Nickel and Diming

I read this on Great Z's post and as almost always I agree with his sentiment if not his solutions.

I have always taken my role as a gate-keeper into health care very seriously and so I try with limitations to give the patient not only the best but the most cost effective care. In the scheme of things anesthesiology are not big contributors to hospital costs but ever since I started practice we have had to look at every little cost.

As I mentioned, one of the advantages of getter older is the perspective one gets over practices over the years.

When I started I did my first rotation in pediatric anaesthesiology (the result of this is that to this day, I know the dose in mg/kg of every drug). One of the anesthetists, an older British fellow used what was called the Liverpool technique. This involved 70% N2O, curare, and morphine. No volatile! It was a marvelous anaesthetic from a practitioner point of view; you reversed the muscle relaxant, turned on 100% O2 and the child woke up (or was never asleep?). They all received 0.2 mg per kg of morphine so they were comfortable as well. There was never any hypotension and as the children woke up promptly, laryngospasm was infrequent. What was more significant was the cost. Each case must have cost less than $1 in drugs. The other anaesthetists at the hospital used a similar technique with small doses of halothane.

When I went to the adult hospital for my first adult rotation, the anaesthetist (after admonishing me for trying to figure out the dose of pentothal in mg/kg) chided me for turning on Isoflurane. "You really like the expensive stuff", he said, turning off the Isoflurane and turning on the Enflurane. We of course used Bain circuits with their 5 L flows then.

So it went during my residency. The first time I used vecuronium on a case, the staffman warned me that the patient would sit up during the case. I told him I planned to also put the patient to sleep.

It was the introduction of propofol when we first became aware of costs. I was on staff then at a larger community hospital. Our first attempt at using it was rebuffed by pharmacy, however by sending our bad cop anaesthetist to the next P&T committee, we were able to obtain a rationed supply. Each anaesthetist was rationed to 6 200 mg vials a week. This resulted in a lot of after hours borrowing from other people's carts (we had our own carts there, something I wish I had where I am now) and of course diluting with pentothal to create what I called "President's Choice" propofol. It also lead to the widespread practice of "saving" propofol in syringes or in the original vial until we found out how easily propofol could be contaminated.

Propofol is of course unquestionably better than pentothal for short cases; less so for long cases. It has of course eclipsed pentothal which is actually temporarily unavailable in Canada. Propofol does allow for earlier discharge from recovery room and day surgery however the clinical significance of this is questionable because discharge times are more affected by factors like hospital policy, availability of porters and whether the patients ride home has showed up. In addition savings from shorter stays are only realized if the shorter stay is accompanied by staff reductions.

When I joined the CofE, they were in the midst of a massive cost cutting exercise. The administrative strategy du jour was to give each department a budget which they had to keep within. Therefore our department was responsible not only for our drug and disposable costs but also for the cost of our techs. This was an interesting exercise where we learned that for years our techs had manipulated their shifts to maximize the amount of overtime they got, something that should have been easy to fix but which we never really got a handle on. Drug costs were another matter. Pharmacy was able to give us a monthly figure of how much we spent on drugs which we divided by the number of cases to come up with a cost per case. This was quite rough as cases at the CofE went anywhere from 30 minutes to 30 hours. Our average cost per case varied from $15 to $20 per case. This was something we all strived to reduce although that is the cost of a single suture or 2-3 doses of Ancef.

We subsequently went through decade and a half of very little control in anaesthetic costs during which Sevoflurane, Desflurane, Rocuronium, and Remifentanyl where introduced. Much of the research on Sevoflurane and Desflurane was done during my residency which is when (unlike today's residents) I actually read journals. It was pretty clear to me and to other residents that Desflurane and Sevoflurane were going to be huge busts. Desflurane for example requires a special heated pressurized vaporizer, which Sevoflurane breaks down to toxic metabolites. All this for a recovery time which is statistically but not clinically significantly better than Isoflurane. Despite this, when I go into my room today, I will have the choice of Sevoflurane or Desflurane because we only have room for two vaporizer on our machine and it was too expensive to keep Isoflurane vaporizers which nobody was using around. Des and Sevo are really triumphs of marketing over science. Remifentanyl on the other hand is a huge advance although I remember poo-pooing it. "What is the use of a short acting narcotic," I used to say.

But getting back to Great Z's discussion about how everybody else gets expensive drugs and we don't. This has also been my observation and of course I remember the fights as I outlined above we had to just be able to try out new drugs. This also applies to some anaesthesia drugs and products which other specialties get before us. I remember, as a resident, when midazolam came out, anaesthesia requested it and were denied; then gastroenterology requested it and got it, therefore we also got. The same thing happened with EMLA cream which pediatrics got after anaesthesia was turned down (we soon found out that EMLA is worse than useless). At the CofE, our emergency physicians got rocuronium before anaesthesia did (aside from the spectre of half trained ER docs burning their airway bridges with a non-depolarizer; what an insult to anaesthesia!).

We haven't (yet) come to point of not having propofol, we have as a mentioned temporarily and I suspect permanently lost pentothal. I could certainly see that anaesthesia could be at risk. Even in a country the size of Canada, a corporate bean counter could look at the potential profits to be made by making propofol versus what can be made using the third generation version of Lipitor and decide that maybe they won't make propofol anymore.

Perhaps however the answer is not to demand our own expensive third generation drugs but to ask why we are using what are for the most part unproven and in many cases harmful drugs in place of the old standbys. Take hypertension for example. The Canadian guidelines from 1999 which they have not seen fit to revise state:

1. Initial therapy should be monotherapy with a thiazide
diuretic, preferably at a low dose, a β-adrenergic antagonist
or an angiotensin-converting-enzyme (ACE) inhibitor
(grade A). If the response is inadequate or there
are adverse effects, substitute another drug from the initial
drug therapy group (grade D).
2. Combination therapy, either with a thiazide diuretic
and a β-adrenergic antagonist or with a thiazide diuretic
and an ACE inhibitor, should be used if there is
only a partial response to monotherapy (grade A).
3. If blood pressure is still not controlled, or there are
adverse effects, try other classes of antihypertensive
drugs (calcium-channel blockers, angiotensin II receptor
antagonists, α-adrenergic antagonists or centrally
acting agents) either as monotherapy or in
combination (grade D). Consider possible reasons
for a poor response to therapy, such as noncompliance,
secondary causes of hypertension or interactions
between prescribed treatment and diet or other
drugs (grade D).

So when was the last time you saw a patient on a hydrochlorthiazide for hypertension? Or a beta blocker except when there is some ischemic heart disease. They are usually on about 3 different drugs that you have never heard of (but will soon learn about when you read in the newspaper how that drug has been pulled from the market because it is killing people). Psychiatry is the same. Everybody is on a cocktail of "atypical antipsychotics" all of which have side effects of weight gain. Like we need more obese patients. This has rubbed on onto family practice where these drugs are being prescribed for things like insomnia and anxiety.

Enough of this rant. Like the title says, I used to be disgusted now I try to be amused. It is getting harder.