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'The price of everything and the value of nothing': cost awareness in anaesthesia.

Cost awareness for the drugs and disposables commonly used by anaesthetic staff has previously been poor. In our study, fifty anaesthetic staff were asked to estimate the cost of thirty-three commonly used drugs and disposables. Expensive items were consistently underestimated whereas inexpensive items were consistently overestimated. There was no overall correlation between the number of years of anaesthetic experience and cost awareness. These findings demonstrate poor knowledge regarding the cost of drugs and consumables amongst anaesthetic staff.

KEYWORDS Anaesthetic costs / Cost awareness / Anaesthesia

Introduction

Over the past fifteen years, the introduction of new drugs, expiry of existing drug patents and reduction in drug production costs, all within a competitive pharmaceutical market, have led to fluctuations in the price of drugs. It is important that the anaesthetist is familiar, not only with advances in drug development, but also their associated costs.

Poor cost awareness in anaesthesia has been demonstrated for many years. Thirty years ago Simpson (1978) found ignorance amongst a small group of junior anaesthetists. Fairbrass and Chaffe (1988) analysed fifty questionnaires completed by anaesthetic staff and concluded that the costs of the majority of drugs, fluids and disposables were consistently overestimated with the exception of a few expensive items which were underestimated. A repeat study revealed no significant improvement in cost awareness in the intervening years (Mills & Chaffe 1993). In a Danish study Schlunzen et al (1999) also found that inexpensive items were consistently overestimated whilst expensive ones were underestimated, but found no difference in knowledge between different grades of staff. Egan et al (2007) demonstrated similar results in the UK.

In the current study, it was investigated whether there has been an improvement in fiscal knowledge amongst anaesthetic staff of different grades compared with seventeen years ago (Bailey et al 1993). The hypothesis that expensive drugs and consumables are consistently underestimated whereas inexpensive ones are invariably overestimated was tested. Results between different grades of staff were compared, certain aspects of economics in anaesthesia are discussed and finally suggestions for reducing expenditure are made.

Methods

A methodology similar to that used by Bailey et al (1993) was employed in order to make direct comparisons. A questionnaire listing twenty drugs and thirteen consumables or fluids used in perioperative anaesthetic practice was designed. The questionnaire had been adjusted from that of Bailey et al (1993) to include drugs that were commonly used nowadays at Guy's and St Thomas' NHS Foundation Trust, London. Drugs included: analgesics, induction agents, neuromuscular blockers and volatile anaesthetic agents; consumables/fluids included intravenous cannulae and tubing, commonly used intra-operative fluids, and airways (Appendix A).

Without prior warning, the questionnaire was handed to ten anaesthetic staff in each of the following categories: consultant, specialty trainee year 6/7 (ST6/7), specialty trainee year 4 (ST4), specialty trainee year 1/2 (ST1/2) and operating department practitioner (ODP) in the Department of Anaesthetics at Guy's and St Thomas' NHS Foundation Trust in October 2008. The fifty participants were asked to write an estimate of the cost next to each of the items without referring to price lists or advice from other individuals. The questionnaire-filling process was performed by the participant in our presence. Fully completed questionnaires were anonymised and filed by grade only. Correct prices were obtained from the British National Formulary (BNF 56), by contact with the supplies manager of the trust, or by direct contact with the manufacturer. The cost of blood was obtained from personal communication with a consultant haematologist in the trust.

Kruskal-Wallis test was applied to the average absolute percentage errors (AAPE) for the expensive items, non-expensive items and all items with respect to the true cost in order to trace any significant differences between combinations of two groups. In particular, the influence of education or experience to accuracy was assessed. A p-value of less than 0.05 was considered to be statistically significant.

Based on previous studies (Bailey et al 1993, Mills & Chaffe 1993, Schlunzen et al 1999, Egan et al 2007), the hypothesis holds that the overestimated items are inexpensive ones, whereas the underestimated items are expensive. For the sake of simplicity, an item was considered to be well estimated if the median estimate was within [+ or -] 25% of the true cost. An item was considered 'expensive' if the true cost was more than 3 [pounds sterling] and 'inexpensive' if less than 3 [pounds sterling].

Results

Fifty questionnaires were initially returned, three of which were not fully completed and were subsequently replaced by questionnaires from three new participants of the same grade.

Examining all responses regardless of grade, twenty per cent were within 25% of the true cost, thirty-seven per cent were within 50% and seventy-six per cent were [+ or -]100%. Of the 33 drugs and consumables, 12 were within the [+ or -]25% accuracy range, 11 were overestimated and 10 were underestimated.

In a direct comparison between groups, ST1/2 trainees significantly underestimated item prices overall when compared with consultants. No other statistically significant differences in accuracy were observed between grades of staff with respect to average absolute percentage errors (Table 1)

The costs of expensive items such as volatile agents, packed red cells, and neuromuscular blocking agents were underestimated whereas the costs of inexpensive items, such as plastic disposable equipment, non-steroidal anti-inflammatory drugs, opioids and sedatives, were overestimated (Figure 1).

[FIGURE 1 OMITTED]

Discussion

Cost awareness amongst anaesthetic staff is poor and the results are similar to our previous study (Bailey et al 1993). As predicted, the cost of cheap consumables was consistently overestimated whereas the cost of expensive items, such as volatile anaesthetic agents, was underestimated. Overestimation of inexpensive items is a known phenomenon amongst consumers. Aalto-Setala and Raijas (2003) found similar behaviour in grocery shoppers and suggested that this phenomenon is likely to be due to caution, an argument which could be extended to the present study.

Variation in accuracy was seen even within the same group of drugs. For example, the cost of the non-proprietary fentanyl was overestimated whilst that of the newer patented remifentanil was underestimated. The cost of rocuronium was well estimated but that of vecuronium was estimated at 62% lower than its true value, possibly due to staff assuming that the introduction of rocuronium into the marketplace had led to a reduction in the price of vecuronium.

The cost of a unit of packed red cells was considerably underestimated, but this lack of knowledge is understandable as the cost is estimated from administration fees and the price of tests and treatments on each sample donated to the National Blood Transfusion Service, which generates a price that clinicians are unlikely to be familiar with.

Comparison between grades of staff

Apart from ST1/2 trainees, who tended to underestimate true costs for more items and in most cases provided the least accurate answers, cost awareness did not increase with the education or experience of anaesthetic staff.

Comparison with previous studies and interventions

Overall cost awareness of consumables and drugs used in anaesthetics has not changed significantly and results are similar to a study published seventeen years ago (Bailey et al 1993) (Table 2). A few drugs which were overestimated in the previous study were now underestimated, for example only 12% of participants overestimated the price of vecuronium compared with 92% in the 1993 study.

The present study demonstrates that, even though anaesthetic staff have good knowledge of relative differences between drug prices, there is poor knowledge of absolute cost. Lack of involvement in departmental budgeting may contribute to ignorance. Occasionally, anaesthetists may be warned by the pharmacy department if there is excessive use of expensive drugs when cheaper and equally efficacious alternatives are available. Price labelling is rare on products that anaesthetists use.

Studies have also found poor cost awareness amongst other medical specialties. In a systematic review Allan et al (2007) argued that doctors recognise their limitations with regard to cost awareness but that they wanted more information and felt that if the information was provided then it would enable them to reduce costs without compromising patient care. One study demonstrated that price labelling alone had little impact on anaesthetists' choice of drugs (Horrow & Rosenberg 1994), but another found that placing price labels on vials of neuromuscular blocking agents, together with an education programme regarding prices, encouraged the use of less expensive drugs and reduced the total expenditure on neuromuscular blocking agents by 12.5% within twelve months (Lin & Miller 1998).

Economics of anaesthesia

Cheap drug choices may compromise patient care and prove more expensive overall. For example, using more expensive anaesthetic drugs which allow rapid patient recovery with a low incidence of adverse effects such as post-operative nausea and vomiting is more cost effective than opting for cheaper, less effective alternatives (Rowe 1998); the cost of a 30-minute delay to an operating session is significantly more than is saved by changing from an expensive drug to a cheaper one (Broadway & Jones 1995).

Twenty years ago setting high fresh gas flows during maintenance of anaesthesia was standard practice. The rationale was to ensure adequate ventilation to prevent hypoxaemia and hypercarbia. Today, monitoring of expired gas concentrations, the routine use of sodalime, and the availability of sophisticated safety alarms make low gas flow techniques standard practice without compromising patient outcome. Using low flow anaesthesia can reduce the cost per hour of anaesthesia by at least a third compared with previously employed techniques (Rowe 1998).

An hour long anaesthetic using fentanyl and propofol induction and maintenance with 1 MAC sevoflurane in oxygen and nitrous oxide at 2l.min--1 fresh gas flow costs 9.76 [pounds sterling], which compares favourably with a total intravenous anaesthetic (TIVA) technique with fentanyl, propofol infusion and air/oxygen mixture, which costs 10.67 [pounds sterling]. Ekbom et al (2007) found that there was a 20% higher cost if an oxygen/air mixture was used rather than nitrous oxide due to the increased requirement for sevoflurane to ensure unconsciousness, but that this may have been offset by the price of an expensive antiemetic which would be required more often in the nitrous oxide group of patients.

There are also variations in costs within surgical subspecialties. For example Schuster et al (2004) showed that personnel costs and total costs are higher in subspecialties whose operations are of relatively short duration. Regional anaesthetic techniques may be more cost-effective than general anaesthesia provided that the surgery is amenable to this. Gonano et al (2006) concluded that spinal anaesthesia was more cost effective in patients undergoing hip or knee replacement because of lower fixed and variable costs including reduced postoperative pain and quicker recovery.

In this era of economic recession anaesthetic staff must take fiscal responsibility. Both direct and indirect costs should be taken into account when considering anaesthesia, for example the use of nitrous oxide is cheap but the increased incidence of post-operative nausea and vomiting necessitating the administration of expensive anti-emetics such as ondansetron may outweigh the economic benefit of using nitrous oxide (Purhonen et al 2006). On the contrary desflurane is expensive (Buchinger et al 2006) but the fast patient recovery characteristics that are associated with its use may lead to cost savings by reducing the time that patients spend in the recovery area. In addition, the increased use of monitors such as bispectral index (BIS) to assess the depth of anaesthesia may lead to a reduction in total anaesthetic drug consumption (Eger et al 2000).

Although economic factors are important they must never detract from providing high quality patient care since anaesthetic drugs comprise only 5% of a hospital pharmacy budget and only 1% of the total cost of a surgical procedure (Demeere et al 2006) and the requirement for additional drugs or personnel to treat complications or prolonged patient recovery has significant cost (Smith 2001).

To reduce the unnecessary use of expensive drugs or equipment when cheaper equally effective alternatives are available it may be necessary to introduce departmental guidelines, develop educational programmes or even provide financial incentives (Stockal 1998). Within the private sector in the UK there certainly appears to be more fiscal responsibility than in the NHS where practitioners perceive they have less 'ownership' of departmental budgets.

Conclusion

This study demonstrates that cost consciousness amongst anaesthetic staff has not changed significantly over the last fifteen years. In an effort to reduce excessive costs, raising awareness of fiscal responsibility is important. Further observational and interventional multi-centre studies in both the private and public sectors are needed to examine the effect of price labelling and the use of cost-effective drugs in order to provide recommendations for cost reduction of anaesthetic drugs and consumables.

Limitations of the study

A total of fifty anaesthetic staff may not be a large enough sample to represent a population. It must be taken into consideration that prices of consumables and drugs may vary over time and depend on the manufacturer and size of order.
APPENDIX A

Modified version of the questionnaire including the actual cost
for each item. Participants were asked to write the estimated
cost next to each of these items without using any sort of reference.
[British National Formulary (BNF 56)]

                                                              Price
Disposables and                                          (UK[pounds
fluids                                                   sterling])

Intravenous cannulae   22g venflon                             0.62
and tubing             16g venflon                             0.62
                       IV infusion tubing                      1.45
Intravenous fluids     1l Hartmanns solution                   0.67
                       Gelofusine (500mL)                      4.70
                       Blood (1 unit packed cells)           130.00
Airways                Plastic oral ET tube (9mmID)            1.43
Miscellaneous          roll of 1 inch pink elastoplast         1.25
disposables            roll of ribbon gauze                    0.49
                       2ml syringe                             0.03
                       10ml syringe                            0.06
                       3 ECG electrodes                        0.15

Drugs

Sedatives Induction    Midazolam 10mg (2mg/ml)                 0.65
agents                 Thiopentone (500mg)                     3.06
                       Propofol (200mg)                        2.33
                       1% Propofol TCI syringe (50ml)         10.67
Neuromuscular          Suxamethonium (100mg)                   0.64
blockers               Atracurium (50mg)                       3.37
                       Vecuronium (10mg)                       3.95
                       Rocuronium (50mg)                       3.01
                       Pancuronium (4mg)                       1.20
Opioids                Fentanyl (100mcg - 2ml)                 0.54
                       Fentanyl (500mcg - 10ml)                1.65
                       Morphine (10mg)                         0.60
                       Remifentanil (5mg)                     25.58
Non-steroidal          Diclofenac suppository (100mg)          0.30
anti-inflammatory      Ketorolac (30mg/ml)                     1.14
drugs
Volatile anaesthetic   Halothane (250ml)                      20.00
agents                 Isoflurane (250ml)                     47.50
                       Sevoflurane (100ml)                   123.00
Reversal agents        Atropine (0.6mg)                        0.51
                       Neostigmine/glycopyrrolate              1.01
                       mixture (1ml)


Acknowledgement

We thank Virginia Zabeli (MSc) for providing statistical analysis.

References

Aalto-Setala V, Raijas A 2003 Actual market prices and consumer price knowledge Journal of Product & Brand Management 12 (3) 180-192

Allan GM, Lexchin J, Wiebe N 2007 Physician awareness of drug cost: a systematic review PLoS Medicine / Public Library of Science 4 (9) e283

Bailey CR, Ruggier R, Cashman JN 1993 Anaesthesia: cheap at twice the price? Staff awareness, cost comparisons and recommendations for economic savings Anaesthesia 48 (10) 906-909

Broadway PJ, Jones JG 1995 A method of costing anaesthetic practice Anaesthesia 50 (1) 56-63

Buchinger H, Kreuer S, Paxian M, Larsen R, Wilhelm W 2006 Desflurane and isoflurane in minimal-flow anesthesia. Consumption and costs with forced fresh gas reduction Anaesthesist 55 (8) 854-860

Demeere JL, Merckx Ch, Demeere N 2006 Cost minimisation and cost effectiveness in anaesthesia for total hip replacement surgery in Belgium? A study comparing three general anaesthesia techniques Acta Anaesthesiologica Belgica 57 (2) 145-151

Egan T, Varveris DA, Carse J, Smart NG 2007 Anaesthetic drug cost awareness Anaesthesia 62 (3) 307-308

Eger EI, White PF, Bogetz MS 2000 Clinical and economic factors important to anaesthetic choice for day-case surgery Pharmacoeconomics 17 (3) 245-262

Ekbom K, Assareh H, Anderson RE, Jakobsson JG 2007 The effects of fresh gas flow on the amount of sevoflurane vaporized during 1 minimum alveolar concentration anaesthesia for day surgery: a clinical study Acta Anaesthesiologica Scandinavica 51 (3) 290-293

Fairbrass MJ, Chaffe AG 1988 Staff awareness of cost of anaesthetic drugs, fluids, and disposables British Medical Journal (Clinical Research Ed.) 296 (6628) 1040

Gonano C, Leitgeb U, Sitzwohl C, Ihra G, Weinstabl C, Kettner SC 2006 Spinal versus general anesthesia for orthopaedic surgery: anesthesia drug and supply costs Anesthesia & Analgesia 102 (2) 524-529

Horrow JC, Rosenberg H 1994 Price stickers do not alter drug usage Canadian Journal of Anesthesia 41 1047-1052

Lin YC, Miller SR 1998 The impact of price labelling of muscle relaxants on cost consciousness among anesthesiologists Journal of Clinical Anesthesia 10 (5) 401-403

Mills G, Chaffe A 1993 Is cost-awareness really improving? Health Trends 25 (1) 38-40

Purhonen S, Koski EM, Niskanen M, Hynynen M 2006 Efficacy and costs of three anesthetic regimens in the prevention of postoperative nausea and vomiting Journal of Clinical Anesthesia 18 (1) 41-45

Rowe WL 1998 Economics and anaesthesia Anaesthesia 53 (8) 782-788

Schlunzen L, Simonsen MS, Spangsberg NL, Carlsson P 1999 Cost consciousness among anaesthetic staff Acta Anaesthesiologica Scandinavica 43 (2) 202-205

Schuster M, Standl T, Wagner JA, Berger J, Reimann H, Am Esch JS 2004 Effect of different cost drivers on cost per anesthesia minute in different anesthesia subspecialties Anesthesiology 101 (6) 1435-1443

Simpson M 1978 The cost of anaesthetic drugs and equipment Anaesthesia 33 (1) 53-59

Smith I 2001 Cost considerations in the use of anaesthetic drugs Pharmacoeconomics 19 (5) 469-481

Stockall CA 1998 New drugs in anaesthesia: can we afford them? Canadian Journal of Anesthesia 45 (5) R95-105

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About the authors

Marios Hadjiipavlou MBBS, BSc

Foundation Year 2, General Surgery, Queen Mary's Hospital, Sidcup

Craig Bailey MBBS, FRCA

Consultant Anaesthetist, Guy's and St Thomas' NHS Foundation Trust, London

No competing interests declared

Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk.

Access is also available to non-members who pay a small fee for each article download.

'The price of everything and the value of nothing' from Lady Windermere's Fan by Oscar Wilde (1892-Lord Darlington; Act III).

Marios Hadjipavlou and Craig R. Bailey

Correspondence address: Marios Hadjipavlou, General Surgery, Queen Mary's Hospital, Sidcup, DA14 6LT. Email: marioshad@doctors.org.uk

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication September 2010.
Table 1 Average absolute percent error (%) categorised by grades
of staff

                            Consultant   ST6/7   ST3/4/5

Consumables (n=13)              261.4    193.9     289.0
Drugs (n=20)                    111.7    114.3     142.8
Volatile gases only (n=3)        59.0     46.8      55.8
All items (n=33)                167.8    144.1     197.6

                            ST1/2     ODP    mean

Consumables (n=13)          250.5   295.8   258.1
Drugs (n=20)                110.3    76.5   111.1
Volatile gases only (n=3)    78.7    50.9    58.2
All items (n=33)            162.9   158.7   166.2

Table 2 Comparison of under- and over-estimations of consumables
and drugs in the current and 1993 studies (n=50)

                                  Current Study

n=50                      Under-estimated   Over-estimated

2ml syringe                      2                48
10ml syringe                     9                41
3 ECG electrodes                 4                42
ET tube                         12                38
Fentanyl 100mcg (2ml)           14                36
Roll of ribbon gauze            16                34
IV infusion tubing              30                20
Halothane (250ml)               32                 9
1l Hartmanns solution           37                13
Vecuronium (10mg)               44                 6
Atracurium (50mg)               45                 5
1U blood (packed cells)         45                 5

                                     1993 Study

n=50                      Under-estimated   Over-estimated

2ml syringe                      1                49
10ml syringe                     2                48
3 ECG electrodes                 3                47
ET tube                          5                45
Fentanyl 100mcg (2ml)            2                48

Roll of ribbon gauze            42                 8
IV infusion tubing               6                44
Halothane (250ml)                5                45
1l Hartmanns solution            5                45
Vecuronium (10mg)                4                46
Atracurium (50mg)               44                 6
1U blood (packed cells)         12                38
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Title Annotation:CLINICAL FEATURE
Author:Hadjipavlou, Marios; Bailey, Craig R.
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:4EUUK
Date:Dec 1, 2010
Words:3257
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