Anaesthesia is administered with the goal of safely establishing satisfactory conditions for the performance of a therapeutic or diagnostic procedure, and a prompt recovery with minimum postoperative sequelae [1–6]. Because anaesthetic drugs do not provide direct therapeutic benefits per se, both patient and doctor are less likely to accept adverse side-effects from anaesthetic drugs and techniques. With the continued growth in ambulatory surgery, the prompt return to ‘street fitness’ (i.e. resumption of normal activities) has assumed increasing importance [1,7]. The availability of shorter-acting neuromuscular relaxants in the last few years (e.g. rocuronium, mivacurium) has clearly increased the ability of anaesthesiologists to meet these demands. However, the introduction of newer drugs has coincided with a major change in the financing of health care in the United States. The various models for studying the cost benefit of newer muscle relaxant drugs are discussed.
With the advent of managed care, global and capitation fees, there has been a movement away from payments on an indemnity basis to a system where payments remain fixed regardless of the number of services provided. The success of these new programmes in reducing health care costs have made them attractive to employers, and these market-based reforms have rapidly changed the way health care is provided in the United States. In the current health care environment, clinical departments with high resource utilization (e.g. the operating rooms) are no longer considered profit centres but cost centres. The challenge for practitioners is to maintain the same high quality of care while consuming fewer resources by practising ‘value-based’ anaesthesia care . Although the costs of drugs used for anaesthesia constitute less than 6% of the total costs of perioperative care , they are highly visible and represent an easy target for administrators to scrutinize . As limits are placed on the total resources available for health care, practitioners must begin to examine carefully the economic consequences of replacing current therapeutic regimens with newer drugs that are more expensive.
The analysis of the relation of costs of drug therapy to health care systems has been termed pharmacoeconomics, and four types of analytical techniques are commonly used for this purpose, namely cost minimization, cost benefit, cost effectiveness and cost utility analyses . Most of the recent emphasis in anaesthesia has been placed on cost containment or cost minimization, where the aim is to provide a service for the least amount of money without regard to patient outcome . Cost benefit and cost effectiveness analyses take outcome into consideration. In a cost benefit analysis, the outcome is expressed in monetary terms, while in cost effectiveness analysis, the costs per unit of effect (or successful outcome) are determined. When the outcome is adjusted by patients' opinions about the quality of their life, this is termed a cost utility analysis. Unfortunately, these terms are often misused .
An appropriate cost assessment is essential and similar for all four analytical techniques. The costs of a therapeutic regimen will also vary with the perspective of the person making the assessment. From an institutional perspective, the true costs of using a particular drug are not limited to the acquisition cost of the amount administered, but include the costs for storing, dispensing and administering the drug, drug wastage, as well as the labour and material costs to treat side-effects . Many studies of anaesthetic drugs have used charges as a substitute for costs . However, the cost-to-charge ratio is lower for anaesthesia services compared with other areas of the hospital, and the use of charges as a substitute for costs, lead to overestimates of resource consumption by the anaesthesia department .
In the present health care setting, the pressure to control costs has led many operating room managers to adopt the simplistic view that the drug with the lowest acquisition price is the preferred drug and that there are no cost consequences associated with differences in the duration of action or side-effects of drugs in the same class . While concerns were raised about the financial impact of introducing desflurane in ambulatory surgery, Weiskopf and Eger emphasized that the critical factors affecting the cost of volatile anaesthetics include the cost per millilitre of liquid anaesthetic, the volume of vapour that results from each millilitre of liquid, the effective potency of the anaesthetic and the background flow rates of the gases that are chosen . A less-soluble volatile anaesthetic, e.g. desflurane, may be used with a lower background flow rate than a more soluble agent, and still produce a similar relation between delivered and alveolar gas concentrations . For example, at flow rates <1 L min−1, it is more economical to use desflurane than isoflurane to achieve minimal alveolar concentration, despite the differences in costs and volume of liquid required . Even with the older inhalation agents, the practice of reducing flow rates after an initial high flow rate during the early rapid-uptake phase, is a simple but highly effective method of cost minimization [16,18].
Other suggestions for cost minimization of anaesthetic drugs include the preferential use of older and less expensive induction agents (thiopental vs. propofol), neuromuscular blocking agents (pancuronium vs. vecuronium or rocuronium) and opioids (fentanyl vs. sufentanil or alfentanil) [7,12]. These cost evaluations have not taken into consideration the savings (if any) from earlier awakening and improved side-effect profiles. Yet, for many inpatients undergoing long surgical procedures, the pharmacokinetic properties of drugs such as propofol, remifentanil, desflurane, sevoflurane, mivacurium and midazolam offer no clinically significant advantages over the longer-acting drugs. However, any cost savings from practice guidelines that limit the use of these more rapid and shorter-acting drugs in ambulatory surgery cases may be offset by longer recovery times, an increased incidence of side-effects and delayed discharge [7,19,20].
The use of propofol for both induction and maintenance of anaesthesia has been compared with inhalation agents isoflurane, desflurane and sevoflurane [1,3,21,22]. The time from the end of surgery to tracheal extubation, eye opening, following commands with propofol anaesthesia was significantly longer compared with desflurane. Yet, the incidence of postoperative emesis was lower in the propofol group . These data would suggest that use of postanaesthesia care unit (PACU) resources is decreased in patients receiving propofol. The relative costs of each regimen would depend on fresh gas flow rates in the inhalation groups and the amount of drug wasted in the propofol group.
Decisions based solely on the acquisition cost of drugs without considering personnel cost may fail to achieve the desired cost savings. Because personnel costs constitute a major proportion of costs in the operating and recovery room suites, anaesthetic techniques that are associated with a greater need for nursing services may be more expensive. For example, Suver and colleagues analysed the cost of induction and maintenance of anaesthesia with propofol vs. thiopental/isoflurane from the perspective of the chief financial officer of a health maintenance organization . The model included the cost of the clinical labour involved in administering the drug, as well as the fixed costs associated with the facility. The use of propofol for induction and maintenance of anaesthesia during intra-abdominal surgical procedures with a duration of <4 h reduced the total cost of surgery by US$202.71 (about €236) compared with the costs of using thiopental/isoflurane. The robustness of the conclusions with regard to all major parameters was maintained during sensitivity analysis . Using computer simulations of the flow of patients through a recovery room area, Marais and colleagues have claimed that the preferential use of propofol over a thiopental/isoflurane regimen would reduce nursing costs by 25% . However, these are theoretical rather than actual savings and a definitive study is still required to show actual cost savings. A follow-up study should go beyond merely demonstrating shorter recovery times in the PACU and phase II (step-down) units. The investigators must demonstrate that the decreased stays in the operating room and recovery units resulted in reduced expenditures on nursing salaries, or the completion of additional cases in the same operating session.
Time-and-motion studies have been used to identify personnel costs, but it may be inappropriate to assume that there is a linear relation between labour costs and the time spent in providing a clinical service. Even if a patient spends an additional 15–30 min in the PACU or step-down unit, institutional costs may not be affected, unless overtime costs are incurred . Similarly, if all other aspects of nursing care remain unchanged, more rapid awakening after anaesthesia may not be associated with decreased institutional costs, unless an additional case can be completed with the same staff  or the PACU can be closed following earlier discharge of the last patient . In addition, more rapid recovery in the operating room suites may not be translated into earlier discharge readiness if patients require more sedation and analgesia in the PACU. For example, studies have shown that children who received sevoflurane were awake earlier than those receiving halothane [27–29]. However, if they are more agitated in the PACU and received more sedative and analgesic medications, the time to achieving ‘home readiness’ may not differ between the two inhaled anaesthetics [27–29]. In other studies, a mandatory minimum stay in the PACU negated any benefits from achieving earlier discharge readiness .
Even if the time to discharge of all patients undergoing general anaesthesia was decreased, there may not be a substantial decrease in PACU costs in tertiary-care centres . In a recent study, Dexter and Tinker used computer simulations to show that the peak number of patients in the PACU had a greater effect on PACU economics than the choice of anaesthetic drugs because personnel costs accounted for 98% of the total costs . These investigators concluded that a greater effect would be achieved by arranging an operating room schedule to optimize admission rates to the PACU.
Fast tracking concepts
If the use of short-acting drugs would permit a safe transfer of patients from the operating room suites directly to the less labour-intensive phase II recovery area (or postsurgical ward), major cost savings to the institution could be achieved . Bypassing of phase I recovery (i.e. the PACU) has been termed ‘fast tracking’ in ambulatory surgery . Cost savings may also be achieved if the mix of nurses to aides is changed in the PACU. With a more rapid recovery, as fewer patients remain deeply sedated in the PACU, the duration of time they are ‘at risk’ for airway obstruction is decreased. This would reduc the need for highly skilled ‘one to one’ type of nursing care. The adoption of fast tracking procedures may permit the institution to use fewer nurses in the recovery areas. The cost benefits from fast tracking may be easier to demonstrate in free-standing ambulatory care centres, where ‘perioperative’ nurses are cross-trained to work in both the operating room and the PACU. However, even greater overall savings could be achieved in the hospital setting if nursing practices eliminated the need for a minimum stay in the PACU.
Fast track protocols have also been adopted for cardiac surgery patients with the aim of reducing costs by decreasing intensive care and hospital stays [32–34]. Greater emphasis is now placed on identifying patients who may undergo early tracheal extubation after coronary artery surgery without an increased risk of morbidity and mortality . The fast track protocol involves intensive preoperative education of patient and modifications of the anaesthetic technique to effect early (4–8 h) postoperative tracheal extubation, as well as more extensive use of perioperative corticosteroids, digoxin, metoclopramide, docusate and ranitidine. The fast track protocol is associated with aggressive ambulation of the patients and cardiac rehabilitation, such that the patient is out of bed on the first day after operation, walking in the hall on the second day, and up a flight of stairs on the third day . To facilitate early extubation in appropriately selected patients, anaesthetic techniques are based on the use of volatile anaesthetics, supplemented by minimally effective doses of narcotics and propofol, rather than the so-called high-dose narcotic anaesthesia . Postoperative sedation with propofol, which has a rapid offset of action, may be particularly advantageous. In a number of studies, the mean time to tracheal extubation, peak weight gain, intensive care unit and hospital stays were decreased significantly in ‘fast tracked’ patients, without any associated increase in morbidity and mortality, as noted by the absence of significant differences with respect to infection, operative mortality, and 30-day hospital readmission rates.
Finally, there may be benefits to society from the use of shorter-acting drugs if patients could return to work earlier or their caretakers could more readily resume their normal activities. In a study of Swedish women, drug costs in patients who received propofol/alfentanil while undergoing voluntary interruption of pregnancy procedures were higher than in a group receiving thiopental/nitrous oxide (72 Swedish Kroner (SEK) [€7.82] vs. 15 SEK [€1.63]) . However, the patients in the propofol group used less sick leave (mean difference of 0.8 days patient−1) and returned to work earlier. In Sweden, social insurance provided 210 SEK (€22.8) per day of sick leave and patients could use up to 7 days of sick leave without a medical certificate. The authors calculated that the propofol-alfentanil regimen was associated with a net saving to society of 111 SEK (€12.1) per patient. In addition, drug choices should include some input from patients regarding their personal preferences. In the Swedish study described, patients receiving propofol-alfentanil judged they had recovered from the anaesthetic earlier than the control group. Pharmaceutical companies need to support more studies along these lines to demonstrate societal benefits from the use of the newer, more costly drugs. It has been suggested that a new drug should not replace an existing drug unless it is shown to be more effective, associated with less side-effects or is less expensive (e.g. cisatracurium vs. atracurium).
The introduction of newer, shorter-acting anaesthetic drugs such as rapacuronium is economically justified if improvements in recovery and work patterns can be demonstrated. Fast tracking anaesthetic techniques can facilitate the perioperative process and may prove to be cost beneficial for the patient and the healthcare system [37–44]. From an institutional perspective, earlier achievement of discharge criteria must be accompanied by earlier actual discharge times. If the use of the newer drug is associated with decreased recovery times, reduced payments for skilled nursing and/or an earlier return to work by the patient, its preferential use can be financially justified. However, doctors should examine marketing claims of cost savings with the same scrutiny as claims of enhanced drug efficacy . For example, claims of increased efficacy and decreased recovery times with the use of prophylactic ondansetron compared with the older antiemetics have not been confirmed when droperidol is used in low doses (0.625 mg) .
Finally, the safety and value of modern anaesthetic care has been well documented [10,47]. Anaesthetic practices have advanced to the point where cost savings from variations in drug use are less than the cost reductions that can be achieved by ‘system-wide improvements in efficiency of resource utilization, including personnel, space, time, consumables and capital investments’ . It is important to remember that the cost to a facility of a 30-min delay in the arrival of a surgeon is greater than the cost of a 2-h infusion of propofol . In conclusion, pharmacoeconomics can be useful in providing justification for the use of new drugs in anaesthesia .
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