Economic aspects of regional anaesthesia

Abstract

Editor—Gonano and colleagues1Gonano C Kettner SC Ernstbrunner M Schebesta K Chiari A Marhofer P Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery.Br J Anaesth. 2009; (doi:10.1093/bja/aep173)Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar reported cost reduction and greater operational efficiency with ultrasound-guided (US) regional anaesthesia (RA) for interscalene block when compared with general anaesthesia (GA) for arthroscopic shoulder surgery. We would like to complement their report with constructive criticism. The authors incorrectly state that little is known about the economic aspects of RA techniques. Economic aspects of RA have been previously reported in a number of recent publications.2Williams BA DeRiso BM Figallo CM et al.Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery.J Clin Anesth. 1998; 10: 570-578Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 3Williams BA DeRiso BM Engel LB et al.Benchmarking the perioperative process: II. Introducing anesthesia clinical pathways to improve processes and outcomes and to reduce nursing labor intensity in ambulatory orthopedic surgery.J Clin Anesth. 1998; 10: 561-569Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 4Williams BA Kentor ML Williams JP et al.PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more phase II nursing interventions.Anesthesiology. 2002; 97: 981-988Crossref PubMed Scopus (58) Google Scholar, 5Williams BA Kentor ML Vogt MT et al.The economics of nerve block pain management after anterior cruciate ligament reconstruction: significant hospital cost savings via associated PACU bypass and same-day discharge.Anesthesiology. 2004; 100: 697-706Crossref PubMed Scopus (146) Google Scholar, 6Hadzic A Williams BA Karaca PE et al.For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia.Anesthesiology. 2005; 102: 1001-1007Crossref PubMed Scopus (229) Google Scholar, 7Ilfeld BM Mariano ER Williams BA Woodard JN Macario A Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case–control, cost-minimization analysis.Reg Anesth Pain Med. 2007; 32: 46-54PubMed Google Scholar Importantly, many of these studies have addressed both monetary2Williams BA DeRiso BM Figallo CM et al.Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery.J Clin Anesth. 1998; 10: 570-578Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar 3Williams BA DeRiso BM Engel LB et al.Benchmarking the perioperative process: II. Introducing anesthesia clinical pathways to improve processes and outcomes and to reduce nursing labor intensity in ambulatory orthopedic surgery.J Clin Anesth. 1998; 10: 561-569Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar 5Williams BA Kentor ML Vogt MT et al.The economics of nerve block pain management after anterior cruciate ligament reconstruction: significant hospital cost savings via associated PACU bypass and same-day discharge.Anesthesiology. 2004; 100: 697-706Crossref PubMed Scopus (146) Google Scholar 7Ilfeld BM Mariano ER Williams BA Woodard JN Macario A Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case–control, cost-minimization analysis.Reg Anesth Pain Med. 2007; 32: 46-54PubMed Google Scholar and non-monetary costs (e.g. time, tabulated nursing labour duties, and/or patient symptoms),2Williams BA DeRiso BM Figallo CM et al.Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery.J Clin Anesth. 1998; 10: 570-578Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 3Williams BA DeRiso BM Engel LB et al.Benchmarking the perioperative process: II. Introducing anesthesia clinical pathways to improve processes and outcomes and to reduce nursing labor intensity in ambulatory orthopedic surgery.J Clin Anesth. 1998; 10: 561-569Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 4Williams BA Kentor ML Williams JP et al.PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more phase II nursing interventions.Anesthesiology. 2002; 97: 981-988Crossref PubMed Scopus (58) Google Scholar, 5Williams BA Kentor ML Vogt MT et al.The economics of nerve block pain management after anterior cruciate ligament reconstruction: significant hospital cost savings via associated PACU bypass and same-day discharge.Anesthesiology. 2004; 100: 697-706Crossref PubMed Scopus (146) Google Scholar, 6Hadzic A Williams BA Karaca PE et al.For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia.Anesthesiology. 2005; 102: 1001-1007Crossref PubMed Scopus (229) Google Scholar, 7Ilfeld BM Mariano ER Williams BA Woodard JN Macario A Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case–control, cost-minimization analysis.Reg Anesth Pain Med. 2007; 32: 46-54PubMed Google Scholar as all future similar studies should. The setting of their study1Gonano C Kettner SC Ernstbrunner M Schebesta K Chiari A Marhofer P Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery.Br J Anaesth. 2009; (doi:10.1093/bja/aep173)Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar in an Austrian hospital was based on an inpatient system. Therefore, the significance of their data may be limited within the context of the modern health-care trends towards outpatient surgery. In their model, the bottleneck of patient transfer from the post-anaesthesia care unit (PACU) to the ‘ready bed’ hospital ward is more likely the cost driver of PACU staffing, rather than PACU length of stay for symptom management, per se. In contrast, using recovery discharge criteria for surgical outpatients, the concept of PACU bypass after RA has been associated with significant hospital cost savings, time savings, and/or labour reduction over GA in a wide range of outpatient orthopaedic surgery models.4Williams BA Kentor ML Williams JP et al.PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more phase II nursing interventions.Anesthesiology. 2002; 97: 981-988Crossref PubMed Scopus (58) Google Scholar, 5Williams BA Kentor ML Vogt MT et al.The economics of nerve block pain management after anterior cruciate ligament reconstruction: significant hospital cost savings via associated PACU bypass and same-day discharge.Anesthesiology. 2004; 100: 697-706Crossref PubMed Scopus (146) Google Scholar, 6Hadzic A Williams BA Karaca PE et al.For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia.Anesthesiology. 2005; 102: 1001-1007Crossref PubMed Scopus (229) Google Scholar 8Williams BA For outpatients, does regional anesthesia truly shorten the hospital stay, and how should we define postanesthesia care unit bypass eligibility?.Anesthesiology. 2004; 101: 3-6Crossref PubMed Scopus (30) Google Scholar 9Williams BA Kentor ML Fast-track ambulatory anesthesia: impact on nursing workload when analgesia and antiemetic prophylaxis are near-optimal.Can J Anaesth. 2007; 54: 243-244Crossref PubMed Scopus (12) Google Scholar Finally, the use of US during the practice of RA is not a prerequisite in achieving the economic benefits.10Liu SS Zayas VM Gordon MA et al.A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.Anesth Analg. 2009; 109: 265-271Crossref PubMed Scopus (124) Google Scholar 11Casati A Danelli G Baciarello M et al.A prospective, randomized comparison between ultrasound and nerve stimulation guidance for multiple injection axillary brachial plexus block.Anesthesiology. 2007; 106: 992-996Crossref PubMed Scopus (233) Google Scholar Although the introduction of US continues to refine the practice of RA, the actual methods of RA delivery have been comparable with regard to clinical efficacy and safety.10Liu SS Zayas VM Gordon MA et al.A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.Anesth Analg. 2009; 109: 265-271Crossref PubMed Scopus (124) Google Scholar 11Casati A Danelli G Baciarello M et al.A prospective, randomized comparison between ultrasound and nerve stimulation guidance for multiple injection axillary brachial plexus block.Anesthesiology. 2007; 106: 992-996Crossref PubMed Scopus (233) Google Scholar Most importantly, benefits of RA have been demonstrated in a number of well-defined patient care contexts, regardless of the methods used to administer RA. P. Marhofer* (on behalf of all co-authors) Vienna, Austria * E-mail: [email protected] Editor—We appreciate the comments by Williams and colleagues regarding our study.1Gonano C Kettner SC Ernstbrunner M Schebesta K Chiari A Marhofer P Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery.Br J Anaesth. 2009; (doi:10.1093/bja/aep173)Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar It is true that our findings are based on an inpatient system, which is clearly mentioned in the Discussion section. The Austrian health system supports an inpatient system, and we do not agree with their comment that this system is not associated with modern health care. Our results clearly indicate the minor influence of PACU costs and the major influence of block success in providing a reduction in overall costs. It is also clearly shown that the success rate of interscalene brachial plexus blocks can be significantly increased when US guidance is used to identify the nerve roots and the spread of local anaesthetic.12Kapral S Greher M Huber G et al.Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade.Reg Anesth Pain Med. 2008; 33: 253-258Crossref PubMed Scopus (0) Google Scholar The study by Liu and colleagues10Liu SS Zayas VM Gordon MA et al.A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.Anesth Analg. 2009; 109: 265-271Crossref PubMed Scopus (124) Google Scholar investigates the influence of the guidance method on nerve injury during interscalene brachial plexus block. In summary, we believe that the findings in our study are concordant with a modern health system. Both inpatient and outpatient systems have advantages and disadvantages. From the point of safety and patients’ comfort (e.g. postoperative pain therapy), the inpatient system may in fact be better.13Delbrouck C Dauty M Huguet D Dubois C Rehabilitation after shoulder rotator cuff surgery: in-patient or day-hospitalization (about 76 cases).Ann Readapt Med Phys. 2003; 46: 207-213Crossref PubMed Scopus (11) Google Scholar In particular, those patients requiring GA show a high percentage of unplanned hospital admissions.6Hadzic A Williams BA Karaca PE et al.For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia.Anesthesiology. 2005; 102: 1001-1007Crossref PubMed Scopus (229) Google Scholar