The Cost Efficacy of Hypothetically Eliminating Adverse Anesthetic Outcomes from High-Risk, but Neither Low- nor Moderate-Risk, Surgical Operations

Abstract

Comment This desktop, hypothetical study based on retrospective data collection is thought-provoking and interesting. Nonetheless, as Dr. Patricia Kapur1 states in her lucid accompanying editorial, many aspects of this study are conjectural; several assumptions have been made that limit the interpretation of the findings as well as the applicability of the conclusions. First, relative risk was not clearly defined. Many of us would not consider kidney transplantation, for example, to be a “low” or, depending on circumstances, perhaps even “moderate” risk operation. Indeed, for truly low-risk procedures (cataract surgery, carpal tunnel repair, breast biopsy, etc.), minimization of anesthetic sequelae such as excessive sedation, protracted emesis, or inadequate postoperative analgesia may reduce costs if patient flow is expedited, fewer unanticipated admissions occur, fewer personnel are required, and fewer resources are consumed. Additionally, the authors' method of calculating “costs” as a percentage of the overall hospital charges may be a poor reflection of the actual resource consumption involved. Indeed, there is no fixed relationship between true economic costs and charges, with the latter historically relying on comparisons with competing hospitals' charges and imprecise assessment of internal costs. This study claims that improving quality of perioperative management would be relatively ineffective in decreasing costs for low- and moderate-risk procedures. Although this may be true if one restricts one's analysis to the costs generated in the surgical facility, such may not be the case when societal costs are considered. Kapur1 appropriately points out that, particularly for ambulatory surgery, improvements in anesthetic care that can promptly return patients to their baseline level of functioning may accrue meaningful savings to the patient, the family, the workplace, and the community. Moreover, if medico-legal and disability costs are considered, improving anesthetic care may be cost effective even for low-and moderate-risk procedures. The authors point out that, even for high-risk patients undergoing high-risk procedures, decreasing perioperative complications is not the least expensive way to reduce total hospital costs: “The easiest way is to not operate on patients at high risk for complications.” Perhaps this is a path society will increasingly elect in future years. Although unconfirmed within the boundaries of the current study, the authors' proposal that overall cost reductions for operations that are already safely managed must be achieved by improved efficiency in management of time, capital, expendable resources, and personnel seems congruent with the findings of Macario and colleagues2 discussed in the preceding abstract.