Doing more with less

Over the past few years, anaesthetic drug budgets have remained relatively static, while some departments have seen active cost reduction programmes implemented. Over a similar period, the number of surgical operations performed nationally has increased by about 20%[1,2]. The complexity of surgery also appears to be increasing, with the spending on the five most common surgical procedures having gone up by at least 50% from 1998 to 2002 [3]. Combining these statistics clearly demonstrates that the average per case cost of anaesthesia has decreased. This is all the more remarkable, given the high quality of care which we are expected to provide and that we have been able to introduce some new anaesthetic agents during this period. Whenever budgets come under scrutiny, attention is always drawn to the top spending items. However, appropriate cost considerations are needed since these items include expensive drugs (high cost per treatment, e.g. chemotherapy agents) and drugs whose costs are high because they are used in a high number of treatments (top line agents); these latter agents invariably include anaesthetics. In recent times, we have seen relatively few new anaesthetic drugs (and the prospect of others seems remote), so those there are stand out dramatically. Increasingly, anaesthetists are being forced to defend their use of these agents and sound evidence on which to base our arguments can be difficult to find. We are usually aware of some small clinical benefit, such as faster recovery, greater cardiovascular stability or improved ease of use, but demonstrating clear differences in patient outcome or indirect financial benefits is rather more difficult. For example, in my own subspeciality of day surgery, given the perceived clinical and financial benefits of rapid recovery from anaesthesia leading to early discharge from hospital, the majority of controlled clinical trials show, at best, only slightly earlier awakening and no difference in discharge times following anaesthesia with sevoflurane, desflurane or propofol compared with isoflurane. The fact that there is no clear difference between discharge times for a variety of agents used for maintenance of anaesthesia in this setting, it is more likely that other clinical or administrative factors have a greater influence than the agent used for the anaesthetic., A recent economic analysis in Anaesthesia concluded that propofol-isoflurane was a more cost-effective option for day surgery than anaesthesia based primarily on either propofol or sevoflurane [4]. Although propofol demonstrated the well-known reduction in postoperative nausea and vomiting (PONV), this was at a cost of about £300 per case prevented. While the randomised controlled trial is the ‘gold standard’ for evidence-based medicine, these trials do have some limitations. They invariably involve some degree of compromise, meaning that they may not truly reflect optimal administration of the anaesthetics under consideration. For example, studies comparing intravenous and inhaled anaesthetics often mandate the use of opioid analgesics in all groups despite them not always being necessary in association with inhaled anaesthesia, with which they certainly increase the incidence of PONV [5,6] and may delay recovery. Furthermore, fresh gas flows are often far higher than necessary [4], thereby increasing costs considerably. In addition, randomised trials often only include relatively healthy patients. The Department of Health expects that 75% of elective surgery will be performed on a day-case basis by 2005 [7]. Patient selection criteria have already been broadened considerably [8] and it is likely that older and sicker patients will increasingly present as day cases. Newer anaesthetic agents may offer specific advantages for such patient groups. For example, induction with sevoflurane causes less reduction in arterial blood pressure in elderly patients compared to propofol [9,10]. Similarly, times to awakening, orientation and tracheal extubation were all significantly shorter following sevoflurane-remifentanil compared to sevoflurane alone in obese (body mass index > 30 kgm−2) patients undergoing laparoscopic cholecystectomy [11], a group in whom delayed recovery would surely be disadvantageous. Other outcome differences may be too subtle to measure. Nurses working in the day case unit frequently report that ‘specialist’ day-case anaesthetists achieve quicker and smoother recovery of their patients than their colleagues who visit the unit on an ‘occasional’ basis (British Association of Day Surgery, personal communication), perhaps in part reflecting the use of newer anaesthetic drugs. Focusing on the ‘headline’ drugs in pharmacy reports can miss other significant sources of expense. Regular and frequent use of ‘cheap’ drugs which are inappropriate can amount to quite a substantial cost, especially if harmful effects are also produced. For example, metoclopramide is still often prescribed as a prophylactic anti-emetic, yet it is almost totally ineffective in preventing PONV [12]. The combined costs of a useless drug, managing the outcome which it fails to prevent and treating the adverse effects which it induces all make metoclopramide the least cost-effective anti-emetic [13]. In a similar way, morphine is an inexpensive analgesic, yet its routine intra-operative administration to patients having intermediate day surgery procedures (e.g. inguinal hernia repair, varicose vein surgery) often results in delayed recovery, sedation, dizziness and PONV. While this might be acceptable if pain relief were problematic, in practice the vast majority of such patients are comfortable after a non-steroidal anti-inflammatory drug and wound infiltration with local anaesthetic [14]. What of the future, will we be allowed any new drugs? This may already be a somewhat academic point, as the number of potential new anaesthesia-related drugs in active development is severely limited. Several pharmaceutical companies which were once prominent in our field are no longer investing in research programmes. This is partially because they now see no possibility of recovering their development costs, even if a promising compound could be brought to market. As more of our products become generic, we can also expect to see far less financial support from the pharmaceutical industry for research, education and meetings. Some of the major sponsors of large national meetings have already gone and the available pool is rapidly shrinking. It has been argued that education could be provided at a far lower cost than that associated with drug company sponsorship [15]. But who will attend educational activities, increasingly encroaching into our ‘free’ time, without at least a reasonable venue, edible food and reputable speakers? As the health service struggles to modernise, some new money is being made available to facilitate change. The expansion of day surgery was announced along with the commitment of £68 million between 2002 and 2004 [16] and some of this money should be directed towards anaesthesia so that we may use those drugs which we believe offer advantages to our patients rather than continuing to struggle to do more with less. The author has received research funds and honoraria from various pharmaceutical companies, but particularly from Abbott Laboratories.