Postanesthesia Care Unit Costs Research Articles

Impact of Sugammadex Versus Neostigmine/Glycopyrrolate on Perioperative Efficiency.

PurposeNeuromuscular blockade in the operating room necessitates the utilization of reversal agents to accelerate postoperative recovery and sustain operating room patient throughput. Cholinesterase inhibitors represent the historical standard of care for neuromuscular blockade reversal within anesthesia practice. Sugammadex, a synthetic gamma-cyclodextrin, was introduced to the market with evidence of more rapid and predictable reversal of neuromuscular blockade compared to alternative agents. Higher medication acquisition costs have limited more extensive use of sugammadex compared to that of neostigmine/glycopyrrolate. The purpose of this study was to examine the impact of sugammadex versus neostigmine/glycopyrrolate on perioperative efficiency to validate medication acquisition cost value.MethodsA retrospective investigation was performed of patients with a surgical procedure at Houston Methodist Hospital from July 31, 2017 through August 1, 2018. The primary endpoint was time from reversal medication administration to operating room exit. Patient-specific doses were assessed to calculate average medication acquisition costs. The economic benefits of sugammadex were measured through review of average operating room and postanesthesia care unit costs per minute.ResultsThere were a total of 640 surgical cases at Houston Methodist Hospital eligible for inclusion into the research study. The time from medication administration to operating room exit was significantly faster for sugammadex compared to neostigmine/glycopyrrolate (P<0.001) upon univariate analysis. However, when measured with linear regression, the difference in operating room exit time between sugammadex and neostigmine/glycopyrrolate was no longer statistically significant (P=0.122). Medication acquisition cost review highlighted a difference of $178.20, favoring use of neostigmine/glycopyrrolate.ConclusionThe utilization of sugammadex does not correlate to consequential time saved in the operating room or extrapolation to workflow capacity for increased surgical case volume. Consideration of the medication acquisition cost promotes more restrictive use of sugammadex to indications with clinical relevance.

Adverse Respiratory Events Increase Post-anesthesia Care Unit Stay in China: A 2-year Retrospective Matched Cohort Study.

Despite growing attention to patients' safety worldwide, no data were available on the impact of adverse respiratory events (AREs) on post-anesthesia care and post-operation care in China. This study evaluated the occurrence of AREs, the impact of AREs on length of stay (LOS) in post-anesthesia care unit (PACU) and postoperative time in hospital, and PACU cost and inpatient healthcare costs. A retrospective, matched-cohort study was conducted by prospectively collecting the data of 159 AREs in PACU during 2016-2017 in an university hospital in China. Records were reviewed by pre-trained, qualified nurses and/or anesthesiologists. The incidence and the impact of AREs were analyzed. The LOS in PACU and postoperative time in hospital and the costs in PACU and inpatient healthcare costs were also obtained. Results showed that there were 253 AREs involving 156 patients. Hypoxia (n=141, 55.73%) and respiratory depression (n=70, 27.67%) were the most common AREs. Measurement data including body mass index (BMI) (22.85±4.36 vs. 22.32±3.83), duration of procedure (138.47±77.33 min vs. 137.44±72.33 min), duration of anesthesia (176.35±82.66 min vs. 174.61±78.08 min), LOS (16.53±10.65 days vs. 16.57±9.56 days), inpatient healthcare costs ($9465.57±9416.33 vs. $8166.51±5762.01), and postoperative LOS (11.26±8.77 days vs. 11.19±8.30 days) showed no significant differences between ARE and matched groups (P>0.05). Duration (81.65±54.79 min vs. 38.89±26.09 min) and costs ($31.99±17.80 vs. $18.72±8.39) in PACU were significantly different in ARE group from those in matched group (P<0.001). Proportion of patients with prolonged stay in PACU was significantly higher in ARE group than in matched group (18.59% vs. 1.28%), with an odds ratio (after matching) of 17.58 (95% CI=4.11 to 75.10; P<0.001). The AREs that occurred during the immediate postoperative period in PACU increased the incidence rate of prolonged stay, delayed the PACU stay, and increased the costs in PACU, resulting in the need of higher levels of postoperative care than anticipated, but the postoperative LOS and inpatient healthcare costs were unchanged.

Laparoscopic Restorative Proctocolectomy with Ileal S-Pouch

Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.

Pharmacoeconomics of propofol in anesthesia.

Pharmacoeconomic data on the use of propofol in anesthesia are reviewed, with consideration of clinical characteristics that affect overall costs. Propofol is more expensive than many other anesthetics but its use can affect the costs of perioperative care as well as costs not directly related to the health care system, such as those associated with time off work. Using propofol can result in earlier discharge from the postanesthesia care unit (PACU), which can result in lower PACU costs. Anesthesia induction and maintenance with propofol versus barbiturates for induction and volatile anesthetics for maintenance have been associated with a lower frequency of postoperative nausea and vomiting (PONV) in the immediate postoperative period. A reduced frequency of PONV may improve the ability to increase patient flow through the PACU, which may reduce PACU costs. The cost of treating PONV in the PACU might not be high enough to justify the use of more expensive agents such as propofol solely for their reduced propensity to cause PONV. Propofol use has been associated with significantly shorter times to extubation of cardiac-surgery patients compared with the use of other agents. Early extubation has, in turn, been associated with shorter hospital stays, shorter stays in the cardiac intensive care unit, and lower hospital charges. Policy changes regarding criteria for discharge from the PACU may need to be implemented if the economic advantages of propofol are to be realized. Anesthesia with propofol, compared with other agents, has been associated with shorter stays in the PACU. Whether using propofol decreases the costs of care is unclear.

Analysis of Strategies to Decrease Postanesthesia Care Unit Costs

Background The goal of this study was to identify interventions that anesthesiologists can make to decrease total costs of a postanesthesia care unit (PACU). Methods Data were collected retrospectively from patients who underwent ambulatory surgery at our tertiary care center. Results Supplies and medications accounted for only 2% of PACU charges. Personnel costs, which depend on the peak number of patients in the PACU, accounted for almost all PACU costs. If nausea and vomiting could have been eliminated in each patient who suffered this complication, without causing sedation, the total time to discharge for all patients would have been decreased by less than 4.8% (95% confidence interval Conclusions Anesthesiologists have little control over PACU economics via choice of anesthetic drugs. The major determinant of PACU costs is the distribution of admissions.

Reply

Department of Anesthesia, The University of Iowa, Iowa City, Iowa 52242-1079.In Reply:--Cost-effectiveness studies compare the costs of different therapies to achieve the same outcome. In the part of our study that used charges, we did not do a cost-effectiveness analysis. Instead, we addressed whether strategies to decrease postanesthesia care unit (PACU) supply costs would decrease PACU costs substantively. They would not. Hagan points out that "one of the benefits of cost-effecttiveness studies is the ability to provide to policy-makers alternatives in resource allocation." Although I agree, I think that other types of cost analyses can be beneficial. This minor part of our study was a valuable prelude to most of our analysis.To assess the significance of supplies on PACU costs, we used relative charges as proxies for relative costs. We did not make this assumption capriciously but did so based on studies that have evaluated the validity of the relationship. [1,2]Nevertheless, the important question is not whether relative charges are statistically different from relative costs. They will be under many circumstances. The important question is whether the degree of inaccuracy is sufficient to affect our conclusions. Charges for supplies accounted for 2% (95% confidence interval 0-3%) of the PACU bill. Therefore, I think that a change in the analysis is unlikely to show that supplies were a major part of the bill. We could have increased our sample size. However, I am skeptical that we then would have found supplies to be important cost items in the PACU.Finally, Hagan states that "the number of personnel required does not depend on the peak number of patients in the [PACU]." If this statement were true, our results would be of little value. However, the claim is incorrect. The American Society of Post-Anesthesia Nurses (ASPAN) recommends that each PACU nurse care for two or fewer patients simultaneously. Following their standard, the peak number of nurses required equals half the peak number of patients.Hagan's point about the number of personnel leads to the question of whether PACU personnel costs are proportional to the peak number of patients in the PACU. This relationship between cost and peak number of patients will hold for almost all PACUs. However, there are exceptions. The relationship assumes that there are dedicated PACU nurses. For example, some ambulatory surgical centers do not have dedicated PACU personnel. By having these nurses perform other (non-PACU) duties when they are not needed in the PACU, perioperative costs can be decreased. I do not know of a study that has assessed whether this cost-saving approach affects the quality of patient care.Franklin Dexter, M.D., Ph.D.; Department of Anesthesia; The University of Iowa; Iowa City, Iowa 52242-1079.(Accepted for publication March 9, 1995.)