Economics and Intravenous Anaesthesia

1. Economics and Intravenous Anaesthesia Lawrence Rowe Consultant Anaesthetist Norfolk and Norwich University Hospital

2. Perceived advantages TIVA: Yuil and Simpson, BJA CEPD Reviews Vol 2 No1, Feb 2002

3. Perceived disadvantages TIVA: Yuil and Simpson, BJA CEPD Reviews Vol 2 No1, Feb 2002

4. Why is there a problem with anaesthetic drugs? • Historical • Halothane • Atracurium and Vec • Launched as induction agent vs Thiopentone • Myths • Difficult to work out costs • Drug and therapeutics committees

5. OECD • UK per capita outlay for health $1374 in 1995 • 25% less than OECD average • 19% less than EU15 average • In 2003 it was $2231 • 5% less than OECD average

6. Health Expenditure 1990-2003 (OECD data)

7. Norfolk & Norwich University Hospital www.nnuh.nhs.uk

12. In defence of IV anaesthesia... • clinical arguments • quality arguments • other issues…pollution etc • the economic argument

13. Economic analysis • Cost minimisation • Cost benefit analysis • Eg more cases • Cost effectiveness analysis • Eg patient satisfaction • Cost utility analysis • QuaLY’s • Willingness to pay

14. Cost comparison: A desflurane- versus a propofol-based general anesthetic techniqueRosenberg et al, Anesthesia andAnalgesia 1994, 79(5):852-5 • ‘desflurane offers a cost effective alternative to propofol for ambulatory anesthesia’ • a cost minimisation analysis • no mention of nausea or vomiting • no mention indirect costs • mean PACU stay: 109 min (IVA), 123 min (Des) (n=25 each group: p=0.09)

15. Cost minimisation • Anaesthetic drugs are cheap

16. And they’re getting cheaper… • £10 in 1987 is now worth £5.64 approx • Or would have to sell for £17.72 to have the same value now (www.westegg.com/inflation)

17. Average drug costs for 5 common procedures Time (min): 11 24 28 32 7

18. Average anaesthetic costs for Laparoscopic Sterilisation(n=21)

19. What about other costs?

20. UK General Anaesthesia costs in perspective, Churnside RJ et al, Br Jnl of Medical Economics 1996; 10: 83-98 day case hernia day case varicose veins inpatient hernia inpatient major abdominal surgery

22. New pumps…

23. Alaris

24. £3.20 £0.74 £1.80

25. NNUH Business Case • DPU used 2747 prefilled syringes in 1yr • Savings = £22,360.58 per yr • 6 pumps = £16,200 (book price) • Time to pay back = 8.7 months • ROI over 5 yrs 690% • Savings over 5 yrs = £99,835.59 • 4 theatres 6 pumps

26. Lorenzo Romano Amedeo Carlo Avogadro, conte di Quaregna e di Cerreto (1776 - 1856)

27. Some typical anaesthetic costs:

28. Maintenance…

29. Remifentanil (0.2mcg/kg/min)

30. Remifentanil (0.2mcg/kg/min) **assuming 20% less hypnotic

31. Remifentanil (0.2mcg/kg/min) **assuming 20% less hypnotic *including saving on Fentanyl

32. Remifentanil (0.2mcg/kg/min) **assuming 20% less hypnotic *including saving on Fentanyl

33. Remifentanil (0.2mcg/kg/min) **assuming 20% less hypnotic *including saving on Fentanyl

34. Weak anaesthetic sparing effect Modest analgesic effect Emetic Not for air filled spaces Interferes with BIS Neurotoxic B12 and Folate metab Reduces WCC Greenhouse gas Destroys ozone Potent analgesia Significant hypnotic sparing Rapid metabolism in all patients to non toxic metabolites No environmental effects N2O vs Remifentanil

35. Low Flow: Hidden costs • Soda lime • Approx £1 per hour • Increases with low flow • CO, Substance A, spont combustion • Maintenance • Changing soda lime • valves

37. Hidden costs • Soda lime • Approx £1 per hour • Increases with low flow • Maintenance • Changing soda lime • Valves • COSH • Scavenging • Monitoring • Fume cupboards • ventilation

38. Hidden costs • Soda lime • Approx £1 per hour • Increases with low flow • Maintenance • Changing soda lime • Valves • COSH • Scavenging • Monitoring • Fume cupboards • Ventilation • Occupational exposure

39. But what about economics? • Cost benefit • Cost effectiveness

40. Cost benefits • Improved theatre efficiency • Faster turnaround • More cases per list

41. 19 min • 14 min • 19 min Interaction for Alfentanil

42. 8 min • 6 min • 12 min Interaction for Remifentanil

43. New NNUH: Has anyone seen the reception area?

44. Operation Times for Inguinal Hernia Repair (n=103) ANOVA: p<0.001 50 Operation time (min) 40 30 20 10 0 Consultant Senior Reg Reg SHO

45. Cost benefits • Improved theatre efficiency • Faster turnaround • More cases per list • Shorter recovery stay

46. Cost benefits • Improved theatre efficiency • Faster turnaround • More cases per list • Shorter recovery stay • Less PONV

47. Unplanned admissions from the Day Procedure Unit: • £265 per overnight stay • treatment of emesis: • ondansetron • nursing time • prevents bed being used for elective surgery: loss of income £????

48. Ondansetron • £6.50 per patient • but £265+ for an overnight admission • we found ondansetron to be 80% effective when used after cyclizine as rescue therapy • £6000 savings in first six months • >3000% return on investment!

49. But what about economics? • Cost benefit • Cost effectiveness

50. Comparative analysis of costs of total intravenous anaesthesia with propofol and remifentanil vs. balanced anaesthesia with isoflurane and fentanylEpple J et Al European Journal of Anaesthesiology 2001;18(1):20-28. • Total cost 12.25 euro less in TIVA group • Patient satisfaction: 93.2% TIVA vs 65.6% Fent/Iso group • Cost effectiveness = Total cost / fraction of completely satisfied patients • TIVA= 176 euro, Fent/Iso= 268 euro • Also showed possible to treat more patients or finish significantly earlier with TIVA