Key points

Introduction

Surgery costs a great deal of money. Cost should be easy to quantify as it appears to be objective, but determining the exact cost of a procedure is very difficult and almost always subjective. Direct and indirect costs must be considered from the perspective of all parties: the patient, the health care system, the provider, society, and so forth. Analyses cannot be limited to per-case costing from only the purveyor’s perspective. Social costing and the qualitative outcomes of the intervention are critical variables to consider when calculating and comparing cost.

A significant amount of money spent on health care is driven and controlled by anesthesiology. An estimated 3% to 5% per annum comes under the auspices of anesthesia providers through their control of the operating and recovery rooms, and through the supplies and services they consume preparing patients for a procedure, and tending to their aftercare. There are significant cost savings to be had by choosing a regional or local anesthesia technique for plastic surgery procedures, but research to this end is limited. Many advantages with respect to cost are assumed, but lack validation through rigorous evaluation.

Many plastic surgery procedures can be performed under local anesthesia. In fact so commonplace is the use of local anesthesia that practitioners execute a many procedures under local anesthesia without much thought to the implications of the anesthetic technique on outcomes and cost. What constitutes a local anesthetic procedure is subject to debate: Plastic surgery can be performed using direct infiltration, field blocks, nerve blocks, plexus blocks, intravenous regional anesthesia (IVRA), and spinal blocks, and all of these techniques can be supplemented with adjuvant conscious sedation or monitored anesthesia care (MAC). Caution must be exercised when assumptions about cost are made across this variety of techniques.

Plastic surgeons tend to concern themselves less with the cost of an intervention, focusing, rightly so, on outcomes. The literature echoes this sentiment. The percentage of gross domestic product spent on health care is more than 10% for the top 10 spenders worldwide. In the United States this amounts to some US$2.6 trillion per year and about CAN$200 billion per year. In the province of Ontario, Canada’s most populous province, 50% of the provincial budget is allocated to health care and, if unchecked, is projected to increase to 80% of the budget by 2030. Escalation should be expected, based on the technology-driven nature of health care. Every health care provider should be concerned with cost. Resources are not limitless. The implication of the anesthesia technique used on plastic surgery procedural costing is explored in this article, as are future avenues for research planning to this end.

Introduction

Surgery costs a great deal of money. Cost should be easy to quantify as it appears to be objective, but determining the exact cost of a procedure is very difficult and almost always subjective. Direct and indirect costs must be considered from the perspective of all parties: the patient, the health care system, the provider, society, and so forth. Analyses cannot be limited to per-case costing from only the purveyor’s perspective. Social costing and the qualitative outcomes of the intervention are critical variables to consider when calculating and comparing cost.

A significant amount of money spent on health care is driven and controlled by anesthesiology. An estimated 3% to 5% per annum comes under the auspices of anesthesia providers through their control of the operating and recovery rooms, and through the supplies and services they consume preparing patients for a procedure, and tending to their aftercare. There are significant cost savings to be had by choosing a regional or local anesthesia technique for plastic surgery procedures, but research to this end is limited. Many advantages with respect to cost are assumed, but lack validation through rigorous evaluation.

Many plastic surgery procedures can be performed under local anesthesia. In fact so commonplace is the use of local anesthesia that practitioners execute a many procedures under local anesthesia without much thought to the implications of the anesthetic technique on outcomes and cost. What constitutes a local anesthetic procedure is subject to debate: Plastic surgery can be performed using direct infiltration, field blocks, nerve blocks, plexus blocks, intravenous regional anesthesia (IVRA), and spinal blocks, and all of these techniques can be supplemented with adjuvant conscious sedation or monitored anesthesia care (MAC). Caution must be exercised when assumptions about cost are made across this variety of techniques.

Plastic surgeons tend to concern themselves less with the cost of an intervention, focusing, rightly so, on outcomes. The literature echoes this sentiment. The percentage of gross domestic product spent on health care is more than 10% for the top 10 spenders worldwide. In the United States this amounts to some US$2.6 trillion per year and about CAN$200 billion per year. In the province of Ontario, Canada’s most populous province, 50% of the provincial budget is allocated to health care and, if unchecked, is projected to increase to 80% of the budget by 2030. Escalation should be expected, based on the technology-driven nature of health care. Every health care provider should be concerned with cost. Resources are not limitless. The implication of the anesthesia technique used on plastic surgery procedural costing is explored in this article, as are future avenues for research planning to this end.

Are the outcomes equivalent?

Implicit in the comparison of different techniques is the assumption that outcomes are equivalent. General anesthesia (GA) carries the risk of death as well as other major medical complications. There is a wealth of research demonstrating a decrease in postoperative symptoms and complications when local anesthetic techniques are used; similarly, there is a body of literature showing no untoward or obvious increase in surgical complications as a result. However, as risks such as respiratory complications decrease as a result of avoiding GA, the risks directly attributable to the local anesthetic technique must increase. The cost of the treatment of complications incurred, and the savings realized through the avoidance of others, must be factored into the costing equation, thus complicating the problem of accurate allocation.

Lalonde has prolifically published on the use of local anesthesia for plastic surgery procedures. His work also serves as an excellent example of what is required to demonstrate equivalence. In lieu of publishing a case series with no untoward complications, he first demonstrates equivalence in outcomes when different anesthesia techniques are used, and then demonstrates favorable cost and efficiency metrics. This first step of demonstrating outcome equivalence is essential before undertaking cost comparisons.

Costs beyond mere dollars and cents

Many allude to cost without understanding the difference between the modalities of cost analysis commonly used in health care. The standard 4 analyses are :

• 1.
  

  Cost analysis

  
  
• 2.
  

  Cost-benefit analysis

  
  
• 3.
  

  Cost-effectiveness analysis

  
  
• 4.
  

  Cost-utility analysis

The differences must be appreciated in order to interpret research and apply conclusions to clinical practice. The differences are also integral to research design if an economic analytical component is to be included.

• •
  

  Cost-analysis sums dollars spent

  
  
• •
  

  Cost-benefit analysis assigns dollar values to health care output

  
  
• •
  

  Cost-effectiveness calculates the cost of a specific health care end point

  
  
• •
  

  Cost-utility analysis determines the value of an intervention in terms of its qualitative outcome

A common plastic surgery procedure, the flexor tendon repair, can be used to illustrate these differences. A cost analysis would determine the average amount spent on the surgical repair regardless of outcome; a cost-benefit analysis would calculate the cost of a successful repair; cost-effectiveness analysis would calculate the cost of a return to function or any other given end point; and a cost-utility analysis would determine quality-of-life years (QALY) gained through the intervention, allowing the investigator to ascribe a dollar value to each year gained. The utility analysis is the only type of cost analysis that includes the patient’s perception of value in the calculation while allowing for cross-comparison between disciplines. This type of analysis advantageously allows an institution or individual to compare the value of a dollar spent on different treatments. A provider could compare the value of money spent on flexor tendon repairs with the value of dollars spent on breast reduction, and allocate funding to optimize outcomes in terms of QALY.

Compare apples with apples and oranges with oranges

The significant differences between the modalities of cost analyses highlight the pitfalls of making conclusions and business decisions based on the cost research without understanding the calculations that lead to the conclusions. Unfortunately, very few articles in the plastic surgery literature include some form of economic analysis. The same is true of the anesthesia literature, and most research fails to adequately explain the assumptions used that lead to indirect cost allocation. When one reviews articles comparing anesthesia techniques in plastic surgery procedures looking for cost analysis, the search proves thoroughly unsatisfying.

Many plastic surgeons look to the literature to find support endorsing the safety of performing a particular procedure under local anesthesia. Many do so because it is intuitively less expensive or more profitable, they believe it is safer, or they believe that it expedites time to resolution by avoiding the main operating room, while advantageously increasing throughput and profit.

The ability to perform a procedure using a local anesthesia technique advantageously increases the number of available venues for its execution. Procedures classically executed in hospital operating rooms may be performed in an ambulatory minor procedure suite, an operating room, or an examining room. Based on the law of supply and demand, access to multiple venues for procedural execution will ultimately drive down cost in the long run through supply surplus and the commodification of procedural execution.

Caution must be exercised when equating procedures performed in different venues with respect to both outcomes and cost. It may not be possible to equate sterility, lighting, and instrument availability between the office setting and an operating room; it is easier to do so between a dedicated procedure facility or minor procedure suite and an operating room, but the construction of such a venue must be factored into costing, as must the opportunity cost of the lost real estate to the institution or individual. Procedures performed at different venues cannot be assumed as equivalent entities with respect to cost. While some cost allocations will be the same (cost of equipment, drugs, and so forth) many will vary, and this holds particularly true with respect to indirect allocations. The cost of sterilizing instruments, nurse staffing of the recovery room, even utility consumption, will be drastically different when comparing an office procedure with one performed in a tertiary care center. One might intuit that costs are less for office procedures, but a rigorous cost analysis may prove otherwise; a well-run public hospital may have a lower indirect per-case cost allocation than may a high-end private hospital or aesthetic institute. This pitfall limits blanket recommendations based on presumptions as opposed to rigorous analysis.