Drug acquisition accounts for a minor share of the costs associated with dobutamine–milrinone escalation in cardiogenic shock: a propensity-weighted cost analysis from Indonesia

BACKGROUND: Adding milrinone to dobutamine (dobutamine-milrinone escalation) in cardiogenic shock (CS) is reimbursed for a limited duration under Indonesia's national health insurance, but the cost structure of escalation remains poorly characterized. This study quantified direct medical charges associated with escalation and the contribution of drug acquisition. RESEARCH DESIGN AND METHODS: Retrospective cohort of 76 adult CS survivors (20 escalation, 56 dobutamine monotherapy) at Indonesia's national cardiovascular referral center, 2020-2024. Covariate Balancing Propensity Score-based inverse probability of treatment weighting, using pre-treatment covariates, estimated adjusted cost ratios (CR) for intensive cardiovascular care unit (ICVCU) and total hospital costs from institutional billing records. RESULTS: Escalation was associated with higher ICVCU costs (CR 2.711; 95% CI 1.912-3.844; p < 0.001) and total hospital costs (CR 2.321; 95% CI 1.372-3.929; p = 0.002). Combined inotrope costs represented 4.3% of ICVCU expenditure in the escalation group, compared with 30.9% for therapeutic and interventional procedures. Baseline vasoactive-inotropic score correlated with total hospital cost (ρ=0.597; p < 0.001). CONCLUSIONS: Drug acquisition represented a minor share of costs associated with dobutamine-milrinone escalation. The findings support consideration of severity- and resource-based approaches to reimbursement rather than focusing solely on duration limits for individual inotropes. Interpretation is limited by the retrospective, single-center, survivor-only design.