From the *Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; †Department of Anesthesia & Critical Care at Cedars Sinai Medical Center in Los Angeles, Los Angeles, California; and ‡Department of Anesthesia & Critical Care, Policlinico Abano-Leonardo Foundation, Abano Terme, Italy.
Accepted for publication October 1, 2009.
Supported in part by the White Mountain Institute, a not-for-profit private foundation (Dr. White is the President). The White Mountain Institute has received funding from Baxter for clinical studies related to the topic of this Editorial. Dr. White is an active participant in Avogent's Speaker Program on “fast-track recovery concepts,” which is sponsored by Baxter Healthcare.
Address correspondence and reprint requests to Dr. Paul F. White, 144 Ashby Lane, Los Altos, CA 94022. Address e-mail to firstname.lastname@example.org.
The health economics article by Dexter et al.1 is extremely topical given the impending changes in the American health care system and the potential impact of these changes on the future practice of anesthesiology and the role of anesthesiologists in perioperative medical care.
Traditionally, the role of anesthesiologists has been narrowly defined by their activities in the operating room (OR) and immediate perioperative period (e.g., intensive care unit). The importance of anesthesia-trained personnel in the areas of patient care outside the OR (e.g., preoperative assessment clinics, diagnostic suites, critical care medicine, and acute and chronic pain management) has dramatically changed the role of anesthesiologists.2 Because more diagnostic and therapeutic procedures requiring anesthesia services are being performed outside of the OR environment, rapid recovery from anesthesia has assumed increased importance in clinical practice. Clinical investigators have developed anesthetic techniques that facilitate a rapid recovery even for patients undergoing complex minimally invasive procedures.3,4
Anesthetic drugs with rapid offset characteristics provide anesthesia practitioners with the tools needed to shift hospital-based procedures to the ambulatory (and office) setting. Unfortunately, short-sighted efforts by hospital administrators (and pharmacy directors) to reduce perioperative costs by limiting the access of anesthesia providers to newer, more costly proprietary drugs may compromise our ability to achieve a rapid and predictable recovery after surgery. The latest effort of these administrators is to limit the use of the relatively insoluble volatile anesthetic desflurane, and force practitioners to switch to less costly generics such as sevoflurane and “good old” isoflurane. Ironically, an earlier unfortunate misinterpretation of a Food and Drug Administration “black box” warning on droperidol by these same hospital administrators and pharmacy directors prevented many anesthesia practitioners from using this highly cost-effective generic antiemetic5 for routine prophylaxis, and led to a dramatic increase in the use of a much more expensive proprietary antiemetic (i.e., Zofran [ondansetron], GlaxoSmithKline, Research Triangle Park, NC).6
The pharmaceutical industry also shares blame for the reluctance of many physicians to adopt newer drugs because of unrealistic pricing. For example, sugammadex (Bridion, Schering-Plough, Kenilworth, NJ) was recently introduced into clinical practice outside of North America at a price that is 50–100 times greater than the commonly used reversal drug combination consisting of neostigmine/glycopyrrolate. Sugammadex has clear advantages over the traditional reversal drugs (i.e., neostigmine and edrophonium) when reversing a moderate-to-deep neuromuscular block.7–9 Although the clinical advantages of sugammadex (versus conventional reversal techniques) when reversing a more typical “shallow” block have not been firmly established, it is certainly possible that the routine use of sugammadex could facilitate the fast tracking of patients requiring tracheal intubation for surgical procedures of uncertain duration (e.g., diagnostic laparoscopic surgical procedures). However, current pricing policies for sugammadex are more likely to preclude its use for routine reversal of residual neuromuscular blockade, resulting in sugammadex being relegated to use as an emergency reversal drug.10
The Dexter model, reported in their systematic review of the literature,1 suggests that switching from the relatively insoluble desflurane to more soluble agents such as sevoflurane and isoflurane makes it more difficult to consistently fast track patients because of the increased variability in the time to extubation. Elective noncardiac surgery patients cannot be fast tracked if they cannot be extubated in the OR. In their meta-analysis of published studies comparing early recovery after maintenance of anesthesia with sevoflurane and desflurane,1 these investigators found that the use of desflurane was associated with shorter average times to awakening and extubation and, more importantly, less variability. A predictable time from discontinuing the maintenance anesthetic to tracheal extubation (or removal of a supraglottic airway device) is essential to achieve efficient throughput in the OR and a consistent fast-track recovery.2,11
As pointed out by Dexter et al.,1 an important limitation in using the anesthesia information management system (AIMS) database for this analysis is that a 2-min difference is within the measurement error of the data because of the clock display used with the AIMS system.12 In discussing the limitations of their retrospective data analysis, Dexter et al.1 further emphasized the importance of performing prospective clinical trials monitoring prolonged extubation times and the implications with respect to patient throughput and the direct costs of surgical care.
Dexter et al.1 also noted that significant intangible costs are associated with prolonged delays in tracheal extubation. Given the reduction in the average and variance in the times to extubation, an expected 75% reduction in the incidences of delayed extubations could be achieved by maintaining anesthesia with desflurane rather than sevoflurane. Predictably, use of a more soluble volatile agent such as isoflurane would result in an even greater degree of variability. One of my former clinical research fellows, Dr. Brian Fredman, worked on early clinical trials with both sevoflurane and desflurane. Dr. Fredman returned to Israel after completing his fellowship training and wanted to introduce desflurane at his institution. His colleagues argued that they were so highly skilled in using propofol and isoflurane for maintenance of anesthesia that the newer and more costly desflurane was unnecessary. He organized a prospective, randomized, comparative clinical trial involving the use of propofol, sevoflurane, or desflurane for maintenance of anesthesia in elderly patients.13 Although the differences in emergence times were only a few minutes shorter with desflurane, the average time to achieve the optimal fast-track score was 50% shorter with desflurane compared with isoflurane, and the percentage of patients who were considered “fast-track” eligible increased from 44% to more than 70%.13
In 1995, Dexter and Tinker14 evaluated the impact of delayed awakening from anesthesia and the occurrence of postoperative nausea and vomiting on recovery costs. Although preventing postoperative nausea and vomiting and using short-acting (“fast emergence”) drugs each produced a 5%–7% savings with respect to recovery costs, utilizing these newer drugs and techniques to facilitate recovery by reducing side effects and streamlining the recovery process (and reducing personnel costs) could reduce overall recovery costs by more than 30%.14 As recently suggested by Dexter and Epstein,15 a consequence of the lack of knowledge and inherent bias among decision makers has made these stakeholders focus on “strategies to avoid small delays in time that are not economically important” (e.g., first case start times). Using essentially the same AIMS database that was utilized by Dexter et al.,1 many hospital administrators have erroneously concluded that the small differences in early recovery times with desflurane make no significant difference in the overall cost of perioperative care. As reported by Dexter et al.,1 the principal financial benefit of reducing the time to extubation is achieved through the reduction in direct OR costs. Not surprisingly, the reduction in direct costs will be largest for surgical procedures in which the time to extubation is the “bottleneck to OR exit” and for surgical facilities where ORs are consistently used for more than 8 h per day.
The Dexter et al. model of extubation time also has implications for national health care policy. Because most anesthesia providers are compensated based on the amount of time they spend in direct patient care, the efforts of administrators to limit practitioners' access to newer drugs (e.g., desflurane) and monitoring devices (e.g., cerebral monitors) that can improve early recovery profiles may actually increase health care costs and put more money into the pockets of anesthesia providers! Although Dexter et al. had previously stated that “anesthesiologists alone cannot reasonably decrease case times sufficiently to permit 1 extra case to be reliability scheduled during a workday,” these findings only applied to surgical facilities with fixed hours of OR time (i.e., no “add on” cases), and very few surgical facilities in the United States utilize this practice model.
Dexter et al.16 previously suggested that based on an analysis of strategies to decrease costs in the postanesthesia care unit (PACU), “anesthesiologists have little control over PACU economics via choice of anesthetic drugs.” However, they do via their choice of the anesthetic technique. When general (tracheal) anesthesia, spinal anesthesia, and local anesthesia with sedation were compared for anorectal surgery procedures, anesthesia control time was reduced by more than 40% when a local sedation technique (i.e., monitored anesthesia care) was chosen.17 In addition, times to discharge home were significantly reduced when the local sedation technique was utilized for this frequently performed surgical procedure. Similar results were obtained for outpatients undergoing hernia repair surgery.18 Clearly, in a busy ambulatory setting, these seemingly modest changes may allow the surgeon to perform an additional case per OR block or to finish his/her cases without the need for “overtime” personnel.
Despite the clearcut advantages of using either local sedation17,18 or general anesthesia (with a laryngeal mask airway device)19 for facilitating the recovery process, many of the anesthesia practitioners at the public hospital in Dallas where these studies were conducted continued to use spinal anesthesia for these procedures, and the hospital was paying nurses “overtime” because of the additional time required for recovery of motor and sensory function. Clearly, there is a need to perform additional prospective comparative studies20 involving nonintubated patients to determine whether the use of desflurane will offer similar advantages over the less costly inhaled agents such as isoflurane and sevoflurane for facilitating the recovery process.
Finally, in an effort to appease the “bean counters” at their institutions, leaders of some academic anesthesia training programs are restricting (or even preventing) residents from using newer anesthetic drugs. This questionable practice may be akin to “throwing out the baby with the bath water.” If young trainees are not exposed to new drugs until after completing their training programs, they will either decide never to try the drug or learn how to use it on their own without the benefit of academic mentoring. By forcing young anesthesiologists to learn about new drugs after they enter private practice, we may also be exposing patients to unnecessary risks.
In summary, Dexter et al.1 add to our understanding by demonstrating how to quantify the variability in recovery times after desflurane and sevoflurane and how to monitor differences using AIMS data when randomized clinical trials alone are insufficient for managerial decisions. Use of newer, more rapidly acting anesthetic drugs with faster offset characteristics has facilitated our ability to provide short-stay convenience to patients undergoing increasingly complex surgical procedures. The overall economic benefit of a particular anesthetic choice should be considered as opposed to simply examining the drug acquisition costs. Narrowly focusing on anesthetic drug cost minimization rather than the overall cost of perioperative care may actually reduce the quality of patient care, impede the education of future generations of anesthesiologists, and increase the overall health care costs to society at large.
1. Dexter F, Bayman EO, Epstein RH. Statistical modeling of average and variability of time to extubation for meta-analysis comparing desflurane to sevoflurane. Anesth Analg 2010;110:570–80
2. White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F; Fast-Track Surgery Study Group. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007;104:1380–96
3. Lin J, Iannettoni MD. Fast-tracking: eliminating roadblocks to successful early discharge. Thorac Surg Clin 2005;15:221–8
4. Recart A, Duchene D, White PF, Thomas T, Johnson DB, Cadeddu JA. Efficacy and safety of fast-track recovery strategy for patients undergoing laparoscopic nephrectomy. J Endourol 2005;19:1165–9
5. Tang J, Watcha MF, White PF. A comparison of costs and efficacy of ondansetron and droperidol as prophylactic antiemetic therapy for elective outpatient gynecologic procedures. Anesth Analg 1996;83:304–13
6. White PF. Droperidol: a cost-effective antiemetic for over thirty years. Anesth Analg 2002;95:789–90
7. Miller RD. Sugammadex: an opportunity to change the practice of anesthesiology? Anesth Analg 2007;104:477–8
8. Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg 2007;104:575–81
9. Sacan O, White PF, Tufanogullari B, Klein K. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth Analg 2007;104:569–74
10. Lenz A, Hill G, White PF. Emergency use of sugammadex after failure of standard reversal drugs. Anesth Analg 2007;104:585–6
11. Berberat PO, Ingold H, Gulbinas A, Kleeff J, Müller MW, Gutt C, Weigand M, Friess H, Büchler MW. Fast track—different implications in pancreatic surgery. J Gastrointest Surg 2007;11:880–7
12. Olmsted J, Coxon P, Falcone D, Ignas L, Foss P. World class OR turnaround times: secrets uncovered. AORN J 2007;85:942–9
13. Fredman B, Sheffer O, Zohar E, Paruta I, Richter S, Jedeikin R, White PF. Fast-track eligibility of geriatric patients undergoing short urologic surgery procedures. Anesth Analg 2002;94:560–4
14. Dexter F, Tinker JH. The cost efficacy of hypothetically eliminating adverse anesthetic outcomes from high-risk, but neither low- nor moderate-risk, surgical operations. Anesth Analg 1995; 81:939–44
15. Dexter F, Epstein RH. Typical savings from each minute reduction in tardy first case of the day starts. Anesth Analg 2009;108: 1262–7
16. Dexter F, Coffin S, Tinker JH. Decreases in anesthesia-controlled time cannot permit one additional surgical operation to be reliably scheduled during the workday. Anesth Analg 1995;81: 1263–8
17. Li S, Coloma M, White PF, Watcha MF, Chiu JW, Li H, Huber PJ Jr. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology 2000;93:1225–30
18. Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000;91:876–81
19. Coloma M, Chiu JW, White PF, Tongier WK, Duffy LL, Armbruster SC. Fast-tracking after immersion lithotripsy: general anesthesia versus monitored anesthesia care. Anesth Analg 2000;91:92–6
20. White PF, Tang J, Wender RH, Yumul R, Stokes OJ, Sloninsky A, Naruse R, Kariger R, Norel E, Mandel S, Webb T, Zaentz A. Desflurane versus sevoflurane for maintenance of outpatient anesthesia: the effect on early versus late recovery and perioperative coughing. Anesth Analg 2009;109:387–93