The Role of Cost-Effectiveness Analysis in Global Anesthesia

A growing international consensus recognizes unmet surgical need as a significant contributor to global disease burden.1,2 Filling the gap will require major investments in health workforce training, infrastructure improvement, supply chain stabilization, and deployment of appropriate, reliable, cost-effective, and proven technologies. Improving anesthesia quantity and quality is paramount to improving global surgical care overall, but to make a reliable investment case to governments, international organizations, and international donors, anesthesia providers must work together—and with public health professionals—to better understand our contribution to health, both within the operating room and outside it. Robust cost-effectiveness analyses (CEAs) of anesthesia care are a necessary component of this process. An initial challenge with CEAs as applied to anesthesia is in defining the parameters of the analysis. Traditionally, most CEAs focus on specific, singular interventions. But how valid are traditional CEA approaches in evaluating the practice of anesthesia? Perioperative practice is by definition part of a broader system, a system where technology is crucial but is still just 1 component. Furthermore, many of the technologies, processes, and training programs that are now part of standard anesthesia practice in high-income countries (HICs) are considered indispensable despite not having undergone rigorous preimplementation evaluation studies.3,4 The history of patient safety and improved patient outcomes in HICs has been written by generations of clinicians and academics who sequentially adopted technologies in their drive to prevent common surgery and anesthesia complications.5,6 Examples from the anesthesia machine include the Pin Index Safety System to prevent swapping gases, flowmeter couplers to prevent hypoxic gas mixtures, multiple pressure regulators to prevent barotrauma, vaporizer safeguards, central gas supplies, battery backups, and standards by which devices are evaluated for obsolescence.7 Electrocardiography, blood pressure monitoring, pulse oximetry, and capnography are all likewise now part of a monitoring suite to prevent unrecognized clinical deterioration and are considered standard for all anesthetics. Advances in medication safety profiles and airway equipment have meant that the standard set of each has likewise evolved over time. This is to say nothing of the fact that harnessing the potential of all standard components of anesthesia still depends on the presence of carefully trained clinicians to safely administer appropriate anesthetics,6 which is possible only through structured training programs. Extricating single components of the complex system of anesthesia for CEAs is difficult. Indeed, while a modeling study of cost-effectiveness of pulse oximetry by Burn et al8 unsurprisingly found it to be cost-effective in all scenarios, the authors identified a limited ability to single out the effect of pulse oximetry on patient outcomes as the primary limitation of their studies. CEAs of other isolated components of anesthesia practice are likely to have similar conclusions. Some have argued that such analyses may be unnecessary9 because the benefit of individual components is self-evident. This viewpoint has historically predominated in HICs, and indeed is a guiding principle behind efforts of the Lifebox Foundation (http://www.lifebox.org) to distribute handheld pulse oximeters globally wherever they are needed.10 However, it is our opinion that assuming the health value of all components of anesthesia practice is self-evident is increasingly a questionable assertion in HIC settings. Importantly, it also risks limiting the appeal for government and donor investment in building anesthesia capacity because it does not consider the financial realities of resource-limited settings. Instead, we believe that going forward, anesthesia-focused efficacy trials and CEAs should be conducted on defined combinations of items that represent so-called “platforms” or “bundles” of care, akin to how the World Health Organization has defined lists of essential medicines11 and the Disease Control Priorities, 3rd edition (DCP3), Essential Surgery Volume.12 In the DCP3 example, platforms are defined by a suite of capabilities that include multiple procedures, minimum levels and types of human resources, certain types of infrastructure, medication, and laboratory services. Each platform should be considered to be a single intervention that includes all the components of that tier of services. Such platform-based CEAs would derive information from implementation studies of “self-evident” technologies such as pulse oximetry and the Universal Anesthesia Machine,13 would necessarily include structured clinical training programs for physician and nonphysician providers,14 and would be supplemented with a set of other technologies, medicines, and infrastructure necessary to meet the clinical needs at a certain tier of care. In defining such a list, an initial research effort should start by comparing the components included in the International Standards for the Practice of Anesthesia15 with those that are necessary to providing for the 44 essential procedures at first-level hospitals,12 and supplementing with those that could be identified as crucially missing by our colleagues abroad as has been done by our surgical colleagues.16 A second challenge of CEAs as applied to anesthesia is in collecting data to inform both costing and effectiveness measures. In 2015, when the first anesthesia analysis was provided by DCP3, so little was known about the economics of most anesthesia-related technology and medicines that only comparative costs could be reported, with broad assumptions about their efficacy and, as usual, little consideration of the background health status of the population.17 Costing measurements will require delineations of the capital and maintenance outlays associated with each anesthesia platform. Some of this necessarily will be dependent on the specific low- and middle-income country (LMIC) settings, but HIC hospitals, health systems, industry, and donor organizations can do their part by helping to better understand—and stabilize—the costs of equipment and medications. Effectiveness measurements will require commitment to basic perioperative data collection, including operative volume, complications, and mortality rates,18 to understand patient outcomes and performance such as has been piloted by the International Surgical Outcomes Study.19 Measures of effectiveness, when generalized to the population level in CEAs, should also take into account the epidemiological background of the setting in which they are performed. For example, if the death of a 4-year-old girl is averted by an intervention, for example, traditional CEAs will generally assume that she will proceed to reach a full life expectancy devoid of subsequent illness or injury because as she proceeds to live the rest of her life, there are additional diseases and injuries that she would be at risk of encountering (eg, road traffic accidents, cardiovascular disease, cancer, pregnancy complications). Failing to account for these later risks, which are present in all populations, will necessarily overestimate the cost-effectiveness of all interventions. One option is to ensure that CEA estimates use results from the Global Burden of Diseases, Injuries, and Risk Factors Collaboration to inform the analysis,20 which contains comprehensive mortality and morbidity estimates across all causes and risk factors by age and sex for every country from 1990 to the present. A third challenge is one of financing. Who is to pay for the research? Who is to pay for the implementation? As Farmer and Kim1 pointed out nearly a decade ago—and which is still true today—there is no international fund for surgery and anesthesia, and there is no funding stream in development assistance for health dedicated to surgery and anesthesia capacity.21 The onus is on everyone: LMIC central governments, ministries, and hospitals must make investments to ensure the sustainability of their training programs, develop and maintain infrastructure (including oxygen, clean water, and electricity), stabilize supply chains for medications and supplies, and commit to both collecting data and using the data that are collected. Anesthesia departments, practice groups, and individual clinicians from HICs should help jumpstart such a process by banding together to finance a global initiative to train clinicians and public health professionals from LMICs in perioperative quality improvement, research, and data science and simultaneously help support pilot data collection projects at their home institutions. Clinicians and academic anesthesia programs from HICs are increasingly working to provide clinical care and training in low-resource settings but rarely focus on data collection in their missions and even more rarely invest in helping develop data collection infrastructure and expertise among their host institutions. Investing in data collection and the related infrastructure is feasible and should be seen as a mandatory component of bilateral academic engagement.22 Research funding organizations with an international focus should develop and expand specific funding streams to support perioperative research and research training in LMIC settings. Pharmaceutical and medical equipment companies should work to develop—and sustainably price—highly reliable equipment for resource-limited settings. Finally, international organizations such as the World Health Organization should look to examples like the Global Fund and Gavi, the Vaccine Alliance for how to assemble diverse stakeholders comprising HIC governments and nongovernmental organizations to fund investment in improvement of perioperative health systems.23,24 In summary, we believe that comprehensive CEA is a necessary step in the future of responsible, sustainable, and safe anesthesia care in LMICs. In order for it to be realized, the expense and related challenges must be embraced by all invested in the future of global anesthesia. While it may take decades for the return on investment to be obvious, we trust that such efforts will lead to better outcomes for ministries of health and global economic investors but more importantly for patients and their families. DISCLOSURES Name: Nicholas J. Kassebaum, MD. Contribution: This author helped by providing the expertise on cost-effectiveness analysis and wrote a majority of the rewrite in response to the reviewers. Name: Kelly McQueen, MD, MPH. Contribution: This author helped in the initial topic for the special global edition, provided expertise on the impact of CEA analysis and the conclusions, and provided the final editing. This manuscript was handled by: Angela Enright, MB, FRCPC.