13. The ‘C’ Word

Even when there’s overall agreement a proposed intervention will improve patient safety there’s one word which can stop its implementation.

This word is most often used by those in authority – in accepting the intervention they’ll need to accept the previous way they presided over wasn’t as good.

The ‘C’ word, “COST” will be vocalised in defence of the status quo – those uttering it won’t have really assessed the financial loss in not introducing the safety intervention.

The World Health Organization has a rule of thumb: Three times per-person income per quality-adjusted life year gained is a cost-effective intervention. In the U.S. per-person income is about $40,000, so an intervention that costs less than US$120,000 per quality-adjusted life year would be considered cost-effective (see here).

The healthcare dollar is finite and we must strive to minimise expenditure. However often in introducing a safer piece of equipment this may lead other suppliers to develop similar products driving the market price down.

Further we must consider the cost of not adopting safety interventions. In general, literature shows 4-17% of patients experience adverse events, whereby 44-50% of these events are preventable. It is estimated that human error accounts for 70-80% of these incidents resulting in billions of dollars of loss each year and countless deaths and injuries (see here). Improving the human-system interface should decrease costs and reduce the number and severity of injuries.

In the US the estimated direct costs from adverse events for the public health care sector per year appear to be USD 37.6 to 50 billion, or about 4-6 percent of health expenditure (see here). However these healthcare costs only represent about 22% of societal costs – societal costs take into account factors such as loss of hours worked by the patient and their relatives.

An extensive literature search performed by the European Commission on patient safety practices revealed no cost inefficient programmes, and only one cost-neutral program (see here). One might take from this that any patient safety intervention understood to be effective is highly likely to be cost efficient.

How should we assess the cost effectiveness of a specific intervention?

Let’s take an example. Recently we questioned whether a laryngoscopic device which allows both video and direct laryngoscopy (VL&DL) should be used first line (see here). This is instead of the common practice of using a direct laryngoscope (DL) and in the event of failure, which is infrequent, using a video laryngoscope (VL).

The particular VL&DL discussed requires disposable blades which are purchased at a comparative price to the disposable blades of a direct laryngoscope. However the VL&DL handle costs $2000 compared with the handle of a direct laryngoscope which costs $100 – a cost difference of $1900.

I’ve bought a VL&DL device and use it for all my laryngoscopic intubations – have I wasted my money?

I’m confident no other laryngoscope will perform better in my hands allowing me to attempt laryngoscopic intubation only once, success or failure.

One might point out that a video laryngoscope can be reserved for first line use in cases deemed to be difficult. Using a VL&DL first line makes this honed skill superfluous.

Our ability to assess airway difficulty may not be as great as we believe. One large cohort study in anaesthesia of 3991 difficult airways demonstrated that 93% were not predicted in advance, and of airways predicted to be difficult only 25% were (see here). Further airway management events may be more frequent than we realise. This excellent prospective review over 2 months by Hans Huitnik performed in a busy 16 operating theatre tertiary referral hospital revealed an event rate of 5.9% (2.5 cases per day) with 0.86% severe events (see here). Improved intubation environments may help decrease the economic burden of these events.

Cost savings from using the VL&DL first line may be attained through:
Saving time
– versus those cases where 2 different laryngoscopes used
– airway manipulation can be viewed by the support staff
– reduced number of attempts at laryngoscopy
– trainees attempts can be more easily visualised
– shorter time to declaring that attempts at laryngoscopy have succeeded or failed
Decreasing adverse event rates
– dental damage
– airway trauma
– failure to intubate leading to catastrophic airway loss and death, hypoxic brain or other organ injury, surgical airway (social, psychological, physical repercussions)
– distraction (decreased focus on other activities may increase error risk elsewhere)
– physical and emotional stress to staff members.
Other factors to consider
– improvements in staff morale from introducing an innovative device which makes airway management simpler and more efficient and effective. Supports a forward thinking culture where other similar safety innovations are more likely to be introduced.
– resonates a message to others – ego is not getting the better of staff members. There is a greater focus on human factors, doing the best for each and every patient.
– societal costs e.g. loss of work hours for patients and relatives for dental care following trauma from a direct laryngoscope which may have otherwise been avoided.

Further specific case reports may help illustrate the potential cost savings to be made:

With the benefit of hindsight it is very easy to be critical of this case (one could easily state that with any morbidly obese patient with Mallampati 4 score the VL should be checked and available – note there were no other indicators of airway difficulty). A retrospective view and claim of staff inadequacy will do little to stop the same situation occurring at the hands of another staff member, at another hospital at another time. However if we look at this case going forward and a VL&DL device was used first line for every patient perhaps this story may have been very different. The current cost per minute of theatre time in NSW is A$150. If intubation had been successful first time we are looking at a massive cost saving. Perhaps avoiding this one case alone may have payed for five or more VL&DL devices.

All this being said we should note the mark up on video&direct laryngoscopes is often excessive and welcome other quality manufacturers to the market (see here).

However I don’t believe my money has been wasted and strive to provide to others the patient safety benefits I’ve been afforded.

Another example of where the term COST is often used to stifle change in anaesthesia is with the drug Sugammadex. This retrospective single centre review from Italy (see here) assesses the cost effectiveness from avoiding adverse events through using Sugammadex. Their efforts have likely resulted in ready availability of Sugammadex creating a safer front line work environment for patient care. Perhaps we would be wise to emulate their work in other areas where cost is used as a barrier to change improvement.

If one offers a valid safety solution yet someone in authority utters the ‘C’ word reply with the discourse it deserves.

The cost of doing the best for every patient – priceless.

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