Volume 9, No. 4 • Winter 1994

Safety Danger in Cost Cutting Discussed at ASA

Mark P. Fritz, M.D.

Several scientific papers presented at this year’s annual meeting of the American Society of Anesthesiologists demonstrate how substantial cost savings can be safely achieved through relatively simple changes in practices. Anesthesiology departments are under increasing economic pressures to reduce costs. As various cost saving measures are considered, it is important that we look at how we can best reduce costs without compromising the quality of care and patient safety. The following is a composite summary of the scientific papers presented in the sessions on “Cost Containment in Anesthesia.”

Anesthetic drug costs are a major portion of pharmacy budgets. Costs of anesthetic drugs (particularly vecuronium, isoflurane, and propofol) represent significant expenses in the hospital’s pharmacy budget.

Five agents account for more than 80% of anesthetic drug expenditures. Vecuronium, isoflurane, propofol, midazolam, and atracurium account for the vast majority of a typical departments expenses for pharmaceuticals.(1,2,3,7,9)

More judicious use of expensive intermediate-acting nondepolarizing neuromuscular blocking agents results in substantial savings. Restricting intermediate-acting agents to specific indications (rapid sequence inductions where succinylcholine is contraindicated, and cases of less than 60-90 minutes duration) results in dramatic savings.(1,2,9) Education on price of agents and alternatives (pancuronium/metocurine) may be important.(1,2,7,8,9) Properly using multidose vials or having the pharmacy prepare doses in labeled and tamper-sealed syringes can reduce wastage of unused syringes.”

Use lower fresh gas flows when using volatile agents. A large number of practitioners use greater than 4 L/min total fresh gas flow (FGF) with inhalational agents. Reducing FGF after the initial ‘wash-in’ period results in substantial savings in volatile agents. (2,3,4,7,8) Many pediatric hospitals use low-volume pediatric circle circuits rather than nonrebreathing (Mapleson D, Bain, Jackson-Rees) circuits to reduce FCF and conserve inhalational anesthetics.(2)

Using fentanyl (20ml) rather than more expensive narcotics. Some savings can be achieved through using ‘economy size’ ampules of fentanyl (i.e., one 20 ml ampule rather than two 10 ml ampules) and by using equipotent doses of fentanyl in place of sufentanil and alfentanil. (5,7,8)

Reduce wastage of propofol and midazolam. Large amounts of propofol and midazolam are wasted every day (leftover propofol from 50 ml vials and midazolam from 5 mg or 10 mg vials). Better planning of anticipated dose can help to reduce waste.(9)

Compare the costs of various vendors regularly. The “disposables” market is quite competitive and you can often find vendors with comparable products at a lower cost.(7)

Consider going back to re-usable products. Many departments can realize significant savings by returning to reusable supplies (such as pulse oximeter probes and breathing circuits). (8) You must remember to include the original purchase cost plus the processing costs (cleaning & disinfecting) and eventual replacement costs when comparing reusables to disposables.

Reduce wastage of emergency drugs through pharmacy ‘batching’ of labeled, sealed syringes. A large number of syringes are never used, but were drawn up in case they were needed (succinylcholine, ephedrine, lidocaine), Pharmacies can often prepare unit dose syringes, properly labeled and sealed, that can be saved until they expire.(2,5,9)

Anesthesiologists have a poor understanding of the costs of the drugs they are using. Price posting and educational programs can improve cost consciousness. Residents and faculty had difficulty in accurately estimating the costs of various anesthetic drugs and supplies. Posting the costs of various agents and having educational programs may increase cost awareness, and possibly modify practice habits(3,6,7,8,9)

Pharmacy markups may mask some cost savings. Some hospital pharmacies charge patients and insurance carriers much more than the true acquisition costs. Cost savings that are realized may be obscured by pharmacy pricing policies.”

No increase in morbidity or mortality was reported in implementing these cost-containment measures. Many of these papers specifically looked for any complications that could be attributed to cost containment measures. The sample sizes are small, but no additional complications were reported.

In summary, it would seem that significant savings can be realized by most departments through small changes in daily practices without compromising patient safety.

Dr. Fritz is from the Mason Clinic in Seattle, WA, and chaired the 1994 ASA Subcommittee on Patient Safety, Epidemiology, and Education section of the Annual Meeting.

Abstract References

1. Freund, P. Anesthesiology 1994 Vol 81(3A):Al 197.

2. Holzman, R. Anesthesiology 1994 Vol 81 (3A): A1198.

3. Williams, M. Anesthesiology 1994 Vol 81 (3A): A1199.

4. Williams, M. Anesthesiology 1994 Vol 81 (3A): A1200.

5. Greenberg, C Anesthesiology 1994 Vol 81 (3A): A1202.

6. Shapiro, D. Anesthesiology 1994 Vol 81(3A):A1203.

7. Becker Jr., K. Anesthesiology 1994 Vol 81 (3A): A1204.

8. Parks, J. Anesthesiology 1994 Vol 81 (3A): A1205.

9. Munshi, C. Anesthesiology 1994 Vol 81 (3A): A1206.