The impact of price labeling of muscle relaxants on cost consciousness among anesthesiologists

Poor Cost Awareness Among Anesthesia Providers for Medications, Supplies, and Blood Products

BACKGROUND

The objective of this study was to determine if anesthesia providers can accurately estimate the cost of commonly used medications, supplies, and blood products.

METHODS

This study was conducted between April and June 2019 at an academic tertiary care hospital. Anesthesia providers (certified registered nurse anesthetists [CRNAs], residents, and fellows/attendings) were surveyed on their knowledge of the cost of commonly used therapies. Items were sorted into 12 categories: opioids, non-opioid analgesia, vasopressors, hypertension medications, antibiotics, neuromuscular blockers, reversals, anesthetics, supplies, kits, blood products, and blood-related products. Estimates were considered to be accurate if the median cost differed from the average wholesale price by < 25%, moderately inaccurate if between 25% and 50%, and severely inaccurate if by > 50%.

RESULTS

A total of 107 surveys (CRNAs: 25, residents: 36, fellows/attendings: 46) were returned. The percentage of total items accurately estimated for cost was low (22% for all providers), and was not different between provider types (27% for CRNAs, 23% for residents, 20% for fellows/attendings; p = 0.69). The percentage of items with severe inaccuracies in cost estimation was high and was not different between provider types (56% for CRNAs, 60% for residents, 50% for fellows/attendings; p = 0.53). Rates of under- and overestimation varied widely, with greatest underestimation for vasopressors and blood-related products, and greatest overestimation for non-opioid analgesia and antibiotics. Low- and high-cost category items tended to be overestimated and underestimated, respectively (p < 0.0001).

CONCLUSION

The majority of anesthesia providers have poor knowledge of cost. These findings suggest that cost awareness interventions may be necessary for promoting high-value health care.

Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing With Cost Savings and Reduced Greenhouse Gas Emissions

Anesthetic agents are known greenhouse gases with hundreds to thousands of times the global warming impact compared with carbon dioxide. We sought to mitigate the negative environmental and financial impacts of our practice in the perioperative setting through multidisciplinary staff engagement and provider education on flow rate reduction and volatile agent choice. These efforts led to a 64% per case reduction in carbon dioxide equivalent emissions (163 kg in Fiscal Year 2012, compared with 58 kg in Fiscal Year 2015), as well as a cost savings estimate of $25,000 per month.

Impact of Cost Display on Ordering Patterns for Hospital Laboratory and Imaging Services

BACKGROUND

Physicians "purchase" many health care services on behalf of patients yet remain largely unaware of the costs of these services. Electronic health record (EHR) cost displays may facilitate cost-conscious ordering of health services.

OBJECTIVE

To determine whether displaying hospital lab and imaging order costs is associated with changes in the number and costs of orders placed.

DESIGN

Quasi-experimental study.

PARTICIPANTS

All patients with inpatient or observation encounters across a multi-site health system from April 2013 to October 2015.

INTERVENTION

Display of order costs, based on Medicare fee schedules, in the EHR for 1032 lab tests and 1329 imaging tests.

MAIN MEASURES

Outcomes for both lab and imaging orders were (1) whether an order was placed during a hospital encounter, (2) whether an order was placed on a given patient-day, (3) number of orders placed per patient-day, and (4) cost of orders placed per patient-day.

KEY RESULTS

During the lab and imaging study periods, there were 248,214 and 258,267 encounters, respectively. Cost display implementation was associated with a decreased odds of any lab or imaging being ordered during the encounter (lab adjusted odds ratio [AOR] = 0.97, p = .01; imaging AOR = 0.97, p < .001), a decreased odds of any lab or imaging being ordered on a given patient-day (lab AOR = 0.95, p < .001; imaging AOR = 0.97, p < .001), a decreased number of lab or imaging orders on patient-days with orders (lab adjusted count ratio = 0.93, p < .001; imaging adjusted count ratio = 0.98, p < .001), and a decreased cost of lab orders and increased cost of imaging orders on patient-days with orders (lab adjusted cost ratio = 0.93, p < .001; imaging adjusted cost ratio = 1.02, p = .003). Overall, the intervention was associated with an 8.5 and 1.7% reduction in lab and imaging costs per patient-day, respectively.

CONCLUSIONS

Displaying costs within EHR ordering screens was associated with decreases in the number and costs of lab and imaging orders.

Impact of price display on provider ordering: A systematic review

BACKGROUND

Displaying order prices to physicians is 1 potential strategy to reduce unnecessary health expenditures, but its impact on patterns of care is unclear.

OBJECTIVE

To review characteristics of previous price display interventions, impact on order costs and volume, effects on patient safety, acceptability to physicians, and the quality of this evidence.

DESIGN

Systematic review of studies that showed numeric prices of laboratory tests, imaging studies, or medications to providers in real time during the ordering process and evaluated the impact on provider ordering. Two investigators independently extracted data for each study and evaluated study quality using a modified Downs and Black checklist.

RESULTS

Of 1494 studies reviewed, 19 met inclusion criteria, including 5 randomized trials, 13 pre-post intervention studies, and 1 time series analysis. Studies were published between 1983 and 2014. Of 15 studies reporting the quantitative impact of price display on aggregate order costs or volume, 10 demonstrated a statistically significant decrease in the intervention group. Price display was found to decrease aggregate order costs (9 of 13 studies) more frequently than order volume (3 of 8 studies). Patient safety was evaluated in 5 studies and was unaffected by price display. Provider acceptability tended to be positive, although evidence was limited. Study quality was mixed, with checklist scores ranging from 5/21 to 20/21.

CONCLUSIONS

Provider price display likely reduces order costs to a modest degree. Patient safety appeared unchanged, though evidence was limited. More high-quality evidence is needed to confirm these findings within a modern context.

The effect of charge display on cost of care and physician practice behaviors: a systematic review

BACKGROUND

While studies have been published in the last 30 years that examine the effect of charge display during physician decision-making, no analysis or synthesis of these studies has been conducted.

OBJECTIVE

We aimed to determine the type and quality of charge display studies that have been published; to synthesize this information in the form of a literature review.

METHODS

English-language articles published between 1982 and 2013 were identified using MEDLINE, Web of Knowledge, ABI-Inform, and Academic Search Premier. Article titles, abstracts, and text were reviewed for relevancy by two authors. Data were then extracted and subsequently synthesized and analyzed.

RESULTS

Seventeen articles were identified that fell into two topic categories: the effect of charge display on radiology and laboratory test ordering versus on medication choice. Seven articles were randomized controlled trials, eight were pre-intervention vs. post-intervention studies, and two interventions had a concurrent control and intervention groups, but were not randomized. Twelve studies were conducted in a clinical environment, whereas five were survey studies. Of the nine clinically based interventions that examined test ordering, seven had statistically significant reductions in cost and/or the number of tests ordered. Two of the three clinical studies looking at medication expenditures found significant reductions in cost. In the survey studies, physicians consistently chose fewer tests or lower cost options in the theoretical scenarios presented.

CONCLUSIONS

In the majority of studies, charge information changed ordering and prescribing behavior.

'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.

Cost-consciousness among Swiss doctors: a cross-sectional survey

Background

Knowing what influences physicians attitudes toward health care costs is an important matter, because most health care expenditures are the results of doctors' decisions. Many decisions regarding medical tests and treatments are influenced by factors other than the expected benefit to the patient, including the doctor's demographic characteristics and concerns about cost and income.

Methods

Doctors (n = 1184) in Geneva, Switzerland, answered questions about their cost-consciousness, practice patterns (medical specialty, public.vs. private sector, number of patients per week, time spent with a new patient), work satisfaction, and stress from uncertainty. General linear models were used to identify independent risk factors of higher cost-consciousness.

Results

Most doctors agreed that trying to contain costs was their responsibility ("agree" or "totally agree": 90%) and that they should take a more prominent role in limiting the use of unnecessary tests (92%); most disagreed that doctors are too busy to worry about costs (69%) and that the cost of health care is only important if the patient has to pay for it out-of-pocket (88%). In multivariate analyses, cost-consciousness was higher among doctors in the public sector, those who saw fewer patients per week, who were most tolerant of uncertainty, and who were most satisfied with their work.

Conclusion

Thus even in a setting with very high health care expenditures, doctors' stated cost-consciousness appeared to be generally high, even though it was not uniformly distributed among them.

Undocumented drug utilization and drug waste increase costs of pediatric anesthesia care

The present study was performed in order to identify the cost of drugs used without documenting them in the patients' file and the wastage of drugs in a pediatric anesthesiology ward. In a prospective, blinded, observational design, drug utilization of 610 consecutive patients, undergoing an elective or emergency surgical procedure was evaluated. The number of undocumented drugs per 100 requested units and the number of wasted drugs per 100 requested units were computed and multiplied by its corresponding unitary cost. The median undocumented cost was 92.4 US dollars (95% CI 17.2-216.6 dollars) per 100 requested units. Succinylcholine (40 mg/2 mL) was the main undocumented drug; its use was not documented in approximately 50% cases in which this neuromuscular blocking agent was requested. However, rocuronium and nalbuphine had the highest unjustified cost, 770.6 dollars and 847.0 dollars per 100 requested units, respectively. Ketorolac, diclofenac, metamizol, furosemide, methylprednisolone, sodium bicarbonate, and cisatracurium were requested and documented. The median cost of wasted drug was 141.8 dollars (95% CI 55.8-448.2 dollars) per 100 requested drugs. More than 80% of adrenaline, naloxone, flunitrazepam, ephedrine, and cisatracurium were wasted. However, the highest cost of wasted drugs was for ondansetron, cisatracurium, methylprednisolone, and rocuronium. The uncontrolled availability and use of drugs may represent an important amount of resources wasted without any awareness of the staff in a department of pediatric anesthesia.

A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods

Fifteen anaesthetists were observed while providing anaesthesia for 15 pairs of adult cardiac surgical operations, using conventional methods for one of each pair and a new drug administration system designed to reduce error for the other. Aspects of each method were rated by users on 10-cm visual analogue scales (10 being best). The new system was rated more favourably than conventional methods in terms of safety (median [range] = 8.1 [6.8-9.7] vs. 7.1 [2.6-9.3] cm; p = 0.001) and usability (8.5 [5.9-9.4] vs. 7.5 [3.2-9.8] cm; p=0.027). The new system saved preparation time both before anaesthesia (median [range] = 180 [32-480] vs. 360 [120-600] s; p=0.013) and during anaesthesia (10 [2-38] vs. 12 [10-60] s; p=0.009). Prefilled syringes for the new system increased costs by euro 23.00 per anaesthetic (p = 0.041), but this increase is likely to be offset by the potential of the new system to decrease costly iatrogenic harm by preventing drug error.

Nausées–vomissements postopératoires : avantage et coût d’un programme d’assurance qualité. Partie I : en salle de surveillance post-interventionnelle

OBJECTIVES

To report the efficiency and direct cost induced by a quality insurance programme (QIP) aimed to reduce the incidence of post-operative nausea and vomiting (PONV) in the post-anaesthesia care unit.

TYPE OF STUDY

Prospective and descriptive study.

METHODS

The occurrence and treatment of PONV were prospectively recorded in the post-anaesthesia care unit in a standardised file before and following therapeutic recommendations made by volunteers component of a QIP. Prophylaxis was administered to patients according to a score of risks based on the type of surgery and patient characteristics. The real cost induced by this change of practice was evaluated according to pharmacists' accounts over 1 year.

RESULTS

The QIP was associated to a 33.5% reduction of PONV relative risk and a 50% increase in prophylactic treatments. When this reduction of PONV was extrapolated to the total number of anaesthesia over 1 year, this QIP avoided PONV in 770 patients each year. The increase of cost reached 3572 as the cost by patient receiving a prophylactic treatment increased from 0.66 to 1.

CONCLUSION

Despite an increase in the individual cost of PONV prophylaxis, the selection of patients by a "home" score of risk limits the indications of prophylactic treatment. Thus the increase in cost remains in acceptable ranges.

Preferences of Mexican anesthesiologists for vecuronium, rocuronium, or other neuromuscular blocking agents: a survey

BACKGROUND: Several neuromuscular blocking (NMB) agents are available for clinical use in anesthesia. The present study was performed in order to identify preferences and behaviors of anesthesiologists for using vecuronium, rocuronium or other NMB agents in their clinical practice. MATERIAL AND METHODS: The cross-sectional survey was applied at the Updated Course of the Colegio Mexicano de Anestesiología performed last year. Of 989, 282 (28.5%) surveys were returned. RESULTS: Most anesthesiologists were working at both public and private hospitals, performed anesthetic procedures for hospitalized and ambulatory patients, and anesthetized children as well as adults. Respondents did not consider mechanomyography as the gold standard method for neuromuscular monitoring. The T25 was not recognized as a pharmacodynamic parameter that represents the clinical duration of the neuromuscular block. Most answered that vecuronium induces less histamine release than rocuronium, had never used any neuromuscular monitor, did not know the cost of vecuronium and rocuronium, and preferred rocuronium in multiple-sampling vials and vecuronium in either a vial for single or multiple sampling. Rocuronium was preferred for emergency surgery in patients with full stomach only. Almost all of anesthesiologists that conserve the unused drug did it without refrigeration and more than 30% conserve the unused drug in one syringe for further use. CONCLUSION: Vecuronium was preferred for most clinical situations, and the decision for this choice was not based on costs. Storage of unused drugs without refrigeration in a single syringe for purpose of future use in several patients represented a dangerous common practice.

Drug wastage contributes significantly to the cost of routine anesthesia care

STUDY OBJECTIVE

To complement previous studies that employed indirect methods of measuring anesthesia drug waste.

DESIGN

Prospective, blinded observational study.

SETTING

Operating rooms of a single university hospital.

SUBJECTS

Anesthesia providers practicing in this setting who were completely unaware of the conduct of the study.

MEASUREMENTS

All opened and unused or unusable intravenous (IV) anesthesia drugs left over at the end of each workday were collected over a randomly selected typical 2-week period.

MAIN RESULTS

166 weekday cases were performed. Thirty different drugs were represented in the 157 syringes and 139 ampoules collected. Opioid waste as well as opened vials that became outdated were counted in the tally. Based on actual hospital drug acquisition costs, $1,802 of drugs were wasted during this 2-week period ($300/OR), amounting to an average cost per case of $10.86. On a cost basis, six drugs accounted for three quarters of the total wastage: phenylephrine (20.8%), propofol (14.5%), vecuronium (12.2%), midazolam (11.4%), labetalol (9.1%), and ephedrine (8.6%). Because incompletely used syringes or vials that were discarded in the trash were not measured in this analysis, the results may underestimate the total cost of drug wastage at this institution by up to 40%.

CONCLUSIONS

The results of this study are similar to those of previous studies that employed electronic record keeping techniques to calculate drug waste. Intravenous drugs that are prepared but unused may be a significant cost of intraoperative anesthesia care. Methods to reduce the amount of drug wasted are proposed.