title: Limiting the accessibility of cost-prohibitive drugs reduces overall anesthetic drug costs: a retrospective before and after analysis.
abstract: OBJECTIVE
  Cost effectiveness is becoming increasingly important in today's healthcare environment. Remifentanil, dexmedetomidine, and desflurane are costly agents that often have suitable alternatives to their use. We sought to identify changes in cost and outcomes following interventions that limited the availability of these drugs.
  
  
  METHODS
  We calculated anesthetic drug costs for all operating room procedures performed before and after the accessibility interventions. We retrospectively compared drug costs per case and the frequency of agent use before and after the interventions. In addition, we analyzed the incidence of adverse outcomes, including delayed out-of-room times, postoperative nausea and vomiting (PONV), unplanned intubations, use of naloxone, and reintubations. Wilcoxon-Mann-Whitney and Chi square analyses were used to quantify differences in cost, use, and outcomes between cohorts.
  
  
  RESULTS
  Of the 27,233 cases we identified, 24,201 cases were analyzed. The mean anesthetic drug costs per case were significantly lower after the interventions vs before at ($21.44 vs $32.39, respectively), a cost savings of $10.95 (95% confidence interval, $9.86 to $12.04; P < 0.001). Additionally, a comparison of data after vs before the interventions revealed the following results: remifentanil use was significantly lower (3.5% vs 9.2% of cases; P < 0.001). Dexmedetomidine use did not differ significantly (0.4% vs 0.5% of cases; P = 0.07), and desflurane use was significantly lower (0.6% vs 20.2% of cases; P < 0.001). There was no significant relationship between the interventions and the frequency of delayed out-of-room times (15.5% vs 15.9%; P = 0.41), unplanned intubations (0.02% vs 0.03%; P = 0.60), and reintubations (0.01% vs 0.03%; P = 0.28). Postoperative nausea and vomiting decreased significantly after the interventions (22.8% vs 24.4%; P = 0.003), and naloxone use showed a significant increase (0.22% vs 0.11% of cases; P = 0.04).
  
  
  CONCLUSIONS
  Reducing the accessibility of these cost-prohibitive agents resulted in significant anesthetic drug cost savings and decreased utilization of remifentanil and desflurane. The interventions had no significant effect on patient recovery time, incidence of unplanned intubations, or incidence of reintubation, but they were associated with a decrease in PONV and an increase in naloxone use.
authors.affiliation: Vanderbilt University School of Medicine, 2215 Garland Ave, Nashville, TN, 37232, USA, ariana.k.tabing@vanderbilt.edu.
authors.forename: Ariana K
authors.initials: AK
authors.lastname: Tabing
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Ehrenfeld
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Wanderer
mesh_terms: D000328:Adult; D000368:Aged; D000762:Anesthesia Recovery Period; D000777:Anesthetics / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D003362:Cost-Benefit Analysis; D000077335:Desflurane; D020927:Dexmedetomidine / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D016527:Drug Costs; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D007530:Isoflurane / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000191:economics; D008297:Male; D008875:Middle Aged; D009270:Naloxone / Q000008:administration & dosage; D010880:Piperidines / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D020250:Postoperative Nausea and Vomiting / Q000453:epidemiology; D000077208:Remifentanil; D012189:Retrospective Studies
chemical_list: D000777:Anesthetics; D010880:Piperidines; D009270:Naloxone; D020927:Dexmedetomidine; D000077335:Desflurane; D007530:Isoflurane; D000077208:Remifentanil