Example of cost calculations for an operating room and a post-anaesthesia care unit

OBJECTIVE

The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us.

METHODS

Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU).

RESULTS

The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost.

CONCLUSION

Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making.

Costs optimization in anaesthesia

OBJECTIVES

The aim of this study is to analyze the direct cost of different anaesthetic techniques used within the Author's hospital setting and compare with costs reported in the literature.

METHODS

Mean cost of drugs and devices used in our local Department of Anaesthesia was considered in the present study. All drugs were supplied by the in-house Pharmacy Service of Parma's General Hospital. All calculation have been made using an hypothetical ASA1 patient weighting 70 kg. The quality of consumption and cost of inhalation anaesthesia with sevoflurane or desflurane at different fresh gas flow were analyzed, and the cost of total venous anaesthesia (TIVA) using propofol and remifentanil with balanced anaesthesia were also analyzed. In addition, direct costs of general, spinal and sciatic-femoral nerve block anaesthesia used for common plastic surgery procedures were assessed.

RESULT

The results of our study show that the cost of inhalational anaesthesia decreases using fresh gas flow below 1L, and the use of desflurane is more expensive. In our Hospital, the cost of TIVA is more or less equivalent to the costs of balanced anaesthesia with sevoflurane in surgical procedure lasting more than five hours. The direct cost was lower for the spinal anaesthesia compared with general anaesthesia and sciatic- femoral nerve block for some surgical procedures. (www.actabiomedica.it).

[Costs of anesthetics and other drugs in anesthesia]

INTRODUCTION

Drugs are real and transparent costs of treatment, which are subject to constant monitoring and changes. The study was aimed at measuring and analyzing consumption of anesthetics and other drugs in anesthesia in the Clinical Centre of Serbia.

MATERIAL AND METHODS

This paper is part of a five-year (2005-2009), academic, pharmacoeconomic retrospective-prospective study (the 4th phase). We calculated the costs of anesthetics and other drugs in all anesthetized patients at the Institute of Anesthesia and Reanimation, Clinical Center of Serbia in 2006. The data, obtained from the Clinical Centre of Serbia Database, were analyzed by descriptive statistical methods using computer program Microsoft Office Excel 2003 and the Statistical Package for the Social Sciences (SPSS) for Windows.

RESULTS

The amount of money spent for the application of 33,187 general and 16,394 local anesthesia and 20,614 anesthesiology procedures was 83,322,046.36 RSD (Euros 1,054,705.4), which was 5.93% of the funds allocated for all drugs used at the Clinical Center of Serbia. Of the total fund for drugs, 57.8% was spent for anesthetics (local anesthetics 1.20%) and muscle relaxants, whereas 42.2% was spent for other drugs in anesthesia. The highest amount was spent at the Emergency Center (35.8%), then at the Cardio-surgery (11.9%) and the Neurosurgery (10.9%) because of the large number and length of surgical interventions.

CONCLUSION

There is no space for rationalizing the costs of anesthetics and other drugs in anesthesia.

[Cost of anaesthesia at the university hospital]

BACKGROUND

The costs of anaesthesia in Polish hospitals are usually calculated as a percentage of the cost of the surgical procedure, or as a percentage of the total cost of the operating theatre. These methods cannot be accurate, since they do not take into consideration, the specifics of anaesthesia. Therefore, a new method of calculation, based of the actual use of materials and manpower, has been introduced in our institution.

METHODS

Anaesthesia procedures were divided into nine categories, according to risk of anaesthesia, type of surgery, type of anaesthesia, and working hours of the anaesthetic personnel. Each category was priced in points which expressed the actual value of the service provided, and the resulting totals were allocated to surgical specialties.

RESULTS

The costs of anaesthesia calculated by the new method differed markedly from previous calculations. The number of anaesthetics between 2008 and 2010 increased by 20%, while the cumulative costs of anaesthesia rose by only 13%, when compared to the previous method of calculation. Changes in anaesthesia costs, in various surgical specialties, varied from -49% to +65%, and were not related to the number of procedures.

CONCLUSION

The new scoring system made it possible to calculate actual anaesthesia costs in various surgical specialties. It is logical and practical and merits recommendation.

[Pharmacoeconomics: basic concepts and applications to clinical anesthesia]

The economic evaluation of medications and health care technology has gained importance in recent years. Health care resources are limited and their use must be optimized so that we can take the greatest possible advantage. Pharmacoeconomics seeks to analyze the best therapeutic drug choices to obtain the desired outcome in specific cases or in populations. The 4 approaches used in pharmacoeconomics are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. This review examines the characteristics of each type of study using examples from anesthesiology, a field in which pharmacoeconomics is beginning to play a role.

[Wastage of anesthetic related drugs in a university hospital]

BACKGROUND

The cost of wasted anesthetic related agents has not been clear in Japanese hospitals. We investigated whether the trainees in anesthesiology influence the cost of wasted anesthetic related agents.

METHODS

Investigation was carried out at the University of Tokyo Hospital. We interviewed each trainee in anesthesiology about all prepared anesthetic drugs and wasted ones at the end of each anesthetic management.

RESULTS

The percentage of wasted ampoules of anesthetic related agents was 15.85%, but the percentage of wasted cost was 5.15%. A large difference was not observed in transition of training period, and this percentage was not improved by training. We considered that this wasted cost is within permissible ranges in comparison with other reports.

CONCLUSIONS

During the training it is also important to develop a sense of medical economics.

[Monitoring the depth of anaesthesia: why, how and at which cost?]

The precise titration of anaesthetic agents is necessary to avoid the consequences of a too light depth of anaesthesia such as unexpected intraoperative awareness, as well as a too deep level of anaesthesia, which can be deleterious in terms of postoperative morbidity and mortality. The clinical evaluation of the depth of anaesthesia is poorly sensitive and specific. It does not permit to distinguish between pharmacodynamic components of anaesthesia. Several paraclinical depth of anaesthesia indices are currently available. Most of them are mainly designed to monitor the depth of the hypnotic component of anaesthesia. Their calculation is mostly based on the mathematical analysis of the electroencephalogram. They are efficient at reducing the incidence of unexpected intraoperative awareness, adjusting anaesthetic depth at an individual scale, predicting the time needed for recovery, allowing early extubation of patients, reducing their length of stay in the post anaesthesia care unit, and limiting the number of episodes of peroperative over and under dosage of anaesthetic agents. The knowledge of conditions that may impede the accurate interpretation of those indices is mandatory for an optimal use. Although undoubtedly beneficial for the patients, the use of those monitors is frequently responsible for supplementary' costs, particularly when the procedure is short.

Induction of Anaesthesia

In developed countries, the choice of an anaesthetic agent for induction of anaesthesia remains based mainly on its pharmacodynamic properties. Until now, cardiovascular effects were the main factor in this decision. However, other factors, such as the depth of anaesthesia and effects on cortisol synthesis, can modify this simplistic view. A better understanding of the relationships between the pharmacokinetics and pharmacodynamics of these drugs, and the availability of new techniques, such as target-controlled infusions of anaesthetic drugs and inhalation induction, have led practitioners to the understanding that the way a drug is administered is a far more important factor for maintaining haemodynamic stability than the specific agent used. The ability of a drug to maintain spontaneous ventilation and to relax the upper airway is another factor in this decision, especially when considering difficult intubation, laryngeal mask insertion or tracheal intubation without neuromuscular blockade. Beyond the factors mentioned above, anaesthetists adapt current practice to suit patients' willingness to comply with anaesthesia and to avoid the adverse effects that are most often feared by the patient. Although most practitioners are not concerned with the cost of anaesthesia, cost-containment policies have led some institutions to restrict the use of the more expensive drugs to particular indications. However, this is too simplistic an approach for the reduction of global costs, as other direct medical costs, such as those for staffing, form a greater proportion of total costs than do direct drug costs. Cost-benefit and cost-efficacy studies of the anaesthetics used for induction of anaesthesia are needed to help anaesthetists to choose a drug based on both cost and pharmacodynamic or pharmacokinetic properties.

Spinal versus general anesthesia for orthopedic surgery: anesthesia drug and supply costs

Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.

Parents' willingness to pay for diminishing children's pain during blood sampling

BACKGROUND

Blood sampling is a frequent medical procedure, very often considered as a stressful experience by children. Local anesthetics have been developed, but are expensive and not reimbursed by insurance companies in our country. We wanted to assess parents' willingness to pay (WTP) for this kind of drug.

PATIENTS AND METHODS

Over 6 months, all parents of children presenting for general (GV) or specialized visit (SV) with blood sampling. WTP was assessed through three scenarios [avoiding blood sampling (ABS), using the drug on prescription (PD), or over the counter (OTC)], with a payment card system randomized to ascending or descending order of prices (AO or DO).

RESULTS

Fifty-six responses were collected (34 GV, 22 SV, 27 AO and 29 DO), response rate 40%. Response distribution was wide, with median WTP of 40 for ABS, 25 for PD, 10 for OTC, which is close to the drug's real price. Responses were similar for GV and SV. Median WTP amounted to 0.71, 0.67, 0.20% of respondents' monthly income for the three scenarios, respectively, with a maximum at 10%.

CONCLUSIONS

Assessing parents' WTP in an outpatient setting is difficult, with wide result distribution, but median WTP is close to the real drug price. This finding could be used to promote insurance coverage for this drug.

[Sedative practice in intensive care units results of a Maghrebian survey]

OBJECTIVES

sedation is central to the management of intensive care patients. The aim of this study was to establish the current sedation practice in Maghrebian intensive care units (ICUs). The use of sedation policies with or without a written protocol, the use of scoring systems, the influence of costs on drug choice, the most common drugs for sedation and the use of neuromuscular blocking agents.

METHODS

a self-administered questionnaire composed of 20 items was sent to 138 intensivists in the Maghreb working in 25 teaching hospitals and 16 private clinics.

RESULTS

50 of 138 questionnaires were returned (response rate = 36.2%). Midazolam and Fentanyl were the main sedative agents used (respectively 98% and 87%) less than 14% of the ICUs used the Propofol mainly in the first 48 hours. A sedation policy was adopted in 63.6% with a written protocol in 20% of cases. Sedation scoring systems were noted in 14.3% of cases (RAMSAY scale in 100%). Economic aspect was important for 64.6% of ICUs.

DISCUSSION

sedation may seem secondary in the initial management of intensive care patients, only 63% of our respondents had a sedation policy and 20% a written protocol though its use is thought to improve outcome and reduce costs. Economic aspect was important for the choice of the drug to use (64%), this may explain the preferential use of Midazolam 98% in association with an analgesic (Fentanyl: 85%) while Propofol is used only in 14% though pharmacoeconomic studies may be in fact in favor of the latter. Neuromuscular blocking agents are less frequently used (16%) mainly because of the risk of complications.

[Health-related quality of life in anaesthesiology and perioperative medicine]

The authors present an analysis of literature data regarding correlations between health-related quality of life (HRQL), quality of anesthesia, quality assurance and pharmaco-economic factors in the context of patient-based individual perception of a life threatening situation in the perioperative period. The main attention was given to the quantification of HRQL as a new clinical parameter and methodological problems were emphasized.

Effect of Different Cost Drivers on Cost per Anesthesia Minute in Different Anesthesia Subspecialties

Background

Little is known about differences in costs to provide anesthesia care for different surgical subspecialties and which factors influence the subspecialty-specific costs.

Methods

In this retrospective study, the authors determined main cost components (preoperative visit, intraoperative personnel costs, material and pharmaceutical costs, and others) for 10,843 consecutive anesthesia cases from a 6-month period in the 10 largest anesthesia subspecialties in their university hospital: ophthalmology; general surgery; obstetrics and gynecology; ear, nose, and throat surgery; oral and facial surgery; neurosurgery; orthopedics; cardiovascular surgery; traumatology; and urology. Using regression analysis, the effect of five presumed cost drivers (anesthesia duration, emergency status, American Society of Anesthesiologists physical status of III or higher, patient age younger 6 yr, and placement of invasive monitoring) on subspecialty-specific costs per anesthesia minute were analyzed.

Results

Both personnel costs for anesthesiologists and total costs calculated per anesthesia minute were inversely correlated with the duration of anesthesia (adjusted R2 = 0.75 and 0.69, respectively), i.e., they were higher for subspecialties with short cases and lower for subspecialties with longer cases. The multiple regression model showed that differences in anesthesia duration alone accounted for the majority of the cost differences, whereas the other presumed cost drivers added only little to explain subspecialty-specific cost differences.

Conclusions

Different anesthesia subspecialties show significant and financially important differences regarding their specific costs. Personnel costs and total costs are highest for subspecialties with the shortest cases. Other analyzed cost drivers had little effect on subspecialty-specific costs. In the light of these cost differences, a detailed cost analysis seems necessary before the profitability of an anesthesia subspecialty can be assessed.

Effects of Bispectral Index Monitoring on Ambulatory Anesthesia

Background

Ambulatory surgery is growing in popularity worldwide. For example, 50-70% of surgical procedures in North America are performed on an ambulatory basis. Use of Bispectral Index (BIS) monitoring for titration of general anesthesia may allow use of less anesthetics, reduction in side effects, and faster patient recovery.

Methods

MEDLINE and other databases were searched for randomized controlled trials examining the use of BIS monitoring versus standard practice in ambulatory surgery patients. Outcomes were extracted from these articles, and a meta-analysis was performed.

Results

One thousand three hundred eighty subjects from 11 trials were included in the meta-analysis. The use of BIS monitoring significantly reduced anesthetic consumption by 19%, reduced the incidence of nausea/vomiting (32% vs. 38%; odds ratio, 0.77), and reduced time in the recovery room by 4 min. However, these benefits did not result in significant reduction in time until patient discharge from the ambulatory surgery unit. Cost analysis using pooled costs to reflect North America, Europe, and Asia indicated that use of BIS monitoring increased the cost per patient by 5.55 US dollars because of the cost of BIS electrodes.

Conclusions

The use of BIS monitoring modestly reduced anesthetic consumption, risk of nausea and vomiting, and recovery room time. These benefits did not reduce time spent in the ambulatory surgery unit, and cost of the BIS electrode exceeded any cost savings.

Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge

BACKGROUND

Anterior cruciate ligament reconstruction is a complex outpatient surgical procedure often associated with pain. Traditionally, the procedure is performed under general anesthesia and often requires the use of the PACU. Refractory pain and/or nausea/vomiting occasionally leads to an unplanned hospital admission. In this study, the authors examine the associations of nerve block analgesia for these patients and its associated reductions in PACU use, hospital admission, and hospital costs.

METHODS

This was an observational, nonrandomized study in which existing data regarding patients' day-of-surgery outcomes were merged with hospital cost data. We reviewed a consecutive sample of 948 men and women who were in good health and underwent anterior cruciate ligament reconstruction in an outpatient surgery unit between July 1995 and June 1999.

RESULTS

The use of nerve block analgesia was associated with reduced PACU admissions to 18% and decreased unplanned hospital admission rates from 17% to 4%. Multivariate linear regression analysis showed that patients bypassing the PACU had an associated hospital cost reduction of 12% (P = 0.0001), whereas patients who needed hospital admission had an associated hospital cost increase of 11% (P = 0.0003).

CONCLUSIONS

The use of nerve blocks for acute pain management in patients undergoing anterior cruciate ligament reconstruction is associated with PACU bypass and reliable same-day discharge. Although the cost savings for this one procedure are unlikely to generate sufficient cost savings via staffing reductions, extrapolating these results to a large volume of all types of invasive outpatient orthopedic procedures may have the potential to create significant hospital cost savings.

Undocumented drug utilization and drug waste increase costs of pediatric anesthesia care

The present study was performed in order to identify the cost of drugs used without documenting them in the patients' file and the wastage of drugs in a pediatric anesthesiology ward. In a prospective, blinded, observational design, drug utilization of 610 consecutive patients, undergoing an elective or emergency surgical procedure was evaluated. The number of undocumented drugs per 100 requested units and the number of wasted drugs per 100 requested units were computed and multiplied by its corresponding unitary cost. The median undocumented cost was 92.4 US dollars (95% CI 17.2-216.6 dollars) per 100 requested units. Succinylcholine (40 mg/2 mL) was the main undocumented drug; its use was not documented in approximately 50% cases in which this neuromuscular blocking agent was requested. However, rocuronium and nalbuphine had the highest unjustified cost, 770.6 dollars and 847.0 dollars per 100 requested units, respectively. Ketorolac, diclofenac, metamizol, furosemide, methylprednisolone, sodium bicarbonate, and cisatracurium were requested and documented. The median cost of wasted drug was 141.8 dollars (95% CI 55.8-448.2 dollars) per 100 requested drugs. More than 80% of adrenaline, naloxone, flunitrazepam, ephedrine, and cisatracurium were wasted. However, the highest cost of wasted drugs was for ondansetron, cisatracurium, methylprednisolone, and rocuronium. The uncontrolled availability and use of drugs may represent an important amount of resources wasted without any awareness of the staff in a department of pediatric anesthesia.

Bispectral index-guided anesthesia in patients undergoing aortocoronary bypass grafting

In this prospective, randomized study, we compared hemodynamics, oxygenation, possible intraoperative awareness, and costs in 62 patients undergoing first-time elective coronary artery bypass grafting at 2 different levels of anesthesia. Depth of anesthesia was assessed with bispectral index (BIS). All patients were anesthetized with sufentanil/midazolam. The dosage of sufentanil/midazolam was adjusted to achieve a BIS level of 45-55 in 32 patients (Group BIS 50), whereas in 30 patients a BIS level of 35-45 was intended (Group BIS 40). Data were obtained at six different time points before, during, and after surgery. All patients were asked about possible intraoperative awareness on the third postoperative day. There were no significant differences of any hemodynamic or oxygenation variables at any time between the two groups. BIS 40 patients received significantly (P < 0.05) more sufentanil (BIS 40, 888 +/- 211 microg; BIS 50, 514 +/- 99 microg) and midazolam (BIS 40, 22.4 +/- 5.6 mg; BIS 50, 16.6 +/- 3.7 mg) than BIS 50 patients. The reduction in anesthetic drugs used saved euro;13.78/US$12.54 per patient (P < 0.05) in Group BIS 50, but one BIS electrode caused additional costs of 19.95 Euros/18.15 US dollars. Time to extubation was not significantly prolonged in Group BIS 40 (BIS 40, 14.3 +/- 4.6 h; BIS 50, 11.8 +/- 3.8 h). There was no explicit memory during anesthesia in either group. BIS-guided reduction of anesthetic medication saved costs and did not increase the risk of intraoperative awareness. However, total costs were increased by monitoring BIS, because of the BIS electrodes.

[Accessible price lists at the anaesthesiologist's workplace enhance cost consciousness as a part of process and cost optimization]

The imminent introduction of the DRG (diagnosis-related-group) system is putting hospitals in Germany under considerable pressure. This requires that personnel are efficiently allocated by optimizing organizational procedures and that the limited resources be distributed in a cost-effective manner. One prerequisite for this is a marked cost-consciousness on the part of those who "incur costs" in providing a service. To increase the awareness of costs in clinical physicians, the cost structures must be transparent. In order to achieve this goal, a project was initiated at the Department of Anaesthesiology at the University Hospital of Heidelberg, which aimed to enhance the cost-consciousness of the staff by making price lists available to anaesthesiologists at the workplace. In addition to the price lists, the 25 most expensive medications and medical products were added as an ABC analysis. The departmental staff was interviewed by questionnaire as to whether this project was reasonable. After 1 year the interview was repeated. The results of the questionnaire showed that in the opinion of the staff, price lists are an effective tool, as cost-consciousness on the part of clinical physicians can be enhanced by making price structures transparent. This is a major prerequisite for individual motivation in the cost-effective management. Although the ABC analyses demonstrate no long-term effect of the price-transparency on the cost structures, the staff showed increased cost-consciousness and individual motivation for economic tasks.

Cost comparisons of pharmacological strategies in open-heart surgery

Open-heart surgery (OHS) is performed to bypass occluded arteries, replace malfunctioning cardiac valves or correct congenital abnormalities. The average cost of OHS varies from $US25 057-$US79 795 (1997 values). The objective of this paper was to review economic studies of pharmacological strategies in open-heart surgery. Pharmacological strategies studied include the prevention of postoperative complications such as atrial fibrillation (AF), bleeding and infection. Modifications in anaesthetic technique have been attempted by using agents that promote early extubation. In addition, strategies for postoperative management of sedation, analgesia and AF and use of neuromuscular blockers have also been compared. The majority of studies in this area have been cost analyses with few cost-effectiveness studies performed. Prophylaxis against AF with amiodarone is associated with a reduction in AF and was cost-neutral compared with placebo. Compared with placebo, prevention of bleeding with antifibrinolytics reduces transfusion costs. In direct comparative studies, lysine analogues, due to lower drug acquisition costs, offset transfusion costs to a greater extent than aprotinin. However, safety concerns with the lysine analogues remain. Erythropoietin decreases transfusion requirements and is cost effective compared with no intervention when the cost of postoperative bacterial complications is included. First- and second-generation cephalosporins prevent postoperative infections. Based on drug acquisition cost, the first-generation agents are less expensive although when administration costs are included, both classes have similar costs. Modifications in anaesthetic technique with short-acting anaesthetic agents, results in higher drug costs although nursing and total hospital costs are typically reduced. For neuromuscular blockers, drug acquisition costs are lowest with pancuronium but administration costs and the cost of adverse events have not been included in existing analyses. Midazolam provides an equivalent level of postoperative sedation to propofol but the acquisition cost is lower. The combined use of propofol and midazolam warrants further investigation, as its use is associated with lower sedative agent costs compared with either agent alone. There is limited data on the economics of postoperative analgesia and the management of AF. As the majority of studies to date are partial cost analyses, additional studies that include length of stay and other hospitalisation data are warranted. In future, cost-effectiveness and cost-utility studies, which incorporate quality of life and the cost of adverse effects and other longer term costs, should be undertaken.

Pharmacoeconomic considerations in anaesthetic use

Healthcare costs are rising in all areas of medicine, especially in high technology specialities such as anaesthesia. Therefore, cost containment and reduction have become major goals in many hospitals and anaesthesia departments. One area that has received substantial attention is the cost of pharmaceutical products, in particular the cost of newer, shorter-acting inhaled and intravenous anaesthetics, analgesics and neuromuscular blocking agents. Numerous pharmacoeconomic studies have been published on the theoretical analysis of anaesthetic drug costs and the potential benefit of various anaesthesia techniques. However, the results are not conclusive and anaesthesia departments continue to seek ways to reduce costs. In this review, we intend to discuss cost terminology, common areas of cost containment in anaesthesia and the relationship of anaesthesia care costs to total perioperative costs.

Desflurane improves the throughput of patients in the PACU. A cost-effectiveness comparison with isoflurane

PURPOSE

In a pharmacoeconomic approach of anesthesia, postanesthesia care unit (PACU) occupancy can be chosen as a criteria of effectiveness to compare two anesthetic drugs with different rates of elimination and different costs of administration. Our objective was to develop a cost-effectiveness approach for the comparison of isoflurane (I) and desflurane (D).

METHOD

In this prospective observational study, 68 patients aged 18-70 received either D or I for maintenance of anesthesia for inpatient abdominal procedures. Length of stay (LOS) in PACU was collected by a blinded observer. After the relationship between duration of surgery and LOS in PACU had been established in the 68 observed patients, we estimated the PACU occupancy according to duration of surgery and time of admission in PACU using a computer model of 204 consecutive patients, based on the hypothesis of an exclusive use of either D or I. Outcome measures were direct costs of the anesthesia procedure and occupancy of the PACU.

RESULTS

The direct cost of the anesthetic was significantly higher with D than with I. This represents an increase of CAN$ 2 708 for the 204 patients. PACU occupancy was reduced by at least one patient (out of five beds) during 26.1% of the time with D (P <0.01).

DISCUSSION

Improving the throughput of patients in PACU by using new halogenated anesthetic agents with faster rates of elimination may outweigh the incremental cost of this strategy. This becomes particularly meaningful in operating theatres experiencing frequent overcrowded periods.

Pharmacoeconomics in anaesthesia: what are the issues?

Newer anaesthetic agents provide a faster onset, easier titration and a more rapid recovery than the older agents, but are more expensive. In assessing the financial consequences associated with their use, it is important to examine the total costs (including personnel costs) and not just the acquisition costs of new drugs. Claims of cost savings from new drugs should be subjected to close scrutiny, with studies designed to demonstrate that the preferential use of the newer drug is associated with actual decreased payments for personnel, an earlier return to normal activities by the patient and/or their caretakers, or the completion of an additional case in the same operating session. It may be necessary to alter work patterns to obtain the full benefits of the new drugs (e.g. bypass of the labour-intensive [phase I] postanaesthetic care unit). Finally, greater cost savings in the operating room can be achieved by increasing efficiency in resource utilization. A delay in starting a case, or a prolonged turnover time between cases, can negate any cost savings related to the anaesthetist's choice of drugs.

Cost optimization in anaesthesia

As a result of the progress which has been made in medicine and technology and the increase in morbidity associated this demographic development, the need and thus the costs for medical care have increased as well. The financial resources which are available for medical care, however, are still limited and hence the funds which are available must be distributed more efficiently. Cost optimisation measures can help make better use of the profitability reserves in hospitals. The authors show how costs can be optimised in the anaesthesiology department of a clinic. Pharmacoeconomic evaluation of the new inhalation anaesthetics shows an example of how the cost structures in anaesthesia can be made more obvious and potential ways savings be implemented. To reduce material and personnel costs, a more rational means of internal process management is presented. According to cost-effectiveness analysis, medications are not divided into the categories inexpensive and expensive but rather cost-effective or non-cost-effective. By selecting a cost-effective drug it is possible to reduce cost at a hospital. For example, sevoflurane at a fresh gas flow of below 3 l/min has been shown to be a cost-effective inhalation anaesthetic which, in terms of the economics, is also superior to intravenous anaesthesia with propofol. In addition to these measures of reducing material costs, other examples are given of how personnel costs can be reduced by optimising work procedures: e.g. effective operating theatre co-ordination, short switchover times by overlapping anaesthesia induction and the use of multifunctional personnel. The gain in productivity which is a result of these measures can positively affect profits, and by optimising the organisation of procedures to shorten the times required to carry out a procedure, costs can be reduced.

[Cost control in anesthesiology--regulating net costs exemplified by anesthetics]

German hospitals are beginning to feel more and more pressure due to rising costs in health care. These are due to continuous increase in health care expenditure and decrease in state insurance contributions. A change in the state insurance system (GKV) is well and truly overdue; the source of income needs to be increased by either raising the compulsory insurance wage base or making other forms of income liable for insurance contributions. Unfortunately, the government is still reluctant to take action. The ruling coalition feels that it is better to limit the increase in expenditure on hospital care by introducing a case-related payment system. Unfortunately, they do not recognize that the main reason for the increase in health care expenditure is the growing medical potential and the higher morbidity of an, on average, older population. These cuts in financial means demand an efficient allocation of the available funds. As far as hospital in-patient care is concerned, this means that hospitals need to reconsider their expenditure and that economic success is dependent on their potential to recognize ways of reducing overall costs. This article illustrates that before the "Diagnosis Related Groups" (DRG) become effective in 2003, one needs to establish the cost price of individual hospital cases. The economic principles of cost-benefit ratios and methods to prevent cost inflation are presented. The methods of making a cost-effectiveness analysis of anaesthetic costs are explained in detail. The aim of this paper is to give the clinician a better understanding of cost management and to motivate staff to initiate cost-control studies.

Improving pharmacy supply-chain management in the operating room

Anesthesia services can account for a significant portion of a healthcare organization's costs. Deaconess Hospital of Evansville, Indiana, used a collaborative, multidisciplinary effort to implement process improvements that yielded significant cost savings while improving patient care. Shifting responsibility for drug distribution from the operating room (OR) nurses to a pharmacist, the hospital established a satellite pharmacy service for the OR. As a result, the hospital was able to improve control of drug distribution and record-keeping, reduce turnaround time for medication preparation, lower its medication charge error rate, and increase the percentage of surgeries that start on time. The success of the OR satellite pharmacy led the hospital to expand satellite pharmacy services to labor and delivery, the cardiac cath laboratory, and the intensive care units.

Costing anaesthetic practice. An economic comparison of regional and general anaesthesia for varicose vein and inguinal hernia surgery

A computerised database of operating theatre activity was used to estimate the costs of regional and general anaesthesia for varicose vein and inguinal hernia surgery. Data retrieved for each procedure included the anaesthetic technique and drugs used, and the duration of anaesthesia, surgery and recovery. The costs of anaesthetic drugs and disposables, salary costs of the anaesthetic personnel and maintenance costs for anaesthetic equipment were considered. Drugs and disposables accounted for approximately 25% of the total cost of an anaesthetic. Anaesthetic times were 5 min longer for regional anaesthesia, but recovery times were 10 min shorter following regional anaesthesia for varicose vein surgery. Staff costs were dependent on the length of time each staff member spent with the patient. Although the number of cases was small, provision of a field block and sedation for inguinal hernia repair was considerably cheaper than other anaesthetic techniques.

Drug use inefficiency: a hidden source of wasted health care dollars

A potential area for departmental savings is to minimize inefficient use of pharmaceuticals. We recorded drug waste data for multiple drugs for a fiscal year and surveyed providers' knowledge of departmental drug waste. Six large-cost or large-volume use drugs were chosen for study: thiopental, succinylcholine, rocuronium, atracurium, midazolam, and propofol. Amounts administered to patients were collected for one year by using a computerized anesthesia record keeper. Total drug distributed was the number of vials restocked by pharmacy for the year. An efficiency index, the percent administered to patients, was calculated for each drug. Drug administration to 25,481 patients was analyzed. Drug use efficiency indices were: atracurium 29%; thiopental, 31%; succinylcholine, 33%; propofol, 49%; midazolam, 53%; rocuronium, 61%. The total cost of unadministered study drugs was $165,667, 26% of the expenditure for all drugs. Most dollars wasted were for propofol, $80,863, and thiopental, $32,839. The reason most cited for drug waste was the disposal of full, or partially full, syringes. Drug wastage represents a significant portion of the entire anesthesia drug budget. Waste reduction strategies should allow a portion of the "avoidable" waste to be reduced.

IMPLICATIONS

Unadministered drug amounts were measured for six study drugs over one fiscal year and found to be significant; the cost of unadministered drugs totaled $165,667. The reason most cited for waste was disposal of full, or partially full, syringes.

Clinical and economic factors important to anaesthetic choice for day-case surgery

Clinical and economic factors that are important to consider when selecting anaesthesia for day-case surgery can differ from those for inpatient anaesthesia. Patients undergoing day-case surgery tend to be healthier and have shorter durations of surgery. They expect less anxiety before surgery, amnesia for the surgical experience, a rapid return to normal (normal mentation with minimal pain and nausea) after surgery, and lower expenses. However, the latter 2 expectations can conflict; older generic drugs have lower acquisition costs but often impose longer recovery times. Longer recovery periods can increase costs by prolonging the time to discharge from labour-intensive areas such as the operating suite or the post-anaesthesia recovery unit. The challenge for today's anaesthetist is to use newer drugs judiciously to minimise their expense without compromising the rate or quality of recovery. Several approaches can secure these aims. Most apply the least anaesthetic needed. 'Least anaesthetic' may mean the particular form of anaesthetic (e.g. local infiltration with monitored anaesthesia care versus a general anaesthetic), or may mean the delivery of the smallest effective dose, perhaps guided by anaesthetic monitors such as end-tidal analysers or the bispectral index. For patients requiring general anaesthesia, a combination of several drugs usually secures the closest approach to the ideal. Drug combinations used usually include a short-acting properative anxiolytic (e.g. midazolam), intravenous propofol (a short-acting potent anxiolytic and amnestic agent) for induction of anaesthesia (and sometimes for maintenance) and primary maintenance of anaesthesia with inhaled nitrous oxide combined with a poorly soluble (low solubility produces rapid recovery; the least soluble is desflurane) potent inhaled anaesthetic delivered at a low inflow rate (to minimise cost). Although old, nitrous oxide is inexpensive and has favourable pharmacokinetic and cardiovascular advantages; however, it is limited in its anaesthetic/amnestic potency, and has the capacity to increase nausea. In children, induction of anaesthesia is often accomplished with sevoflurane rather than desflurane; although sevoflurane is modestly more soluble than desflurane, it is non-pungent whereas desflurane is pungent. Moderate- or short-acting opioids (fentanyl is popular) or nonsteroidal anti-inflammatory agents (especially ketorolac), or local anaesthetics are added to secure analgesia during and after surgery. Similarly, when needed, moderate- or short-acting muscle relaxants are selected. Before the end of anaesthesia, an intravenous antiemetic may be given. With this drug combination, patients usually awaken within minutes after anaesthesia and can often move themselves to the vehicle for transport to the recovery unit. These combinations of anaesthetics and techniques minimise use of expensive drugs while expediting recovery (again minimising cost) with minimal or no compromise in the quality of recovery.

[Auditing of drug use practices in anesthesia]

OBJECTIVES

Internal pharmaceutical practice guidelines were produced in a department of anaesthesia of a University hospital in 1995, after a preliminary evaluation showing controversial and expensive practices. After approval, these recommendations were circulated to all members of the department. Phase I of this study was started 18 months later, to evaluate the compliance of anaesthetists with these guidelines.

STUDY DESIGN

Prospective survey.

METHOD

An audit was performed by a research assistant pharmacist, previously trained, who compared anaesthetic agents and fresh gas flows used during anaesthetics with those recommended in the internal guidelines.

RESULTS

Implementation of guidelines was observed in more than 90% of cases for all agents studied, except for non-depolarizing neuromuscular relaxants. Relaxants of intermediate duration were used in 52% of cases with an expected surgery duration of more than 90 min, in opposition to the guidelines stating that pancuronium should have been administered in such circumstances. These results were presented and discussed. Slight changes in the guidelines (especially concerning monitoring of neuromuscular blockade) were made and evaluated again, using the same method (Phase II). A small but significant improvement was seen with induction agents (use of propofol in non-approved situations: 5 versus 0%, P = 0.03), while a non significant trend toward better implementation of guidelines was seen with non-depolarizing agents (use of pancuronium in surgery of expected duration > 90 min: phase I vs phase II = 47 vs 52%, NS; use of pancuronium in surgery of expected duration < 90 min: phase I vs phase II = 3.5 vs 0%, NS).

CONCLUSION

This study suggests that implementation of internal guidelines is easy when clinical indications of the agents are not controversial.

[Drug expenses from anesthesiologists]

OBJECTIVES

To assess expenses generated by prescriptions from anaesthesiologists in the operating theatre, recovery rooms, surgical intensive therapy units, postoperative care on surgical wards (digestive surgery, orthopaedics, gynaecology, obstetrics, paediatric surgery).

METHODS

Prospective study (one year) with evaluation of the costs induced by intravenous and volatile anaesthetics, morphinic and non morphinic analgesics, neuromuscular blocking agents, crystalloids, antibiotics, intravenous nutrient solutions, blood substitutes, anticoagulants, vitamins and vasoactive drugs.

RESULTS

The expenses resulting from these prescriptions reached the quarter of the total drug hospital budget. They were equally distributed between anaesthesia and intensive therapy units on the one hand and postoperative care on surgical wards on the other hand. Intravenous anaesthetic agents, antibiotics, crystalloids, represented each one more than 10% of the total cost.

CONCLUSIONS

This study demonstrates the weight of prescriptions by anaesthesiologists in the hospital budget. At our hospital, it was mainly due to their activity outside the operating theatre, especially on surgical wards. Therefore anaesthesiologists are essential partners for the elaboration of a cost containment policy.

Cost consciousness among anaesthetic staff

BACKGROUND

Anaesthetists, like all other specialists, need to be aware of the costs of drugs, fluids and disposables commonly used in their clinical practice so that excessive costs and waste can be minimized without compromising patient care or safety. The present study describes cost consciousness among 120 anaesthetic staff members in two Danish anaesthetic departments.

METHOD

A prospective study questioning 120 anaesthetic staff members (69 anaesthetic nurses, 35 senior anaesthetists and 16 junior anaesthetists) about the costs of 29 drugs, fluids and disposable used in routine anaesthetic practice.

RESULTS

After the study period 107 questionnaires (90%) were available for analysis. Thirty-eight percent of all estimated costs were within 50% of the actual costs and 85% were within 100%. The costs of relatively expensive items such as isoflurane, enflurane, sevoflurane and hydroxyethyl starch were consistently underestimated, whereas cheaper items such as narcotic drugs, endotracheal tubes, intravenous tubing, plastic syringes and Quincke spinal needle were consistently overestimated. In general, the anaesthetic staff overestimated the costs by 69% (range -24% to 270%). The anaesthetic nursing group overestimated the costs by 49% (range -24% to 270%), junior anaesthetists by 94% (range 25% to 226%) and senior anaesthetists by 72% (range -14% to 135%).

CONCLUSION

This study shows that the overall consciousness of the costs of anaesthetic drugs, fluids and disposables has to be improved in order to permit the staff to optimize resources.

Long-term pharmaceutical cost reduction using a data management system

Cost containment is an important issue in medicine today, and the ability to control costs and maintain quality patient care presents a challenge to practitioners. Educating practitioners about drug costs has been identified as an effective method, but the benefits of education are usually short-lived. To evaluate the role of education in cost control, pharmaceutical use and performance improvement data were analyzed at a tertiary care institution during two time periods. A total of 4,530 anesthesia records and associated performance improvement data from March to June 1993 were analyzed as a baseline. These data were shared with the clinicians of an anesthesia department and used to educate practitioners regarding the costs and use of injectable pharmaceuticals and to identify areas in which cost savings could be achieved. The same information from 10,600 cases during January to October 1996 were compared with the early group. The expenditures for injectable pharmaceuticals to provide anesthesia were decreased by more than $30,000 per month, or $32 per case, without changing the performance indicators that were monitored, and has been maintained for >3 yr.

IMPLICATIONS

By using a data management system, the cost for medications to provide anesthesia has been reduced without changing the quality of patient care.

New drugs in anaesthesia: can we afford them?

The most important challenge facing physicians today is the dilemma of providing high quality care in a fiscally responsible fashion. Cost can no longer be ignored. Pharmacoeconomics is a fundamental component of medical education. Economic issues should be an integral part of the drug development and clinical trials. While anaesthetists are concerned that the use of less expensive drugs may compromise patient outcome and satisfaction there is little evidence to support such concerns. This is a fertile area for intense future research. Pharmacoeconomics is a dynamic. The cost of drugs is not static, patterns of drug use shift rapidly and clinical practice is in a state of constant change. The answer to cost containment is not simply to cut, cap, delist or merely hope for the best, but rather to manage and modify practice while accommodating changing needs. Educational programmes, guidelines, department policies, system changes and financial incentives can be implemented to ensure consistent and enduring adherence to the principles of pharmacoeconomics and value based care. Some suggest that national societies should create guidelines for cost-beneficial practice. Others favour physician autonomy in drug selection. Changing physician behaviour is difficult. This change will occur gradually and will be the topic of many emotionally charged philosophical debates. There will be great reluctance to deny patients pharmacologically superior drugs based on cost alone, especially since drugs are such a small portion of the total costs. We must exercise caution to ensure that we don't become penny wise and pound foolish. Drug acquisition costs are only one element in a large and complex equation. Concentrating on acquisition drug cost may be dangerous, even naive if we fall prey to knowing the cost of everything but the value of nothing.

[Economic aspects of anesthesia. II. Cost control in clinical anesthesia]

The primary scope of economic analyses is the quantification of the costs (input) in relation to the results (outcome, output). According to whether a similar or different dimension of outcome parameters is chosen, it is possible to differentiate between cost minimisation, cost effectiveness, cost benefit and cost utility analyses. Decision trees and sensitivity analyses serve to develop or examine cost outcome studies. The principal perspective of economic analysis is of crucial significance. In the present overview of cost control programmes in clinical anaesthesia, the perspective chosen throughout is that of budget responsibility in a department of anaesthesiology. With regard to economic factors in clinical anaesthesiology, the cost of medical and nursing staff represents the largest cost block. It is, therefore, essential that personnel is efficiently employed, i.e. how the perioperative procedure is organised. In the area of material costs, blood products--including coagulation factors and plasma substitutes--are particularly cost intensive, followed by medical products and drugs, especially muscle relaxants and inhalational anaesthetics. In the perioperative context, the costs of anaesthesia personnel account for 5-15% of the total costs of patient care, while material costs account for 2-10%. In view of this small portion of the total costs, cost control programmes in anaesthesia can only make a relatively small contribution to reducing overall cost. However, it must be realised that anaesthesia care is vitally important for the perioperative process which means that in this context cost-effectiveness interventions have consequences that also affect other fields, e.g. postoperative pain service besides anaesthesia. In conducting economic analyses, cost considerations or reductions cannot be targeted alone, but must always also integrate outcome aspects so that costs and quality are regarded in relation to one another.

The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses

BACKGROUND

Although approximately 2,000 medical practice guidelines have been proposed, few have been successfully implemented and sustained. We hypothesized that we could develop and institute practice guidelines to promote more appropriate use of costly anesthetics, to generate and sustain widespread compliance from a large physician group, and to decrease costs without adversely affecting clinical outcomes.

METHODS

A prospective before and after comparison study was performed at a tertiary care medical center. Clinical outcomes data and times indicative of perioperative patient flow were collected on the first of two sets of patients 1 month before discussion of practice guidelines. Practice guidelines were developed by the physicians and their associated care team for the intraoperative use of anesthetic drugs. A drug distribution process was developed to aid compliance. Clinical outcomes data and times indicative of perioperative patient flow were collected on the second set of patients 1 month after institution of practice guidelines. Hospital drug costs and adherence to guidelines were noted throughout the study period and for each of the following 9 months by querying the database of an automated anesthesia record keeper.

RESULTS

A total of 1,744 patients were studied. Drug costs decreased from 56 dollars per case to 32 dollars per case as a result of adherence to practice guidelines. Perioperative patient flow was minimally affected. Time (mean +/- SD) from end of surgery to arrival in the post-anesthesia care unit (PACU) increased from 11 +/- 7 min before the authors instituted practice guidelines to 14 +/- 8 min after practice guidelines (P < 0.0001). Admission of inpatients to the PACU receiving monitored anesthesia care increased from 6.5 to 12.9% (P < 0.02). Perioperative patient flow and clinical outcomes were not otherwise adversely affected. Compliance and cost savings have been sustained.

CONCLUSIONS

This study is an example of a successful physician-directed program to promote more appropriate utilization of health care resources. Cost savings were obtained without any substantial changes in clinical outcomes. Institution of similar practice guidelines should result in pharmaceutical savings in the range of 50% at tertiary care centers around the country, with a slightly smaller degree of savings expected at institutions with more ambulatory surgery.

Managing pharmaceutical sales activities in an academic anesthesiology department

To contain costs, departments of anesthesiology must control the use of new, expensive drugs. Conflicts with pharmaceutical companies can arise when they promote drug sales. Pharmaceutical company sales represent anesthesiology department expenses. Anesthesiologists hold diverse opinions on this clash of interests, on the proper roles of pharmaceutical sales representatives in anesthesiology departments, and on the ethics of accepting industry gifts. Our department has managed pharmaceutical sales activities by encouraging discussion of the ethics and legal limits of industry gifts, by banning sales representatives from bringing food into the department, and by adopting The American Medical Association Guidelines on Gifts.