The Pharmacoeconomics of Managing Acute Agitation in the Emergency Department

What Do We Know and How Do We Approach It?

Esther W Chan; David McD Taylor; Jonathan C Knott; Danny Liew; David CM Kong


Expert Rev Pharmacoeconomics Outcomes Res. 2012;12(5):589-595. 

In This Article

Limitations in the Available Literature

The management of behavioral emergencies requires disproportionate amounts of ED staff time, attention and other resources.[5] Despite the recognition of resource implications, few pharmacoeconomic studies have compared sedating drugs for the management of acute agitation in the ED setting.[6] Furthermore, there are no published data on the cost of managing acute agitation in the ED. However, cost issues are commonly addressed in clinical reports, as part of the discussion of patients admitted to the ED or psychiatric units in an agitated state.[7–9]

The published literature has explored modeling strategies for general pharmaceutical costs in hospital.[10] However, if considering the institutional (i.e., hospital) perspective, the cost of drugs (i.e., drug acquisition) is only one aspect. Impact on staff time and total treatment costs should also be considered and, in the case of acute agitation in the ED, should be calculated and estimated specifically in this setting.

In a review of treatments for acutely agitated patients with schizophrenia, Bellnier described the factors to consider when evaluating the cost–effectiveness of various drugs.[9] These include the costs associated with initial drug administration, repeat administrations for agitated patients, duration of acute management and observation (i.e., hospital length of stay), adverse events and relapse.[9] Drug costs in addition to those of the sedating drug should also be included. Adverse events should be considered in cost evaluations as their management may affect the overall cost of therapy.[11] Associated with adverse events are additional treatment (with or without drugs) and staff time for care and monitoring.[11]

With the emergence of atypical antipsychotics and increased demand for pharmacoeconomic evaluations, studies have been conducted in psychiatry[7,8,12–16] and critical care settings.[17,18] Reviews of pharmacoeconomic studies[9,19,20] and impact on quality of life (QoL)[12,14,15,21] have examined patients with a background of chronic mental illness or those in the psychiatry setting. Several pharmacoeconomic studies were descriptive in nature and did not compare alternative interventions.[22,23]

Pharmacoeconomic studies of acute agitation have almost all been conducted in the psychiatry setting and vary in depth and quality. Most were not complete pharmacoeconomic analyses (partial evaluations) and did not apply economic modeling techniques.[7,8,12–14,22,23] Common study limitations included small sample sizes[7,8,13,22] and substantial loss to follow-up.[7,12] In several studies,[12,14,16] there was considerable loss of data that reduced the reliability of analyses. In these studies, patients were discontinued from the study when they failed to respond or required a change to their treatment regimen. Consequently, the reduction in sample size reduced the study power. There were other inherent limitations in the clinical studies on which the pharmacoeconomic studies were based. Open-label,[7] preinterventional and postinterventional[8] and observational study designs[13,22] impacted on the internal validity of the observed clinical and economic outcomes. These limitations are important considerations as they adversely affect the quality of the clinical data required for economic modeling and evaluation.

Among all limitations, the greatest issue was that nearly all pharmacoeconomic studies were not applicable to the management of acute agitation in the ED setting. As many studies investigated oral drug forms, they had limited application in the ED setting, where highly agitated patients frequently refuse oral drug administration.[7,8,12,14,15] Outcome measures were commonly not related to the management of acute agitation (i.e., time to adequate sedation or proportion of patients adequately sedated) but to longer term measures. These include compliance with medications,[7] time to rehospitalizations,[7] functional status based on symptom severity scales (e.g., Positive and Negative Syndrome Scale[7,14] and Brief Psychiatric Rating Scale[12]) over extended time periods, client satisfaction,[7] assault-related injury to staff,[8] wages associated with lost work time[8] and long-term side effects (e.g., weight gain and extrapyramidal side effects[7,8,14]). Also, as the periods of observation or follow-up (i.e., time horizon) were commonly months to years[7,8,12,14–16] there is limited application to the ED setting, where the length of stay is typically hours to days.

Several general comments can be made regarding the cost considerations of drugs used in the management of acute agitation. For patients with schizophrenia in the psychiatry setting, there is a trend toward a positive impact on QoL measures with atypical antipsychotic drugs.[19,21] Two[12,16] out of three studies[12,14,16] that compared olanzapine with haloperidol in patients with schizophrenia reported that olanzapine reduced costs and improved QoL when compared with haloperidol. While QoL measures included considerations of acute agitation and aggression, the findings do not necessarily translate to the management of agitation in the undifferentiated ED patient. Furthermore, the cost items considered in the management of mental illness in the community differ to those of the ED.

In assessing the quality and generalisability of these studies in the ED setting, outcome validity, based on the measurement and analysis of costs, were adversely impacted by the numerous methodical flaws and study limitations. Pharmacoeconomic studies comparing the use of current sedating drugs in acute agitation in the ED are required to gain insight into resource utilization in this setting.

Pharmacoeconomic studies into the management of acute agitation in ED will facilitate decision making with respect to resource allocation. Indeed, such studies are needed to justify and optimize the expenditures associated with the benefits provided by new or alternate treatments in an environment of limited resources.Comparing one drug (e.g., a second-generation antipsychotic) versus another (e.g., a first-generation antipsychotic) using the drug acquisition costs alone is inadequate given that the costs of managing acute agitation in the ED is influenced significantly by factors such as length of stay, staff time and other additional treatments (e.g., management of adverse events). There is a dearth of pharmacoeconomic studies of acute agitation in the ED. Importantly, existing pharmacoeconomic studies exploring the management of agitation in psychiatry and other disciplines cannot be readily generalisable to the ED setting, given the differences in clinical settings and clinical outcomes of interest.