis was ca ied ou by a ying each
pa ame e included in he model wi hin a ange o +/−50%.
Resul s: The es ima ed budge impac o he in oduc ion o sugammadex o he ou ine e e sal o neu omuscula
blockade in Spanish hospi als was a ne sa ing o €57.1 million annually. An inc ease in d ug acquisi ion cos s was
o se by sa ings in pos -ope a i e pulmona y e en s, including 4806 pos -ope a i e pneumonias and 13,996 cases o
a elec asis. The o al cos o complica ions a oided was €70.4 million. All pa ame e s included in he model we e es ed
in sensi i i y analysis and we e a o able o he scena io wi h sugammadex.
(Con inued on nex page)
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* Co espondence: [email p o ec ed]
3
MSD, Mad id, Spain
Full lis o au ho in o ma ion is a ailable a he end o he a icle
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55
h ps://doi.o g/10.1186/s12871-021-01248-2
(Con inued om p e ious page)
Conclusions: This economic analysis shows ha sugammadex can po en ially lead o cos sa ings o he e e sal o
ocu onium-induced mode a e o p o ound NMB compa ed o no e e sal and e e sal wi h neos igmine in he
Spanish heal h ca e se ing. The economic model was based on da a ob ained om Spain and om assump ions om
clinical p ac ice and may no be alid o o he coun ies.
Keywo ds: Neu omuscula blocking agen s, Sugammadex, Economic impac , Spain, Sa e y, Su gical p ocedu es,
Re e sal agen s
Backg ound
Neu omuscula blocking (NMB) agen s a e adminis e ed
ou inely du ing su gical p ocedu es o p o ide muscle
elaxa ion, acili a e he inse ion o an endo acheal
ube, and p e en pa ien mo emen du ing su gical p o-
cedu es equi ing use o gene al anes he ics [1].
When neu omuscula blockade is no longe needed o
be main ained, pa ien s may ei he be allowed o spon-
aneously eco e neu omuscula unc ion o be admin-
is e ed a pha macological e e sal agen o mo e apid
eco e y. Spon aneous e e sal is nei he apid no o
p edic able du a ion, so equen ly, pa ien s may be in-
ad e en ly ex uba ed while s ill expe iencing esidual
neu omuscula blockage [2].
The ace ylcholines e ase inhibi o neos igmine is com-
monly used o e e sal o mode a e neu omuscula
blockade when a leas he second wi ch (T2) o a ain-
o - ou (ToF) s imula ion is p esen . Reco e y o neu o-
muscula unc ion using neos igmine is also no apid
and i s du a ion may no be p edic able [3] which can
lead o an ex uba ion o pa ien s while hey a e s ill ex-
pe iencing esidual neu omuscula blockage, and, in
consequence, he isk o pos -ope a i e pulmona y com-
plica ions including hypoxemia, di icul y b ea hing and
swallowing, uppe ai way p oblems, hype capnia, slu ed
speech, blu ed ision and impai ed clinical eco e y
a e su ge y [2–10].
This inc ease in pos ope a i e mo bidi y can lead o
inc eased leng h o s ay in he pos -anes he ic eco e y
uni s (PACU), an inc eased hospi al leng h o s ay, and,
an inc ease in he needs and cos s o heal h se ices [4,
11,12].
In he pas yea s, new pha macological al e na i es o
e e sal o neu omuscula blockade ha e been in o-
duced. Sugammadex (B idion®, Me ck & Co., Inc., Kenil-
wo h, NJ, USA) a modi ied gamma-cyclodex in, is a
e e sal agen a ailable in Spain since 2009 and indi-
ca ed o e e se neu omuscula blockade induced by he
NMB agen s ocu onium o ecu onium in adul s [13].
In clinical ials, sugammadex has been shown o p o-
duce much mo e apid and p edic able e e sal o
neu omuscula block compa ed o neos igmine, in he
absence o an i-musca inic side e ec s and, in ials
whe e quan i a i e neu omuscula moni o ing was no
equi ed, a s eep educ ion in he incidence o esidual
NMB [11,14–17].
In ecen yea s, he numbe o na ional and in e -
na ional s udies ha highligh he inc ease in complica-
ions associa ed wi h esidual NMB has inc eased. The
equency o esidual NMB anges be ween 24 and 32%
acco ding o he mos ecen se ies, al hough i has been
gene ally es ima ed be ween 6 and 80% depending on
he scope o he e alua ion, placing i as he main com-
plica ion in pa ien s unde going gene al anes hesia [5,
12,18–24].
The RECITE-US s udy es ima ed he bu den and asso-
cia ed isk ac o s o esidual NMB du ing ou ine U.S.
hospi al ca e. The esul s o his p ospec i e s udy
showed ha 64.7% o he pa ien s had esidual NMB
(TOF a io < 0.9%) despi e neos igmine adminis a ion
[25].
A na ional le el, he e a e se e al obse a ional s ud-
ies ha e alua e he incidence o esidual NMB in Spain
[26,27]. A p ospec i e mul icen e s udy conduc ed in
26 Spanish hospi als ound ha 26,7% o a gene al su gi-
cal popula ion in Spain showed esidual NMB in he
Pos anes hesia Ca e Uni (PACU). Pa ien - ela ed and
p ocedu e- ela ed ac o s such as emale gende , longe
du a ion o su ge y, use o benzyl-isoquinolines o halo-
gena ed anes hesic use, lack o in aope a i e neu omus-
cula moni o ing, and use o neos igmine as e e sal
agen o no pha macological e e sal we e mo e p e a-
len in pa ien s showing esidual NMB in he immedia e
pos ope a i e pe iod [26]. Ma inez-Ubie o e al. con-
duc ed a p ospec i e obse a ional s udy o coho s o
e alua e he incidence o Pos ope a i e Residual Cu a i-
za ion (PORC) in he PACU and i is ela ion o he ype
o muscle elaxan and e e sal agen used in 558 pa-
ien s ope a ed unde gene al anes hesia. In his s udy,
he incidence o esidual NMB was much lowe when
he NMB and e e sal agen adminis e ed we e ocu o-
nium/sugammadex (1.15%) han when i was cisa acu -
ium/neos igmine (28.6%) o when no e e sal agen was
used (34%) [27].
Cu en ly, e e sal o NMB con inues o be a sa e y
issue, and so a , he s udies ela ed o e e sal o NMB
a a na ional le el in Spain ha e ocused on pa hophysio-
logical, clinical and epidemiological aspec s. The aim o
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55 Page 2 o 10
his analysis is o es ima e he economic impac o in o-
ducing sugammadex o ou ine e e sal o ocu onium-
induced neu omuscula blockade in Spain.
Me hods
Model o e iew
Me hodologically, a budge impac analysis makes i pos-
sible o e alua e an icipa ed expendi u es o heal hca e
sys ems planning o adop new in e en ions o in o-
duce changes o he cu en clinical p ac ice [28]. We
de eloped a budge impac model ha p ojec ed he ag-
g ega ed annual ne economic impac o using sugam-
madex ins ead o neos igmine o no e e sal agen in a
p opo ion o p ocedu es we e ocu onium is adminis-
e ed. The model was cons uc ed in Mic oso ® Excel®
2016 (Mic oso Co p., Redmond, WA, USA).
We collec ed da a om in e na ional li e a u e and
om o icial Spanish heal hca e da abases. Whe e he
a ailable in o ma ion was insu icien , o da a om
Spanish sou ces we e conside ed inaccu a e, es ima ions
we e p o ided by an expe panel o Spanish esea che s.
The budge impac analysis has been de eloped in ac-
co dance wi h he P inciples o Good P ac ice o Budge
Impac Analysis o he In e na ional Socie y o Pha ma-
coeconomics and Ou comes Resea ch (ISPOR) [28].
Model desc ip ion
This budge impac is based on a compa ison be ween
wo hypo he ical scena ios:
–The cu en scena io: which ep esen s a si ua ion
whe e sugammadex is no a ailable o ou ine
e e sal o NMB
–The al e na i e scena io: whe e sugammadex is
included as a e e sal agen in su gical p ocedu es
wi h mode a e and deep NMB.
Time ho izon
The budge impac model p ojec ed he economic im-
pac o he in oduc ion o sugammadex in Spain o e a
one-yea ime ho izon.
Pe spec i e
The pe spec i e used in his analysis is he Spanish Na-
ional Heal hca e Sys em which only conside di ec
cos s. Pha macological cos o ocu onium and he e-
e sal agen s (neos igmine/a opine and sugammadex)
and di ec cos s o he clinical ou comes we e included
in he model.
P ocedu es
Fi een ypes o su gical p ocedu es in which using NMB
agen s is mo e equen we e included in he model: ap-
pendec omies, he nia epai s, cholecys ec omies,
colo ec al esec ions, gas ic su ge ies, in ac anial su -
ge ies, spinal co d su ge ies, emu su ge ies, hip ac-
u e epai s, knee ac u e epai s, b onchoscopies o
la yngoscopies, ocal co d su ge ies, hy oid gland su -
ge ies, p os a ec omies, hys e ec omies and oopho ec o-
mies. Local da a om nea ly 93% o Spanish public and
p i a e hospi als es ima ed ha he annual numbe o
hese p ocedu es in 2015 was 733,876 [29] (Table 1). Ac-
co ding o Olesnicky e al. [30] coho s udy, 73.3% o
su gical p ocedu es would use a NMB agen du ing he
su gical p ocedu e.
The model di e en ia ed be ween mode a e NMB (in
ou analysis de ined as TOF: 1 o 2 wi ches) and deep
NMB (de ined as TOF = 0 and pos - e anic coun o 1 o
2). We assumed a spli o 80% p ocedu es wi h mode a e
NMB and 20% p ocedu es wi h deep NMB. As he e
was no li e a u e a ailable om Spain, his assump ion
was made based on in e nal ma ke esea ch da a, ha
was alida ed by expe s acco ding o hei hospi al clin-
ical p ac ice. (Fig. 1).
Re e sal agen s
Rocu onium and cisa acu ium a e he neu omuscula
blocking agen s included in he model, as ecu onium is
no a ailable in ou coun y, ep esen ing mo e han
90% o he ma ke . Howe e , sugammadex is no indi-
ca ed o e e se cisa acu ium-induced NMB [13].
The e o e, he model conside ed a p opo ion o in-
s ances o cisa acu ium use which can be swi ched o
ocu onium, pe mi ing he in oduc ion o sugamma-
dex. I was assumed ha 50% o ins ances in which
Table 1 Numbe o su gical p ocedu es ca ied ou in Spain
(2015)
Type o Numbe o su gical p ocedu es
Appendec omies 44,593
He nia Repai s 70,618
Cholecys ec omies 72,483
Colo ec al esec ions 82,435
Gas ic su ge ies 123,401
In ac aneal su ge ies 20,411
Spinal co d su ge ies 49,069
Femu su ge ies 21,415
Hip ac u e epai s 42,120
Knee ac u e epai s 52,493
B onchoscopies/La yngoscopies 21,599
Vocal co d su ge ies 25,673
Thy oid gland su ge ies 21,945
P os ac e omies 31,332
His e ec omies and oopho ec omies 54,289
To al anual numbe 733,876
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55 Page 3 o 10
cisa acu ium was used we e swi ched o ocu onium in
he al e na i e scena io using sugammadex as e e sal
agen . Acco ding o he p ospec i e obse a ional s udy
by Ma inez-Ubie o e al. [27], ocu onium was adminis-
e ed in 64% o hose p ocedu es (Table 2). Due o lack
o local da a di e en ia ing be ween mode a e and deep
NMB, i was assumed he same agen dis ibu ion o
bo h. In he cases whe e neos igmine was conside ed o
e e sal i would be co-adminis e ed wi h he an i-
musca inic agen a opine, so he model e lec ed he
co-adminis a ion o hese wo agen s.
Clinical pa ame e s
The use o sugammadex and neos igmine has been associ-
a ed wi h a isk educ ion o wo pulmona y complica ions
(a elec asis and pos -ope a i e pneumonias). Acco ding o
he da a a ailable when he analysis was pe o med, bo h
complica ions we e conside ed as pos -ope a i e e en s o
in e es o he p esen analysis [27,31]. In he case o he
isk o pos -ope a i e pneumonia, he da a combined wo
sou ces o in o ma ion: he Spanish obse a ional s udies
[27,31] and a clinical ial [25].Thesame isko pos -
ope a i e complica ions was assumed o bo h o mode a e
and deep NMB; his poin was alida ed by he expe
panel.
P opo ion o isk o pos -ope a i e e en s wi h
sugammadex o neos igmine/no e e sal a e p esen ed
in Table 2.
Cos s
Lis p ices o NMB and e e sal agen s we e ob ained
om Bo plus (2019) [32]. A 7.5% discoun was applied
o d ug cos s acco ding o Spanish law [33]. D ug cos s
o speci ic combina ions o NMB agen s, e e sal agen s
and block dep hs a e summa ized in Table 2.To
s anda dize he cos pe dose pe pa ien be ween di e -
en NMB and e e sal agen s, an a e age pa ien weigh
o 75 kg was assumed. The dose o sugammadex used
o NMB e e sal was 4 mg/kg o deep NMB and 2 mg/
kg o mode a e NMB acco ding o he phase III clinical
Fig. 1 Model s uc u e
Table 2 Model clinical pa ame e s alues: base case
Pa ame e Value
Annual numbe o hospi al su gical p ocedu es 733,876
P ocedu es u ilizing an NMBA 73.3%
Type o block Mode a e: 80% Deep: 20%
Re e sal agen use (neos igmine) No e e sal agen : Re e sal agen : No e e sal agen : Re e sal agen :
68.0% 32.0% 68.0% 32.0%
Ins ances wi h use o ocu onium 64.0% 43.5% 64.0% 43.5%
Ins ances wi h use o cisa acu ium 25.0% 25.0% 25.0% 25.0%
Ins ances wi h use o o he agen s 11.0% 31.5% 11.0% 31.5%
P opo ion o ins ances whe e cisa acu ium swi ched o ocu onium 50.0% 50.0% 50.0% 50.0%
Neos igmine / No e e sal agen Sugammadex
Risk o pos -ope a i e a elec asis 7.3% 1.1%
Risk o pos -ope a i e pneumonia 4.0% 1.9%
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55 Page 4 o 10
ials desc ibed in he sugammadex label [13]. Vial was -
age o any unused amoun was no conside ed.
Cos s o pos -ope a i e a elec asis we e de i ed om
he cos pe diagnosis- ela ed g oup (DRG) p o ided by
he Spanish Minis y o Heal h o icial s a is ical si e
[29]. In he case o pos -ope a i e pneumonia, he cos
pe e en was e ie ed om egional a i s ex ac ed
om eSalud da abase [34] (Table 3). Cos o pos -
ope a i e complica ions we e in la ed o €2019. Follow-
ing he In e na ional Socie y o Pha macoeconomics
and Ou comes Resea ch (ISPOR) P inciples o Good
P ac ice o budge impac analysis cos s we e no dis-
coun ed due o he sho ime ho izon used.
Cos o se s ob ained om educing pos -ope a i e pul-
mona y e en s wi h sugammadex compa ed wi h neos ig-
mine o no pha macological e e sal we e calcula ed by
mul iplying he expec ed numbe o e en s (wi h/wi hou
sugammadex) by he cos o each e en and calcula ing
he di e ence be ween he wo scena ios (Fig. 2).
Sensi i i y analysis
De e minis ic sensi i i y analysis (DSA) was ca ied ou
by a ying he ollowing pa ame e s included in he
model wi hin a ange o +/−50%: p opo ion o p oce-
du es using an NMB agen , isk o pos -ope a i e e en s,
cos pe e en , p opo ion o cases when sugammadex is
used in mode a e block and p opo ion o ins ances
whe e cisa acu ium is swi ched o ocu onium, p opo -
ion o ins ances ocu onium is used gi en each e e sal
agen .
Model ou pu s
The esul s o he analysis a e p esen ed in wo le els:
1) a p ocedu e le el: budge impac o u ilizing
sugammadex o a speci ic pa ien e sus
neos igmine o non-pha macological e e sal o a
single ope a ing oom p ocedu e
2) a na ional le el: agg ega e budge impac o
using sugammadex e sus neos igmine o no
pha macological e e sal o all p ocedu es o
whom sugammadex could be used a na ional
le el.
Resul s
A p ocedu e le el, he in oduc ion o sugammadex is
p ojec ed o esul in o a ne sa ing o €249.82 pe p o-
cedu e whe e his agen could be used (31.2% o he
o al numbe o p ocedu es included). Conside ing he
o al annual numbe o hospi al su gical p ocedu es, e-
ga dless o sugammadex usage, he a e age ne sa ing
pe p ocedu e p ojec ed was €73.88 (Table 4).
A na ional le el, om he o al o 733,876 a ge p o-
cedu es conside ed, sugammadex was used in 228,863
o hem (147,542 wi h ocu onium and no e e sal, and
81,321 ocu onium and neos igmine in he p io sce-
na io). The es ima ed budge impac o he ou ine
in oduc ion o sugammadex in Spanish hospi als was
p ojec ed o a ne sa ing o €57.1 million annually
(Table 5). An inc ease in d ug acquisi ion cos s was o -
se by sa ings in pos -ope a i e pulmona y e en s in-
cluding 4806 pos -ope a i e pneumonias ( educ ion o
52% compa ed o p io scena io) and 13,996 cases o
Table 3 Model economic pa ame e s: base case
Pha macological cos s
Agen Dose D ug
Cos
Sou ce
Sugammadex (mode a e
block)
a
2mg €51.34 Bo Plus
Sugammadex (deep block)
a
4mg €102.68 Bo Plus
Neos igmine/A opine 0.5 mg/2
mg
€0.46 Bo Plus
Rocu onium 0.6 mg €1.80 Bo Plus
Pos -ope a i e e en Cos Sou ce
A elec asis €4999.40 DRG cos .
MoH
Pneumonia €4449.72 eSalud.
Oblikue
a
An a e age pa ien weigh o 75 kg was assumed in es ima ing he cos pe
dose, wi h ial was age o any unused amoun
Fig. 2 Modeling o clinical cos o se s associa ed wi h sugammadex Use
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55 Page 5 o 10

a elec asis ( educ ion o 84% compa ed o p io sce-
na io). The o al cos o complica ions a oided was p o-
jec ed o €70.4 million) (Table 6).
Sensi i i y analysis
All scena ios es ed in he de e minis ic sensi i i y ana-
lysis we e a o able o he scena io whe e sugammadex
was used (Fig. 3) esul ing in cos -sa ing s a egies. Ac-
co ding o he sensi i i y analysis, he p opo ion o p o-
cedu es using a NMB agen and he isk o pos -
ope a i e a elec asis o pneumonia we e he pa ame e s
wi h he g ea es impac on he esul s o he economic
model.
Discussion
Se e al s udies showed ha sugammadex can educe he
isk o esidual NMB, enhancing ope a ing oom e i-
ciency [26,27]; howe e , ew s udies ha e assessed he
economic impac o he imp o emen o sa e y ou comes
ela ed o he use o sugammadex. In ou knowledge,
his is he i s s udy o es ima e he economic impac o
sugammadex based on Spanish eal-wo ld da a.
The e is s ill a signi ican incidence o esidual NMB
in he immedia e pos ope a i e pe iod. As i was p e i-
ously men ioned, di e en s udies desc ibed no pha ma-
cological e e sal, o e e sal wi h neos igmine as a
p ocedu e- ela ed ac o mo e p e alen in pa ien s wi h
pulmona y complica ions in PACU [26,27]. Fu he -
mo e, an inc ease numbe o a elec asis and pneumo-
nias was ound in pa ien s who p esen ed esidual
NMB in he immedia e pos ope a i e pe iod and we e
e e sed wi h neos igmine o spon aneously [22,23,
35]. Also, he la es s udy o Capellini e al. [36]e al-
ua ed h ough ul asound scan he con ac ion and
diaph agma ic mo emen o pa ien s e e sed wi h
neos igmine e sus pa ien s wi h sugammadex. This
s udy concluded ha in pa ien s e e sed wi h neo-
s igmine, comple e eco e y o basal diaph agm unc-
ion is poo e compa ed o pa ien s e e sed wi h
sugammadex.
This e idence s ays in line wi h o he s udies whe e
he incidence o pos ope a i e esidual neu omuscula
blockade was assessed by TOF and whe e he incidence
o a elec asis was highe (7.61%) when e e sed wi h
neos igmine compa ed o pa ien s who we e adminis-
e ed sugammadex (1.15%) [27,31].
The e o e, i is c ucial o unde s and he impo ance o
ou ine use o e e sal agen s o a oid he occu ence o
complica ions associa ed wi h he neu omuscula blocking
d ugs esul ing in a cos -e ec i e s a egy [37–39].
In 2010, wo economic analyses assessed he e i-
ciency o e e sal agen s. The s udy ca ied ou by
Mandim el al [40] showed ha he cos pe minu e
o he e e sal wi h sugammadex ($8.34) was lowe
compa ed o neos igmine ($104.86). On he o he
hand, in he UK, Pa on e al. [41] conduc ed a sys-
ema ic e iew o andomized con olled ials o
sugammadex compa ed wi h neos igmine and an eco-
nomic assessmen o sugammadex o he e e sal o
mode a e o deep NMB was pe o med. The s udy
concluded ha he educ ion in eco e y ime associ-
a ed wi h sugammadex e sus neos igmine was 23.37
Table 4 P ocedu e-le el ne budge impac
Block Dep h
A Re e sal
P io NMBA &
Re e sal Agen
P io Scena io
D ug Cos s
Al e na i e Scena io
(incl. sugammadex) D ug Cos s
To al Cos O se s F om
Clinical E en s A oided
Ne Cos
Sa ings
Mode a e Rocu onium + No e e sal €1.80 €53.14 €307.61 -€256.27
Mode a e Rocu onium + Neos igmine €2.27 €53.14 €307.61 -€256.73
Deep Rocu onium + No e e sal €1.80 €104.48 €307.61 -€204.93
A e age pe p ocedu e using
Sugammadex
€1.97 €59.76 €307.61 -€249.82
A e age ac oss all su gical p ocedu es
( ega dless o sugammadex usage)
€0.58 €17.67 €90.97 -€73.88
Table 5 Annual coun y-le el ne budge impac
Block Dep h A Re e sal P io NMBA &
Re e sal Agen
P io Scena io
D ug Cos s
Al e na i e Scena io
(incl. sugammadex)
D ug Cos s
To al Cos O se s F om
Clinical E en s A oided
Ne Cos
Sa ings
Mode a e Rocu onium +
No e e sal
€212,903 €6,272,453 €36,308,198 -€30,248,647
Mode a e Rocu onium + Neos igmine €184,369 €4,321,505 €25,015,106 -€20,877,969
Deep Rocu onium +
No e e sal
€53,225 €3,083,001 €9,077,049 -€6,047,274
To al Budge Impac €450,498 €13,676,960 €70,400,354 -€57,173,892
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55 Page 6 o 10
min, which esul ed in an economic alue o £2.87
pe minu e.
Ozdemi e al. (2010) [42] p esen ed a s udy compa -
ing he cos s o he pulmona y complica ions associa ed
wi h he esidual NMB using sugammadex and neos ig-
mine. Cos s in he spon aneous eco e y g oup we e
CZK 126.45, CZK 114.56 in he neos igmine g oup and
CZK 34.93 in he sugammadex g oup.
All hese pha macoeconomic s udies ha e s udied di -
ec cos s [38–43], howe e , o he indi ec aspec s ha e
no been e alua ed o aken in o accoun , such as he in-
angible alue o he ime sa ed by s a membe s, he
loss o pe sonal and wo k ime o pa ien s and amily
membe s, he impac o cancella ion o subsequen su -
gical p ocedu es, ep og amming o he su gical pa s o
a possible inc ease in su gical wai ing imes.
Al hough mo e p ospec i e s udies a e needed, he e-
sul s o ou analysis a e aligned wi h he p e ious s udies
conclusions, showing ha sugammadex is cos sa ing
compa ed o neos igmine.
Limi a ions
Ou s udy has se e al limi a ions, mainly due o he
numbe o assump ions included in he budge impac
model. The i s limi a ion is ha he spli o mode a e/
deep muscula blockage o 80/20 was based on an in-
e nal ma ke esea ch and no in published da a. Un o -
una ely, we did no ind published s udies suppo ing,
in clinical p ac ice, his dis ibu ion. To educe bias de-
i ed om his assump ion, we alida ed his 80/20 spli
wi h he in es iga o s acco ding o clinical p ac ice in
hei hospi als be o e aken i o de elop he economic
model. Ne e heless, we ha e o ake in o accoun ha
his spli is an o e all es ima ion and can di e in hospi-
als whe e ce ain speci ic p ocedu es a e mo e equen
han o he s ( equi ing, o example, a highe pe cen age
Table 6 Numbe o pos -ope a i e e en s and cos s a oided (na ional-le el esul s)
Block Dep h
A Re e sal
P io NMBA &
Re e sal Agen
Numbe o Pos -ope a i e
e en s (P io Scena io)
Numbe o Pos -ope a i e
e en s (Al e na i e
Scena io)
Cos s o pos -ope a i e
e en s (P io scena io)
Cos s o pos -ope a i e
e en s (Al e na i e
scena io)
Mode a e Rocu onium +
No e e sal
13,296 3599 €54,335,758 €18,027,560
Mode a e Rocu onium +
Neos igmine
9161 2480 €37,435,478 €12,420,372
Deep Rocu onium +
No e e sal
3324 900 €13,583,939 €4,506,890
To al 25,781 6979 €105,355,176 €34,954,822
4806 pneumonia cases a oided
13,996 a elec asis cases a oided
€70,400,354 cos s a oided
wi h sugammadex use
Fig. 3 To nado Diag am. Resul s om he De e minis ic Sensi i i y Analysis)
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55 Page 7 o 10
o pa ien s wi h deep NMB) o depending on he clinical
p ac ice in each hospi al o he cha ac e is ics o su gical
pa ien s. As his could be a c i ical pa ame e , one o he
scena ios included in he DSA educed he p opo ion
o mode a e block in he dis ibu ion and did no esul
in signi ican change in he model.
Second, he assump ion o he dose o sugammadex
used o NMB e e sal was o 4 mg/kg o deep NMB
and 2 mg/kg o mode a e NMB. This assump ion was
based on he phase III clinical ials desc ibed in he
sugammadex label, in which he abo e-men ioned doses
we e used. Again, his was alida ed by he in es iga o s
based on hei clinical p ac ice, bu clinical p ac ice can
di e om hospi al o hospi al and he model could no
be alid should doses di e en o hose desc ibed in he
sugammadex label we e used.
Ano he limi a ion could be he es ima ion o he
cos o pos -ope a i e pneumonias and a elec asis.
The da a was e ie ed om he o icial bulle in o
Conseje ía de Salud de la Jun a de Andalucía del
2016 and upda ed o €2019 conside ing in la ion.
Howe e , hese cos s, specially he a i o pneumo-
nia, could ha e been unde es ima ed because add-
i ional complica ions associa ed wi h pneumonia o
a elec asis we e no aken in o accoun . Depending on
he Spanish egion and he se e i y, he cos o a case
o pneumonia wi h de i ed complica ions can ap-
p oach €8300 [34].
Howe e , he sensi i i y analysis sugges s ha ou con-
clusions a e obus and s able ac oss a ange o pa am-
e e es ima es.
Addi ionally, he model did no conside di e en isk
le els o each pos -ope a i e e en depending on he
ype o su gical p ocedu e.
Finally, se e al po en ial a eas o sugammadex bene i
we e no explici ly modeled due o lack o e idence o
guide modeling, o because ela ed cos o se s would be
small ela i e o hose o pos -ope a i e a elec asis, o
pneumonias. These a eas include: 1) a oidance o e-
sidual neu omuscula blockade and common sequelae
managed ou inely and inexpensi ely in he ope a ing
oom o pos anes hesia ca e uni s [44–46]. Examples o
his sequelae could be uncomplica ed aspi a ion, hypox-
emia, muscle weakness and uppe ai way obs uc ion. 2)
Ope a ing oom ime sa ings unde usual s anda ds o
ca e o neu omuscula moni o ing and ex uba ion. 3)
A oidance o ad e se e en s associa ed wi h neos igmine
ha could po en ially be p e en ed wi h sugammadex
usage. 4) Imp o ed pa ien , su geon and anes he is
sa is ac ion.
Conclusion
This economic analysis shows ha sugammadex can po-
en ially lead o cos sa ings o he e e sal o
ocu onium-induced mode a e o deep NMB compa ed
o e e sal wi h neos igmine o no pha macological e-
e sal in he Spanish heal h ca e se ing. The economic
model was based on da a ob ained om Spain and om
assump ions om clinical p ac ice and may no be alid
o o he coun ies.
Abb e ia ions
DRG: Diagnosis- ela ed g oup; DSA: De e minis ic sensi i i y analysis;
NMB: Neu omuscula blockade/blocking; PACU: Pos anes hesia ca e uni s;
esidual NMB: Residual neu omuscula blockade; T2: Second wi ch;
ToF: T ain-o - ou ; ISPOR: In e na ional Socie y o Pha macoeconomics and
Ou comes Resea ch
Acknowledgmen s
No applicable.
Au ho s’con ibu ions
JY, CS, RBP, PJ, CCL designed he budge impac model, acqui ed he da a,
analyzed and in e p e ed he da a, d a ed and e ised he manusc ip . MUJ,
ABC, PBAM and MA acqui ed he clinical da a, ad ised he in e p e a ion o
he da a, w i e and c i ically e ised he manusc ip . All au ho s ead and
app o ed he inal manusc ip .
Funding
The s udy was unded by MSD, Spain, a subsidia y o Me ck & Co., Inc.,
Kenilwo h, NJ, USA.
A ailabili y o da a and ma e ials
All s udy da a a e p esen ed ei he in he a icle o in he addi ional iles.
Access o non-publicly a ailable da abases used in he analysis (eSalud and
Bo Plus) we e ob ained by subsc ip ion.
Numbe o annual su gical p ocedu es was ex ac ed om Conjun o Minimo
Básico de Da os (CMBD), a public da abase which can be accessed om he
Spanish Minis y o Heal h websi e (h ps://pes adis ico.in eligenciadeges ion.
mscbs.es/publicoSNS/S/ ae-cmbd).
The cos pe clinical e en was e ie ed om he eSalud. This pla o m is
he access po al o he Spanish heal hca e cos s da abase se up by Oblikue
Consul ing. eSalud access pla o m is a ailable on subsc ip ion a www.
oblikue.com/bddcos es.
Lis p ices o NMB agen s and e e sal agen s we e ob ained om Bo plus
(h ps://bo plusweb.po al a ma.com/). Bo plus is he o icial da abase o he
Consejo Gene al de Colegios O iciales de Fa macéu icos and, al hough some o
he p oduc in o ma ion is public, lis p ices a e only a ailable by
subsc ip ion.
Addi ional da a suppo ing he indings o his s udy a e a ailable om he
co esponding au ho upon easonable eques .
E hics app o al and consen o pa icipa e
Access o non-publicly a ailable da abases used in he analysis (eSalud and
Bo Plus) we e ob ained by subsc ip ion. This was a non-clinical s udy ha
did no collec in o ma ion om indi iduals, and e hic commi ee app o al
o in o med consen was no necessa y.
Consen o publica ion
No applicable.
Compe ing in e es s
MSD Spain and Me ck & Co. employees pa icipa ed in he model design,
analysis, in e p e a ion o da a and w i ing o he manusc ip . JY is employee
o MSD L d., UK, and may own s ock and/o hold s ock op ions in Me ck &
Co., Inc., Kenilwo h, NJ, USA. PJ, RBP and CCL a e employees o MSD, Spain.
CS is an employee o Co ance Clinical De elopmen , a con ac esea ch
o ganiza ion p o iding suppo o MSD, Spain. MUJ, ABC, PBAM and MA
decla e NO compe ing in e es s.
Au ho de ails
1
Hospi al Uni e si a io Miguel Se e , Za agoza, Spain.
2
Hospi al Uni e si a io
de Mós oles, Mad id, Spain.
3
MSD, Mad id, Spain.
4
Hospi al Uni e si a io de la
Ma inez-Ubie o e al. BMC Anes hesiology (2021) 21:55 Page 8 o 10
P incesa, Mad id, Spain.
5
MSD L d., Hoddesdon, He o dshi e, UK.
6
Co ance
Clinical De elopmen , Mad id, Spain.
Recei ed: 16 July 2020 Accep ed: 18 Janua y 2021
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