Realistic and Unrealistic Direst Costs in Pharmacoeconomic Anesthesia Studies A

Introduction: Multiplicity of anesthetic services and practice consume few resources individually, but collectively, they mean signifi cant cost. Economic and pharmacoeconomic studies are done in order to rationalize resources. Aim: 1. To calculate the direct expense in anesthesia and reanimation; 2. To compare expenses to the price of anesthesia according to the unit prices of National Health Insurance Fund (NHIF); 3. To compare the duration of general anesthesia with costs in anesthesia departments. Methodology: This paper is a part of the retrospectively-prospective academic study of fourth phase carried out in the Clinical Center of Serbia. With permission of Ethical committee, we have set for 2005 and 2006, the direct cost of 148.876 anesthetic services in 11 departments of Clinical Center of Serbia as tertiary-type institution of medical health care. Research group included all patients of both sexes, children and adults. We compared the direct cost per minute of general anesthesia with average duration of anesthesia in every anesthesia department of surgical clinics. The direct cost was compared with the same, ‘unit’ prices of NHIF. The direct cost was compared with the same, ‘unit’ prices of RHIF. We have used linear and regression statistical product and service solutions model for component cost analysis /SPSS 15/. Results: Most budget resources are selected for the employees’ sallaries (40%), then the medicines and supplies (31,80%) and the other expenses including the analysis and analytic devices (28,20%). Direct costs indicate a linear correlation and statistically marked diff erence p=0,012, F=9,270 compared to anesthesia duration indicating the coeffi cient of correlation r=0,694. Direct costs are highest considering longest segment of anesthesia. We have obtained linear correlation R=0,706 for direct costs excluding the neurosurgical anesthesia with ‘unit prices’of anesthesia and anesthetic services indicating F=9,951 and p=0,01. Conclusions: Anesthesia and anesthetic services show statistically signifi cant and fi nancially signifi cant correlation with the direct costs and duration of anesthesia within different surgical specialties. Cosidering direct costs, only the costs of anesthetic drugs and materials are realistic, and all other elements are determined by law and by contract with NHIF. Other costs, out of the direct costs group shall be theoretically reduced by running the analyzes required for anesthesia and for the planned surgical intervention in primary health care protection. Data base related to surgical data and better computer programs able to monitor multiple parameters during hospital treatment, could determine more precisely the value of anesthetic services.


INTRODUCTION
In modern time, the progress of medical knowledge and technology brings new and more effi cient methods of the treatments in relation to the standard, but more expensive treatments.Health care costs are thus increasing more rapidly than the gross national product of many countries.Economic and pharmacoeconomic assessments are made for the purpose of rationalization of medical resources.
Anesthesiology and resuscitation are the results of primordial human need to alleviate or cause loss of pain, both during the illness and during surgical interventions.As a separate unit within the surgical discipline, anesthesiology, and resuscitation, developed the specifi c principles for each surgical discipline in addition to general principles.Anesthesia, intensive care units (ICU) and the treatment of pain are the courses of developed anesthesiology and resuscitation.Th e safety of patients and the risks of anesthesia, pose just alike high levels of risk to surgical disciplines [1,2].Biochemical and chemical analysis, electrocardiogram and lung x-ray are necessary for anesthesia, due to the assessment of the optimal state of patients' health and the risk of running the anesthesia.Anesthesiology involves diagnosis and treatment of most diseases, primarily surgical, but also cosmetic surgery in healthy people.However, in particular, it doesn't cure any diseases.In economic studies, anesthesiology and Resuscitation are displayed as part of the clinical support in surgery.Anesthesiology is a service organized by the departments of anesthesiology and resuscitation in its master clinics.In secondary and tertiary health care protection during hospital treatment it is the responsibility of anesthesiologists.
In Serbia, the economic structure of anesthetic work is based on data for collection charges of anesthetic services for National Health Insurance Fund (NHIF) which raises and distributes funds to the hospital management.Anesthetic services are fi scally warranted by three groups.Th e fi rst group includes diff erent types of general anesthesia, the second includes various techniques of local anesthesia and the third group includes following anesthetic procedures: anesthesia, analgesia, sedation, analgosedation, controlled hypotension in the ICU, canulation of the central arterial and venous blood vessels, etc. Price list of medical services, and anesthesia was regulated by the Council of the NHIF in the Belgrade in 1990 and it is regularly adjusted [3].Modern regulations, in accordance with European are the nomenclature of health services at the secondary and tertiary level of health care protection in addition to the Regulations on the prices of health care services at the secondary and tertiary levels implemented in 2014 [4,5].
In foreign literature, anesthetic work is measured by the number and duration of anesthesia and is defi ned as the sum of the basic anesthesia unit and the unit of time divided by the total hours of anesthetic work [6,7,8].Longer anesthesia, compared to the shorter anesthesia is considered as factor negatively infl uencing the cost of treatment, as thus increasing the cost of anesthesia.Th erefore, we compared the duration of anesthesia with direct costs.Price does not always correlate with the actual expanses [9].Th e aim is fi nancing of the expanse based on real consumption of resources such as medical staff , knowledge, time, facilities and equipment for each service.
Medicines, medical supplies and appliances are real, visible costs required to be purchased from the pharmaceutical and concomitant industries.Th ese costs are easy to be controlled and checked by those who allocate funds for this purpose and/or use them in their work.
Direct medical costs are costs of the medical procedure.Direct medical costs can be divided into direct expenses of treatments such as doctors' and nurses' payrolls -personal expenses; medicines, non-medicinal supplies, medical, laboratory analyzes and the necessary anesthetic apparatus; hospital day in the ICU as the responsibility of the anesthesiologist, and direct costs of non-health services.Direct non-medical costs include the costs of transport of patients to the hospital and back, but rarely are calculated because the anesthesiologist's work begins with a secondary level of public health.
Indirect costs relate to loss of patients' salaries due to illness, disability or death, if the cost analysis is viewed from the aspect of general population.
Average costs are obtained by dividing the total direct costs of anesthetic services with the total number of applied anesthetic services.
Non-material costs relate to psychological aspects of disease or the therapy, e.g.Discomfort, pain and suff ering although, non -material costs are rarely counted in practice due to obstacles in real numeration of cognitive characteristics.
Marginal costs include costs of additional emergency units.Discounting is an economic term meaning the time advantage and represents in this study a clear actual value of anesthesia.Spending resources and benefi ts in treatments do not happen at the moment and there is time gap between costs and eff ects.Th e discount rate is the contractual category, distinguished by states and greatly infl uenced by infl ation means.
Researches [10,11,12] indicate that the direct costs are mostly infl uenced by the fallowing facts: general condition of the patients, degree of urgency, types and levels of anesthesia procedures, personnel expense, consummation of anesthetics and other medications required for the use of anesthesia and/ or resuscitation, their cost of medical and non-medical materials etc. Th e time required to perform anesthetic services consumption of drugs and the number of hospital days in the ICU, are parameters that increase direct costs [13,14,15].For anesthesia, most frequently applied once, direct non-medical costs and the costs of the hospital, as well as the indirect costs are not signifi cant due to reduced working ability.

THE AIM
According to the existing methodology: 1.To calculate the direct expense in anesthesia and reanimation; 2. To compare expenses to the price of anesthesia according to the unit prices of RFZO; 3. To compare the duration of general anesthesia with costs in anesthesia departments; Personnel costs were calculated as the sum of the gross amount of salary per year, part-time employees, the anesthesiologists having 40 hours of overwork and anesthetists with secondary school qualifi cations and with two-year post-secondary school qualifi cations without overtime (work shift s).Personnel expenses are a fi xed cost because they are calculated according to a Regulation on the coeffi cient for the calculation and payment of salaries of employees in public services [16].Th e personnel costs do not include costs of administrative functions, teaching, Academic Positions and professional titles, continuous training and overtime nurses.Personal incomes of part-time employees were not taken into account.

METHODS
Drugs used in anesthesia were as following: general and local anesthetics, analgesics, antidotes analgesics, and benzodiazepine, muscular relaxants, adrenergic agents, solutions (replacements for blood transfusion), solutions for intravenous administration for parenteral nutrition, electrolytic imbalance, electrolytes etc. Blood transfusion expenses and application of antibiotics were not included for departments of anesthesia and the ICU, but are counted as surgical intervention expenses [17].Materials comprised endobronchial and the other tubes inserted to the airway, aspiration catheters, soda-lime, syringes, needles, gloves, and electrodes for ECG, patches, gauze, bandages, disinfectants, etc.
Th e necessary analyzes for anesthesia included: biochemical (blood count, glucose, urea, electrolytes and urine) hematologic (blood type, prothrombin time, partial thromboplastin time), radiologic (x-ray and lung) and electrocardiogram.Th e costs were valued as the single amount of RSD 2044 or EUR 26.Services such as cardiology, hematologic checkups etc. were not included.Medical equipment used in anesthesia included: apparatus for anesthesia, respirators, cardiorespiratory function monitors, defi brillators, bronchial aspirates, laryngoscopes, masks, intravenous pumps for intravenous administration of drugs, etc.

RESULTS
Th e authors present direct costs of anesthetic services in 2005 and 2006 including all operated patients in the anesthesia departments of the surgical clinics in the Clinical Center of Serbia (CCS).Research groups included all patients of both sexes, children and adults (Table 1).
Average hospital day in ICU under the anesthesiologist's responsibility are presented in Table 3.
Th e diff erence in the number of operated persons, operations and anesthesia services is interpreted by the number of surgical re-interventions and by needed anesthesia services.Operations done in UC are considered as emergency operations and anesthesia.Emer-

Direct costs and "Unit prices" of NHIF
Th e distribution of direct cost elements in the departments of anesthesia and 'Unit prices' is shown in Table 4. Direct costs were the highest in the EC departments of anesthesia (28%), gynecol-ogy and obstetrics (11,63%), cardiovascular diseases (11%), general surgery (8,76%) and in all others were lower.
Cumulative direct costs are shown in Table 5 in percentages for 2006.
Analysis of direct costs has shown that salaries require most resource spending, followed by biochemical analysis, hematologic analysis, drugs, and devices of minimal expenses.
Cumulative Obtained diff erences in direct costs (Tables 5 and 6) are the monetary policy of defl ation in 2006 compared to 2005 by 9%.Defl ation is the opposite of the concept of infl ation and marks a reduction of banknotes in circulation and thereby raising the purchasing value of money.Defl ation policy is combating infl ationary tendencies by disinfl ation reduced to the extent considered as regular value [18], but that does not mean that the fi nancial position of citizens and health care system is in better position.

Other costs
Th e cost analysis of anesthesia in 2006 were 26% and only 2 % for devices.Th ese costs are higher for 42% compared to 2005 due to the acquisition of new devices necessary for anesthesia (Table 4 and 5).All medical devices for anesthesia have certifi cates for use and must be serviced once a year, if necessary even earlier.

General anesthesia average time
Average time of general anesthesia in the operating theaters at surgical clinics is show in Table 7.
Traditionally, longest average time of general anesthesia was noticed in the fallowing departments: anesthesia departments, Neurosurgical, Cardiovascular and Pulmonary Clinic, noting that only a decade ago began rapid technological development in terms of the transition.Since then, more recent techniques and methods are applied in surgical procedures and materials (endoscopes, stents, etc.), signifi cantly reducing the duration of general anesthesia.
We have proven the correlation of direct costs in anesthesia departments in its parent surgical clinics with average duration of general anesthesia (Figure 1).Direct costs indicate a linear correlation and statistically marked diff erence p=0,012, F=9,270 compared to duration of anesthesia with coeffi cient of correlation R=0,694.Direct costs are the highest in longest duration of anesthesia.
We have obtained linear correlation between direct costs as R=0,706, 'unit prices' of anesthesia and anesthesia services as F=9,951 and p=0,01 (Figure 2), excluding the neurosurgical anesthesia.
We attempted, according to available data, to determine the direct costs of Anesthesiology and reanimation as soon as possible.
Realistic and transparent costs include medicines, medical supplies and devices because they have to be purchased from pharmaceutical and other medical companies.Th erefore, they are exposed to constant checking and demanding for reduction of costs by those allocated for this purpose and/or using them in their line of work, administration and Government.Personnel and other costs are contract categories not suffi ciently distinctive and transparent so we consider them as unrealistic costs.
Obtained results of the direct costs in anesthesia have shown that the personal in-come amounted to 40%; drugs and supplies to 31,80 % and other costs to 28,20% of resources.
Personnel costs are higher due to labor of clinical doctors, experts and academics, past work, teaching positions and Continuous Education, which were not considered.It would not be properly compared with other countries due to the diff erence in our methodology of calculating personal income per performance, lists of patients, payment categories etc.Other studies show that the personal costs of anesthesiologists without nursing staff amount to 30% of costs [20].According to our methodology of calculating, personnel costs were higher for larger stuff of anesthesiologists and anesthetists.Being for decades in the transition, it would not be appropriate to comment further reduction in personal incomes as a possibility to reduce the medical treatment costs.
Internationally accepted method of defi ned daily doses-DDD and Anatomic Th erapeutic Classifi cation-ATC of drugs registered in Serbia was used for researching anesthetic and other types of drugs consumption.DDD is mainly expressed in weight values of active substances 20.General and local anesthetics, muscular relaxants and i. v. solutions as well as some other drugs, do not have an established DDD and hence, it is recommend to provide alternative way of displaying the data in unit doses or single doses.Some of the characteristics of anesthetics and other drugs used in anesthesia are: non-repetitive applications, the simultaneous use of multiple group of strong eff ect drugs, various individual doses of the same drug (introduction and maintenance of anesthesia), exclusively intravenous or inhalation drug use, continuous intravenous and inhalation anesthetics application, muscular relaxants and other drugs using inhalation pumps or infusomats etc. Th e same drugs can be administered preoperatively, operatively and postoperatively.Dissolved drugs have limited preservation ability.
Th e studies have shown that the consumption of resources for anesthetic agents and other drugs used in anesthesia are the largest in EC, including 5,93% of the resources of drugs in the CCS, and in accordance with other studies (5%) [21].Higher consumption of drugs was registered in the internal and surgical services [22].
Th e costs of inhalation anesthetics were 22,3%, intravenous 16,6% and of muscular relaxants 14,9%.Local anesthetics consumption included 1,2% of the funds for anesthetics and other drugs used in anesthesia.We do not intend to infl uence the selection of drugs that would aff ect the quality of anesthesia, but to provide prices of latest drugs as modern standard drugs for anesthesia.From the group of inhalation anesthetics, halothane, which has been in use for more than half a century gave way to newer, Sevorane, with a price that is 240 times greater than the cost of a halothane.In the group of intravenous anesthetics, etomidate was present 10 times less than the propofol and was three times cheaper than propofol.
We believe that the small resource savings are possible by reducing supply costs but not by the choice of anesthetics that would aff ect the quality of anesthesia.According to other studies, savings could theoretically be achieved by using local anesthesia whenever possible, then the techniques of anesthesia with low fl ow gases and using cheaper inhalation anesthetics [23,24,25,26].Th e resulting costs of medical and non-medical supplies are less than 3% not representing the real consumption due to imprecise distributions in the departments of surgical clinics.Another study states that the cost of supplies amounts to 2-10% of total costs [27].
Th e costs of laboratory analysis and devices are calculated only once for the anesthesia, but the analysis is repeated multiple times during anesthesia for urgent and highly specialized surgical operations and in the ICU, additionally increasing these costs.
Th e costs of supplies, maintaining and amortization of anesthesia devices, ventilator and monitoring are minimal.If purchase price would be included, the direct cost would be increased up to 10%.Th e research results show that anesthesiologic equipment was scantily restored, unevenly and oft en unalotted as distributed in departments of anesthesia.Certifi cates of devices are regularly updated on the annual bases.Some modern technological solutions are applied in certain departments of anesthesia, such as monitoring patients' wakefulness in anesthesia by bispectral index.According to our opinions, the methodology of calculation of service costs, amortization of equipment and facilities is unconvincing although the study suggests that it is better to count services cost per square meter ( m2 ) than per patient [22,27].
Our results [13][14][15][28][29][30] do not indicate the possibility of further reducing costs and show a highly signifi cant correlation of personnel costs, consumption of anesthetics and direct costs.Th e reason is disconnection between direct costs and 'unit prices' containing the type of anesthetic technique of specifi c duration, per hour and according to Price list of costs agreed with HIF.Considering direct costs, only the costs of anesthetics, drugs and supplies are realistic while all the other elements are determined by law and by contract with HIF.Other costs from the group of direct costs could be theoretically reduced by running analyzes required for anesthesia and for the planned surgical intervention in primary health care protection system.
Costs are infl uenced by the management of the anesthesia department and ICU as well as a way of fi nancing health care protection system.Economic and pharmacoeconomic assessments put emphasis on the quality of the medical treatments and the potential profi ts for public and individual patients.Resources are distributed at government level.Resources for the community are determined by States, based on gross national income per capita and according to the health index of general population.General population health index is indicated by the general and specifi c rates of morbidity, absence rate and degree of disability.Despite these problems, the economic evaluations of drugs are becoming more popular.

CONCLUSION
-Researches have shown that the salaries consume the largest amount of resources (40%), drugs, and supplies (32%) and other costs less than 28%.-In the context of surgical intervention costs, perioperative anesthesia accounts for 10% (ABC analysis).
-Anesthetics and other drugs used in anesthesia consume less than 5% of the agents for hospital drugs.Price of anesthetics and drugs has received considerable attention, especially cost of the newer, shorter duration inhaled anesthetics, intravenous analgesics and neuromuscular blocking agents.We believe that the small resource savings are possible by reducing supply costs but not by a choice of anesthetics that would aff ect the quality of anesthesia.Drugs and supplies are real costs and all other elements of direct costs are considered as agreed categories.Th e work and care of patients is hardest to cover in cash funds.Th e cost of analysis would be minimized if they were done in the primary health protection system.

Figure 1 .Figure 2 .
Figure 1.Linear correlation of direct costs and anesthesia duration

Table 3 .
The

Table 2 .
Total gency operations were 16% of the total, while 84% are elective or planned surgery and anesthesia.Polyclinic of CCS is a collection of the diagnostic potentials of CCS, specialized medical personnel and equipment of high technology including a number of departments of internal medicine and surgical branches, clinic, medical cabinets and daily hospitals.Services are fi scally freed from a debt very inaccurately in all departments of anesthesia and surgical clinics.

Table 4 .
direct costs for 2005 and 2006 are shown in Table 6 in percentage.Direct costs and Unit price per cent

Table 5 .
Direct costs summary per percent in departments

Table 7 .
Number of medical staff has not changed in 2005 and 2006.Annual salary of anesthesiolo-Personal salary of an-

Table 8 .
Average time of general anesthesia in the minute in department