Economic Impact of Integrating ESP Block in Enhanced Recovery After Cesarean Section: A Cost-Effectiveness Analysis

Background: While clinical benefits of erector spinae plane (ESP) block in cesarean delivery have been established, economic evidence supporting its implementation in enhanced recovery after surgery (ERAS) protocols remains limited, particularly in resource-constrained settings.

Objective: To evaluate the cost-effectiveness of ESP block versus intrathecal morphine (ITM) within an ERAS pathway for cesarean delivery in an Algerian tertiary care setting.

Methods: A prospective cost-effectiveness analysis was conducted alongside a randomized controlled trial including 140 women undergoing elective cesarean section. Patients were randomized to ESP block (n=70) or ITM (n=70). Direct medical costs including surgical procedures, medications, postoperative care, and hospital stay were assessed. The incremental cost-effectiveness ratio (ICER) was calculated using reduction in opioid consumption, pain scores, and adverse events as effectiveness measures. Budget impact analysis projected monthly savings based on 100 cesarean deliveries.

Results: Mean total cost per patient was significantly lower in the ESP group (20,000 DA vs 49,000 DA; p<0.001). Monthly budget savings reached approximately 2.9 million DA (60% cost reduction) for 100 procedures. Length of stay was reduced by 2.57 hours (26.74±5.84h vs 29.31±8.08h; p=0.03), with 80% achieving 24-hour discharge versus 65.7% in the ITM group. The ESP block demonstrated superior outcomes in all clinical endpoints: reduced rescue analgesia consumption (p<0.001), lower adverse event rates (PONV: 22.9% vs 65.7%, p<0.001; pruritis: 17.1% vs 81.4%, p<0.001), and higher maternal satisfaction (84.3% vs 62.9%, p=0.014). Cost-effectiveness analysis demonstrated dominance of ESP block (lower costs, superior outcomes).

Conclusions: Integration of ESP block in cesarean ERAS protocols is economically advantageous, generating substantial cost savings while improving clinical outcomes and patient satisfaction. These findings support ESP block as a cost-effective alternative to ITM, particularly relevant for healthcare systems with limited resources.