Anesthesia Costs Research Articles

The efficacy of WALANT technique in Hand Surgery

Background: Nowadays, Wide Awake Local Anesthesia No Tourniquet (WALANT) technique has gained popularity among surgeons because of its use in variety of surgical procedures because it provides excellent hemostasis, eliminating the need of tourniquet, sedation and the risk and cost of general anesthesia. Aims and Objective: In this study, we wanted to evaluate its efficacy and the experiences of the patients and surgeons in different hand surgeries. Materials and Methods: We had 108 patients who underwent various hand surgeries under WALANT technique. Patients and surgeons were requested to fill a questionnaire after the procedure. The procedure was evaluated in terms of the pain compared to a dental procedure, duration of the anesthesia, amount of bleeding and patients’ satisfaction. Results: The mean age of our patients was 42.7 years. A variety of hand surgery was performed in our study. The mean local anaesthetic volume used was 16.5 ml. The Tang grading system was used to evaluate the levels of surgeon’s experience; 75% of surgeons were a Level 2, 18% Level 3 and 7% Level 4. Sixty-four patients experienced WALANT to be less than, 30 patients equivalent to and 8 had more pain compared to a dental procedure. There was a significant correlation between volume of local anesthetic used, duration of surgery and number of procedural components repaired. Both pain and anxiety levels were significantly less intra-operatively and postoperatively as compared to the level at the time of injection. Eighty-seven patients considered it to be better than expected, and would prefer it in the future in case they have to undergo surgery. Conclusion: We observed that our patients were satisfied with their experience on WALANT technique and the surgical procedures, and we recommend the use of this for a variety of hand surgery procedures.

English

Anaesthetic modalities for arteriovenous fistula (AVF) creation include general (GA), local (LA) and regional anaesthesia (RA). Ultrasound guided regional anaesthesia (USRA) proved to have more benefits in AVF creation than the other two. This study conducted at the Douala General Hospital aimed to assess these benefits over GA and RA. A retrospective review was performed on 217 records of patients who underwent an AVF creation between January 2015 and December 2018. The socio-demographic and clinical characteristics of patients were recorded. Analysis of variance, Pearson’s chi-square test and binomial logistic regression were performed and a p value of <0.05 was considered significant. Of the 217 records reviewed, age ranged between 51 and 60 years old, and 71.9% were males. The distribution of AVF according to the anaesthetic type was: 83 (38.2%) for GA, and 68 (31.3%) for USRA. The rate of changeover was significantly associated with the anaesthetic type [GA: null vs. USRA: 8 (11.8%), p < 0.001]. The total anaesthesia administration time and surgical time were significantly associated with the anaesthetic type. The association between the anaesthetic type and the complication was of no statistical importance. This study thus showed that USRA was superior to either GA in AVF creation. The surgical duration mitigated the time required for its performance as compared to GA. It was the most stable in term of cost of anaesthesia and yielded higher rates of functional patency 3 months after the fistulae were created. Key words: Brachial plexus block, arteriovenous fistula, ultrasound, cost of anaesthesia, patency.  

198. Rapid recovery pathway (RRP) utilizing intrathecal morphine decreases overall hospital costs and improves quality of care in adolescent idiopathic scoliosis (AIS)

<h3>BACKGROUND CONTEXT</h3> Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is a complex procedure for which charges can exceed $150,000. Among the total costs, inpatient and intensive unit care contributed 22%. Many institutions have implemented rapid recovery pathways (RRP) to improve patient care following scoliosis surgery. Most RRPs encourage early ambulation, feeding, and stooling in combination with patient-controlled analgesia (PCA). <h3>PURPOSE</h3> This study aims to determine the effects of a multimodal RRP, utilizing intrathecal morphine (ITM) in combination with oral pain medication, on hospital costs and patient management. <h3>STUDY DESIGN/SETTING</h3> Retrospective review. <h3>PATIENT SAMPLE</h3> AIS patients undergoing posterior spinal fusion between 2013 and 2019. <h3>OUTCOME MEASURES</h3> Surgical outcomes and associated costs. <h3>METHODS</h3> Patients after February 2018 were placed in the RRP group. These patients received ITM as part of their multimodal analgesia. Fusion level-matched control patients, treated before February 2018, received hydromorphone PCA as the mainstay of their postoperative pain management. At discharge PCA patients received 14-day prescriptions for oxycodone compared to 7-day prescriptions in the ITM group. Perioperative data, requests for opioid refill, and overall costs were compared using McNemar's and Wilcoxon Signed-Rank tests. <h3>RESULTS</h3> A total of 363 patients were included (PCA: 255, RRP/ITM: 108). BMI (p = 0.786) and median preoperative Cobb angle (p = 0.343) were similar between both groups. RRP patients had a significantly shorter length of stay (3 days vs 5 days, p <0.001) and 65.2% of RRP patients ambulated by postoperative day (POD) 1 compared to 43.4% of PCA patients (p < 0.001). The fraction of patients who requested opioid refills was similar between both groups (p = 0.082). The cost of intraoperative anesthesia was significantly higher for RRP patients ($2,286.87 v $1,958.70, p<0.001). Perioperative hospital stay ($39,990.00 vs $55,680.00, p<0.001) was significantly lower for the RRP patients. Due to different prescription durations, the cost of home opioid medications was $98.94 for PCA patients vs $56.28 for RRP, based on standard Medicaid costs. <h3>CONCLUSIONS</h3> The RRP protocol following PSF had lower total hospital costs and lower home opioid requirements after surgery than the traditional PCA protocol. <h3>FDA DEVICE/DRUG STATUS</h3> intrathecal morphine, oxycodone: Approved.

Postoperative pain management in gynecologic oncology: regional anesthesia effects on time to pain control and achieving postoperative milestones

<h3>Objectives:</h3> We investigated the time to achieve postoperative milestones in patients who underwent exploratory laparotomy for suspected gynecologic malignancy and received either patient-controlled analgesia alone (PCA), PCA with transversus abdominus plane block (TAP), or PCA with continuous epidural infusion (CEI). <h3>Methods:</h3> A retrospective cohort study of patients who underwent open gynecologic oncology surgery in a university was conducted over 18 months. Our primary outcomes included time to achieve the following postoperative milestones: pain control (mean pain score ≤ 5), foley catheter removal, ambulation, flatus, tolerating a regular diet, and control of nausea and emesis. All milestones, except for foley catheter removal, were measured using postoperative day (POD). Foley catheter removal was measured in hours after insertion and analyzed as a categorical variable using quartiles. All postoperative milestones were compared using Fisher's Exact Test. <h3>Results:</h3> Of 214 eligible patients, 127 received PCA alone, 76 received additional TAP block, and 11 received additional CEI. 19 patients without PCA or regional, and 13 patients without PCA, were excluded. Pain control took longer in the CEI group as over half of those who received PCA alone (54%) or TAP (57%) achieved pain control on POD 0 compared to 30% in CEI (p=0.02). Similarly, by POD 3, only 80% of the CEI group had pain controlled compared to 96% in PCA and 85% in TAP (p=0.02). CEI also lagged in time to foley removal as none (0%) of the CEI group had foley removal within the first quartile, 0-15 hours, whereas 23% of the PCA group and 27% of the TAP group had achieved successful removal by that time (p=0.02). This trend continued with 73%, 28%, and 20% of the CEI, PCA, and TAP groups, respectively had foley removal within the last quartile, 41-503 hours (p=0.02). The CEI group also took longer to ambulate with 18% ambulating by POD 1 compared to 59% in PCA and 64% in TAP (p=0.01). Similarly, by POD 2, only 54% of the CEI patients were ambulating compared to 89% in PCA and 90% in TAP (p=0.01). The CEI group lagged in time to regular diet, as only 9% were eating by POD 1 vs 35% in PCA and 29% in TAP, although this finding was not statistically significant (p=0.07). The CEI group also experienced increased time to flatus with 9% on POD 1 compared to 17% in PCA and 7% in TAP (p=0.02). Only 9% of the CEI patients had nausea controlled by POD 1, whereas 48% in PCA and 49% in TAP groups met that milestone by then (p=0.02). It took 3 or more postoperative days for 82% of the CEI group to have controlled nausea. When reviewing these results in the combined regional group (TAP and CEI) vs PCA alone, there were no statistically significant differences except in time to flatus, with 17% of the PCA group passing flatus by POD 1 compared to 7% in the regional group (p=0.03). <h3>Conclusions:</h3> Our study showed that regional anesthesia increased time to flatus in patients who underwent open gynecologic surgery. Although limited by small sample size, CEI was an outlier in time to postoperative milestones, including pain control, ambulation, control of nausea and emesis, and foley removal. Benefits and drawbacks of CEI anesthesia should be considered using full assessment of the effect on postoperative milestones. Further study of costs of CEI vs TAP anesthesia, while not in the scope of this study, can provide further context for decision making. Our results merit future investigation into the effects of regional anesthesia, especially epidural, on time to postoperative milestones.

Cost efficacy of wide local excision of pT1a melanoma in office versus operating room settings

Cost efficacy of wide local excision of pT1a melanoma in office versus operating room settings

The effect of wide-awake anesthesia, intravenous regional anesthesia, and infraclavicular brachial plexus block on cost and clinical scores of patients undergoing hand surgery

The aim of our study was to compare the clinical results and costs of wide-awake local anesthesia no tourniquet (WALANT), intravenous regional anesthesia (IVRA), and infraclavicular brachial plexus block (IC-BPB). The patients were divided into WALANT, IVRA, IC-BPB groups, each with 50 patients. Demographic information, induction time, use of sedation, number of patients who were converted to general anesthesia, time in postanesthesia care unit (PACU), amount of bleeding during surgery, presence of tourniquet pain, hand motor function during surgery, time to onset of postanesthesia pain, discharge time, complications, and anesthesia costs were compared. Sedation was given to 12 IC-BPB patients, 9 IVRA patients and 5 WALANT patients. Of these patients, 6 undergoing IC-BPB, 5 undergoing IVRA and 4 undergoing WALANT were converted to general anesthesia (p = 0.80). PACU time and anesthesia costs were the least in the WALANT group, followed by the IVRA group (p < 0.001, p < 0.001). Intraoperative active voluntary movements were best preserved in the WALANT group; however, bleeding was highest in the WALANT group (p < 0.001, p < 0.001). Tourniquet pain was the higher in the IVRA groups, while postoperative pain in the surgical area developed the fastest in this same group (p = 0.029, p < 0.001). Time to discharge was similar in WALANT and IVRA groups, and the longest in the IC-BPB (p < 0.001) group. There was no difference among the groups in terms of patient satisfaction (p = 0.085, p = 0.242 for the first and second survey question). In the current study, WALANT appears to be a suitable alternative to IVRA and IC-BPB methods, with better preservation of active intraoperative movement, lower cost, and shorter time spent in PACU at the expense of higher bleeding.

Comparison between Target-Controlled Infusion Propofol and Target-Controlled Inhalational Anesthesia Sevoflurane in Mastectomy Surgery in Indonesia

Abstract Background: Health-care system reform in Indonesia is challenging for anesthesiologists in determining the minimum cost of anesthesia and maintaining inflammation and pain to a minimum. This study is aimed to analyze the effectiveness of general anesthesia techniques between target-controlled inhalational anesthesia (TCIA) sevoflurane and target-controlled infusion (TCI) propofol in mastectomy surgery from the perspective of cost, C-reactive protein (CRP) levels, postoperative pain level, postoperative opioid consumption, and side effects. Patients and Methods: This was a randomized controlled trial with permuted block randomization of 60 subjects allocated into TCIA sevoflurane (Group S) and TCI propofol (Group P). In Group S, we used sevoflurane 8 vol% for induction and maintained with sevoflurane 1–1.5 vol%, compressed air, and oxygen. In Group P, we used TCI propofol with target effect 4 mcg/mL and maintained with TCI propofol (target effect of 1–3 mcg/ml), compressed air, and oxygen. Results: The cost in Group S was US$ 36.33 compared to US$ 29.69 in Group P (P = 0.002). The CRP level was comparable between the two groups (38.39 [42.13] vs. 23.88 [45.26]. P = 0.487). There is neither difference in pain score, total morphine consumption, and side effects between both groups in the first 24-h postoperative period, nor morphine consumption in 24 h postoperative. Conclusion: The cost of anesthesia-related expense in TCI propofol is lower than TCIA sevoflurane in mastectomy surgery underwent general anesthesia. There is no significant difference in terms of CRP levels, postoperative pain, postoperative morphine consumption, and incidence of side effects.

Castration and alternatives in pig: advantages and disadvantages

Castration and alternatives in pig: advantages and disadvantages

Ureteroscopic lithotripsy combined with paravertebral block anesthesia or general anesthesia: A propensity matched case–control study

BackgroundTo evaluate the safety, efficacy and cost of paravertebral block anesthesia for ureteral stones patients undergoing ureteroscopic lithotripsy. MethodsFour hundred and eighty-two patients who underwent ureteroscopy for unilateral ureteral stones were incorporated into our retrospective study. A propensity-matched comparison in patients with paravertebral nerve block anesthesia (PVB) group and general anesthesia (GA) group was performed. Intraoperative hemodynamic parameters, operative time, visual analog scale for pain, stone-free rate, anesthetic cost and postoperative hospital stay were compared between the two groups. ResultsSixty-one GA cases were propensity matched to 61 PVB cases. In the PVB group, all the procedures were completed successfully without anesthesia conversion. Significantly less intraoperative severe hypotensive (P = 0.002) and arrhythmia (P < 0.001) episodes in PVB group. There were no significant differences in operative time (p = 0.702), initial stone-free rate (p = 0.686), and total stone-free rate (p = 0.794) between the two groups. The PVB group had lower postoperative pain and prolonged analgesia (p = 0.007). The postoperative hospital stay in the PVB group was significantly shorter (3.20 ± 0.73 vs 3.84 ± 1.32 d, p = 0.001). And the cost of anesthesia was lower in the PVB group (195.47 ± 13.01 vs 396.31 ± 36.45 US dollars, p < 0.001). ConclusionUnder PVB anesthesia, URS can be successfully completed without anesthetic transformation, and its efficacy and safety have been demonstrated. When economic aspects are taken into consideration, PVB seems to be a more economical and effective anesthetic method of URS.

Direct Cost of Anesthesia in Traumatic Patients with Massive Bleeding: a Prospective Micro-Costing Study

Objective:This study aimed to quantify the direct cost as well as cost-to-charge ratio of anesthetic care in traumatic patients with intraoperative massive bleeding.Material and Methods: This study was a prospective observational cost analysis study, conducted in Songklanagarind Hospital, Thailand. Traumatic patients from any mechanisms were recruited. Massive bleeding was defined as estimated blood loss of at least one blood volume in 24 hours or a half of blood volume in 3 hours. The cost components were valued by the bottom-up approach. The direct cost was divided into 4 categories; the labor cost, the capital cost, the material cost and the cost of drugs.Results: From September 2017 to August 2018; 10 eligible patients were included. Seven patients had motorcycle accidents, two patients fell from height and another one was in a minibus accident. Two patients died on the operating table, and another two died within 48 hours. The median direct cost per case was 9,321 Baht (264 United States Dollars), and the cost-to-charge ratio was 0.62. The median Sequential Organ Failure Assessment Score was 8. The median intraoperative blood loss was 3,500 millimeters.Conclusion: Our study provided information on the direct costs of anesthesia in traumatic patients with massive bleeding. The direct cost was 62.0% of the hospital charge. However, this study did not analyze the indirect cost.

Abstract P328: Transcranial Doppler as a Cost-Effective, Safe Screening Tool in Embolic Stroke of Undetermined Source

The diagnostic evaluation of embolic stroke of undetermined source (ESUS) requires investigation of paradoxical embolism via shunts. ESUS evaluation involves a transthoracic echocardiogram (TTE) with saline contrast study, then a transesophageal echocardiogram (TEE) for further evaluation of a patent foramen ovale (PFO), as TTE lacks sensitivity. PFO closure is offered for significant shunts. TEE is the gold standard but transcranial doppler (TCD) may help in the ESUS algorithm for shunts. TCD reduces procedural and anesthetic risk to patients, may be cost-effective, and mitigates risk to providers during the COVID-19 pandemic (1-2). Studies have shown the accuracy of TCD with microbubble for the diagnosis of shunts compared to TEE; a recent meta-analysis found weighted average sensitivity and specificity of 97% and 93%, respectively (3). We propose introducing TCD into the algorithm to evaluate ESUS as a screening tool with similar fidelity to TEE. According to our algorithm, patients under the age of 60 years with ESUS will undergo TTE with microbubble, then those at low risk of valvular disease or cardiac structural pathology will undergo TCD-emboli protocol. Patients with grade 0-2 shunts will receive medical therapy, while shunt grades 3-5 will be referred for intraoperative TEE and closure. We reviewed records of a TCD-emboli protocol followed by TEE from 2014-2020 to ensure similar validity to published data. The sensitivity and specificity of shunt detection amongst 34 patients with ESUS was 94.7% (CI 73.9% - 99.9%) and 93.3% (68.1%-99.8%), respectively. Cost-benefit analysis of patients who received TCD prior to TEE was calculated as the average cost difference. We calculated a conservative estimate of $2741-$3649 in cost reduction per patient, excluding the cost of TEE anesthesia. In conclusion, TCD-emboli protocol is a cost-effective and safe screening tool with high accuracy in comparison to TEE in the diagnostic evaluation of ESUS.

Spontaneous versus mechanical ventilation during video-assisted thoracoscopic surgery for spontaneous pneumothorax: A randomized trial

ObjectiveSpontaneous ventilation video-assisted thoracic surgery (SV-VATS) is reported to have superior or equal efficacy on postoperative recovery to mechanical ventilation VATS (MV-VATS). However, perioperative safety of the SV-VATS blebectomy is not entirely demonstrated. MethodsWe performed a noninferiority, randomized controlled trial (No. NCT03016858) for primary spontaneous pneumothorax patients aged 16 to 50 years undergoing a SV-VATS and the MV-VATS procedure. The trial was conducted at 10 centers in China from April 2017 to January 2019. The primary outcome was the comparison of intra- and postoperative complications between SV-VATS and MV-VATS procedures. Secondary outcomes included total analgesia dose, change of vital sign during surgery, procedural duration, recovery time, postoperative visual analog pain scores, and hospitalization length. ResultsIn this study, 335 patients were included. There was no significant difference between the SV-VATS group and the MV-VATS group in the intra- and postoperative complication rates (17.90% vs 22.09%; relative risk, 0.81; 95% confidence interval, 0.52-1.26; P = .346). The SV-VATS group was associated with significantly decreased total dose of intraoperative opioid agents; that is, sufentanil (11.37 μg vs 20.92 μg; P < .001) and remifentanil (269.78 μg vs 404.96 μg; P < .001). The SV-VATS procedure was also associated with shorter extubation time (12.28 minutes vs 17.30 minutes; P < .001), postanesthesia care unit recovery time (25.43 minutes vs 30.67 minutes; P = .02) and food intake time (346.07 minute vs 404.02 minutes; P = .002). Moreover, the SV-VATS procedure deceased the anesthesia cost compared with the MV-VATS ($297.81 vs $399.81; P < .001). ConclusionsSV-VATS was shown to be noninferior to MV-VATS in term of complication rate and in selected patients undergoing blebectomy for primary spontaneous pneumothorax.

Cost analysis of four types of surgeries for pelvic organ prolapse in a Japanese population.

To compare the perioperative costs analysis between laparoscopic/transvaginal and the mesh/non-mesh surgeries for pelvic organ prolapse (POP) in Japan. From April 2013 to April 2017, 890 patients who underwent POP surgeries were enrolled in this study. Regarding transvaginal native tissue repair (TV-NTR: transvaginal hysterectomy with colpocleisis), transvaginal mesh surgery (TVM), laparoscopic native tissue repair (L-NTR: laparoscopic hysterectomy and uterosacral ligament colposuspension), and laparoscopic sacrocolpopexy (LSC), a retrospective observational study was performed. Patients' age, operation time, blood loss, perioperative complications, length of hospital stay, pre-/postoperative quality of life (QOL) scores, were reviewed from the medical records. The net income, which was calculated by using the income (the operation/anesthesia fee) and the costs (the labor and consumables costs for operation/anesthesia), was evaluated. The operation fees of the L-NTR ($4250) and the LSC ($4833) groups were higher than that of the TV-NTR ($2652) and the TVM ($2913) groups. The labor costs and consumables costs of operation were higher in the LSC ($1589) and the L-NTR ($1500) groups than the TV-NTR ($180) and the TVM ($178) groups. The consumables costs for anesthesia in the four groups were equal. The operation hours were significantly shorter in the TV-NTR and the TVM groups than the L-NTR and the LSC groups. We found that TVM operation was an economically excellent and the most efficient POP operation with shorter operation time and less consumables.

Efficacy, safety, and reliability of surgery on the lumbar spine under general versus spinal anesthesia- an analysis of 64 cases

Quasi-experimental design purposeCompare intra and postoperative parameters, surgeons’ satisfaction, and cost-effectiveness between general anesthesia (GA) and spinal anesthesia (SA) on patients undergoing surgery in the lumbar spine surgery. Overview of literatureSurgery on the lumbar spine is the commonest surgical procedure among all spinal surgical practices. Both the GA and SA are shown to be suitable techniques for performing the surgery safely. GA is used most frequently. But, SA became increasingly more popular because it allows the patient to self-position thereby reducing various complications associated with GA in a prone position. MethodsA total of 64 patients from June 2016 to July 2019 who underwent either discectomy, laminectomy, or lamino-foraminotomy for herniated lumbar disc or canal stenosis in 1 or 2 levels were included. During the study period, 32 patients were non-randomly selected for each of the GA and SA groups. The heart rate (HR), mean arterial pressure (MAP), blood loss, total anesthetic time, surgeons’ satisfaction, analgesic requirements, cost of the procedure, and hospital stay were recorded and compared. ResultsIn the context of demographic characteristics, baseline HR, or MAP, no significant differences were noted between SA and GA groups. Mean anesthetic time, mean PACU time, mean doses of analgesic requirement, cost of anesthesia, and the surgeon’s satisfaction was significantly lower in the SA Group (P < 0.05). The blood loss, duration of operation, and hospital stay were not significant too. No major Intra and postoperative complications were reported nor were significant differences found in either series. ConclusionSafety and efficacy of SA in comparison to GA were similar for the patients undergoing surgery on the lumbar spine. Notable advantages of SA include shorter anesthesia duration, fewer drug requirements, relative cost-effectiveness, and fewer complications rate. Successful surgery can be performed using either anesthesia type.

TO REVİSE OR NOT TO REVİSE! THAT İS THE QUESTİON

OBJECTIVE: The aim of this study was to investigate the costs covered by the hospital during the inpatient treatment process of the patients who underwent hip revision arthroplasty surgery in orthopedics and traumatology clinics of a public hospital and compare with the invoiced amount.MATERIAL AND METHODS: The demographic information and revision reasons of 60 patients who underwent total hip revision arthroplasty operation in a public hospital between 01.01.2016 and 30.09.2017 were determined through Hospital Information Management System records. The patients were categorized under two groups including septic and aseptic. For each patient, the costs of medical consumables, medicine/serum, medical treatment, surgery, anesthesia, imaging services, laboratory procedures, blood and blood products, meal and companion costs, device depreciation expenses, consultation, control examination, preoperative patient preparation stage, surgery, visit and other costs were calculated separately during the inpatient treatment.RESULTS: The total cost of an average patient was 21,956.00 ₺, while the average amount of invoice was 17,220.00 ₺, with a difference of 4,736.00 ₺. This difference was found to be 9,876.00 ₺ in the septic group and 2.534,00 ₺ in the aseptic group. The bill payment made by the Social Security Institution (SGK) to the institution covers 78.4% of the cost of revision hip arthroplasty. In the septic group, the duration of hospital stay, medical expenditure, medication, treatment, surgery, anesthesia, laboratory, imaging, blood center, consultation, visit, meal cost, total cost and invoice amount were found to be significantly higher than the aseptic group (p&amp;lt; 0.05).CONCLUSIONS: Regulations by the Social Security Institution are needed to ensure the fiscal sustainability of public hospitals. In addition, following the medical and technical treatment protocols in revision surgery can help reduce the costs.

Comparison of direct costs of percutaneous full-endoscopic interlaminar lumbar discectomy and microdiscectomy: Results from Turkey.

Microdiscectomy (MD) is a stan-dard technique for the surgical treatment of lumbar disc herniation (LDH). Uniportal percutaneous full-endoscopic in-terlaminar lumbar discectomy (PELD) is another surgical op-tion that has become popular owing to reports of shorter hos-pitalization and earlier functional recovery. There are very few articles analyzing the total costs of these two techniques. The purpose of this study was to compare total hospital costs among microdiscectomy (MD) and uniportal percutaneous full-endoscopic interlaminar lumbar discectomy (PELD). Forty patients aged between 22-70 years who underwent PELD or MD with different anesthesia techniques were divided into four groups: (i) PELD-local anesthesia (PELD-Local) (n=10), (ii) PELD-general anesthesia (PELD-General) (n=10), (iii) MD-spinal anesthesia (MD-Spinal) (n=10), (iv) MD-general anesthesia (MD-General) (n=10). Health care costs were defined as the sum of direct costs. Data were then analyzed based on anesthetic modality to produce a direct cost evaluation. Direct costs were compared statistically between MD and PELD groups. The sum of total costs was $1,249.50 in the PELD-Local group, $1,741.50 in the PELD-General group, $2,015.60 in the MD-Spinal group, and $2,348.70 in the MD-General group. The sum of total costs was higher in the MD-Spinal and MD-General groups than in the PELD-Local and PELD-General groups. The costs of surgical operation, surgical equipment, anesthesia (anesthetist's costs), hospital stay, anesthetic drugs and materials, laboratory wor-kup, nur-sing care, and two main groups (PELD-MD) me-dication diffe-red significantly among the two main groups (PELD-MD) (p<0.01). This study demonstrated that PELD is less costly than MD.

Primary Bankart Repair Versus Arthroscopic Anatomic Glenoid Reconstruction in Patients with Subcritical Bone Loss: A Cost-Utility Analysis.

Background:Anterior shoulder instability and its treatment is a quickly evolving field of interest in orthopaedics, both for patients and for health-care systems. In this study, we aimed to evaluate the cost-effectiveness of arthroscopic anatomic glenoid reconstruction (AAGR) compared with Bankart repair in the treatment of anterior shoulder instability in patients with subcritical glenoid bone loss.Methods:A cost-utility analysis was performed from the perspective of Canada’s publicly funded health-care system. A decision-tree model was created to simulate the progression of patients undergoing either a primary Bankart repair or AAGR. Recently published data were used to determine the recurrence rate and level of glenoid bone loss for the AAGR procedure; the recurrence rate was 1.4% in a cohort with a mean glenoid bone loss of 25.3%. A literature review on the primary Bankart procedure in patients with at least subcritical levels of glenoid bone loss yielded a recurrence rate of 22.9% in patients with a mean glenoid bone loss of 17.5%. AAGR served as the revision surgery for both primary procedures. Health utility scores for anterior shoulder instability were obtained from published literature. Total procedure costs, including costs of operating-room consumables, anesthesia, diagnostic imaging, and rehabilitation, were sourced from a hospital database. A probabilistic sensitivity analysis using 5,000 Monte Carlo simulations was performed, and results were used to create a cost-effectiveness acceptability curve.Results:The AAGR procedure was less costly and led to an improvement in quality-adjusted life years (QALYs) when compared with the arthroscopic Bankart repair in the treatment of patients with anterior shoulder instability with subcritical glenoid bone loss (AAGR, cost = $16,682.77 [Canadian dollars] and QALYs = 5.76; Bankart, cost = $16,720.29 and QALYs = 5.46), suggesting that the AAGR is dominant, i.e., lower costs with higher QALYs. Applying a commonly used willingness-to-pay threshold of $50,000 per QALY gained, the probability that the primary AAGR was more cost-effective was 85.8%.Conclusions:This study showed that, from the perspective of a publicly funded health-care system, AAGR was the economical treatment option when compared with Bankart repair in anterior shoulder instability with subcritical glenoid bone loss.Level of Evidence:Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Is regional anaesthesia worthy with hospital business?

The direct costs of anesthesia and analgesia (including anesthesia fee) represents only 2–4% of the total cost of a surgical procedure. the type of surgical procedure or its duration can make regional anesthesia less expensive or more expensive than general anesthesia. However, optimization of the total time spent inside the OR represents the main factor of the total bill (50–60%). Such a reduction in the total OR time leads to a significant decrease in personnel costs which represents 70% of the cost. Thus, scheduling, organizing flow of patients through the OR is the first improving factor to control. In this field, regional anesthesia can significantly reduce this major cost factor through multiple mechanisms: (1) setting a “block room” to perform blocks in a dedicated space outside the OR for high output short surgical procedures (hand surgery cases) improves the efficiency of the OR by 56%. (2) Regional anesthesia techniques reduce the duration of stay in PACU compared to general anesthesia and even allows more easily to encourage PACU bypass (10–82% of patients). (3) Regional anesthesia and analgesia significantly increase the percentage of surgical procedures which are performed on an ambulatory basis, compared to general anesthesia. Such a shift towards ambulatory surgery leads to a major decrease in nursing budgets for the hospital. (4) Finally, all ERAS surgical procedures require somehow the administration of local anesthetics which can go from intravenous lidocaine (associated to general anesthesia), to infiltration techniques, to nerve blocks. In conclusion, Regional anesthesia techniques, when combined to a strict optimisation of the management of patients flow throughout the whole process, are 2 major factors that significantly improve hospital business.

The costs of human uterus transplantation: a study based on the nine cases of the initial Swedish live donor trial.

What are the costs of live donor uterus transplantation in a European setting? The total costs for preoperative investigations, including IVF, and live donor uterus transplantation including postoperative costs for 2 months, were calculated to be €74564 (mean), with the costs of recipient being somewhat higher than for donor and the cost components of total costs distributed between sick leave (25.7%), postoperative hospitalization (17.8%), surgery (17.1%), preoperative investigations (15.7%), anaesthesia (9.7%), drugs (7.8%), tests after surgery (4.0%) and for re-hospitalization (2.2%). Uterus transplantation has proved to be successful by demonstrations of live births, both after live donor and deceased donor procedures. The transplantation is considered as a complex and expensive infertility treatment. There exist no analyses of costs involved in uterus transplantation. This prospective cohort study included nine uterus transplantations procedures, performed in Sweden in 2013. Study duration of this health economic study included 6-12 months of pre-transplantation investigations and the time interval from transplantation to 2 months after. Nine triads of uterus recipient, partner of recipient and uterus donor participated. All prospective recipients were in stable relationships and performed IVF with their partners before transplantation. The nine donors were relatives or family friends. The recipients and donors underwent pre-transplantation investigations with imaging, laboratory tests and psychological/medical screening prior to transplantation. Transplantation was by laparotomy in both donor and recipient. Standard immunosuppression and postoperative medication were used. After discharge from the hospital, the recipients were followed frequently with laboratory tests and examinations. The mean costs for preoperative investigations, including IVF, and live donor uterus transplantation with postoperative costs for 2 months, were calculated to be €74564 (range €50960-€99658), from a societal perspective. The four largest components were cost of sick leave (€19164), cost of postoperative hospitalization (€13246), surgery cost (€12779) and costs for preoperative investigations, including IVF (€11739). Smaller components were costs for anaesthesia (€7207), costs for drugs (€5821), costs for post-surgical tests (€2985) and costs for re-hospitalization (€1623). The costs of the recipient (€42984) were somewhat higher than the costs of the donor (€31580), but in terms of costs, they should be viewed as one entity. By using a health care perspective, excluding cost for productivity loss, the total costs would be reduced by 26%. A limitation is the restricted sample size and that this is in the experimental, clinical stage of development. The results provide the first information concerning the costs for pre-transplantation investigations and uterus transplantation procedures with postoperative follow-up. We consider the total estimate to be in the higher interval, because of the extensive research protocol. It is likely that the cost of live donor uterus transplantation will vary between countries and that the costs will be lower in a future clinical setting. Funding was received from the Jane and Dan Olsson Foundation for Science; the Knut and Alice Wallenberg Foundation; an ALF grant from the Swedish state under an agreement between the government and the county councils; and the Swedish Research Council. None of the authors have a conflict of interest with regard to the study. NCT01844362.

A Comparison of Surgical Costs between Interval Laparoscopic Sterilization Techniques

Study Objective The purpose of this study was to evaluate factors associated with cost variability between laparoscopic bilateral salpingectomy and tubal fulguration including operating room (OR) time, supply cost, total cost, and recovery time. Design Retrospective chart review. Setting Hospital-based operating room and outpatient surgery center at a community teaching hospital. Patients or Participants Total sample size was 1649 patients. Inclusion criteria were all patients who underwent laparoscopic bilateral salpingectomy or tubal fulguration between January 1, 2013 and December 31, 2019. Patients were excluded if any other procedure was performed at time of sterilization or if they were missing outcome data. Interventions None. Measurements and Main Results Patient demographic data collected included patient age, body mass index, self-reported race, and ethnicity. Outcome data collected included OR time, OR cost, supply cost, total cost, recovery time, and post-operative pain. Cost data was adjusted for medical inflation. Total cost data did not include anesthesia or surgeon cost. When comparing laparoscopic bilateral salpingectomy (n=342) to bilateral tubal fulguration (n=1307), salpingectomy cases had increased OR time, 71.9 minutes versus 55.5 minutes (p Conclusion Total procedure cost, including OR time and chargeable supply cost, was 45% more expensive for laparoscopic bilateral salpingectomy compared to tubal fulguration.