TITLE: COST EFFECTIVENESS OF AN ACUTE PAIN SERVICE (APS)

AUTHORS: Gerhard Brodner, MD, PhD, T. Mollhoff, PhD, H. Buerkle, MD, C. Goeters, MD, M. Grosse-Hartlage, MD, H. Van Aken, PhD
AFFILIATION: Westfälische Wilhelms-University of Munster, Münster, Germany.

INTRODUCTION: The APS combined patient controlled epidural analgesia (PCEA) with early extubation to improve postoperative recovery and reduce stay on intensive care units (ICU) (1). Patients with contraindications received patient controlled intravenous analgesia (PCIA). A documentation system was implemented to analyze cost- effectiveness.
METHODS: PCEA catheters (n=5602) were placed into the center of affected dermatomes. Postoperatively patients received a continuous infusion of bupivacaine 0,175% or ropivacaine 0.2% and 1µg sufentanil/ mL, which was combined with patient-controlled bolus doses of 2mL every 20 minutes. Patients >70 years had no sufentanil. For PCIA (n-634) a bolus of 7.5-15 mg piritramide was administered and a demand bolus was set to 2 mg every 10 minutes (limit/h: 8 mg). The APS adjusted PCEA and PCIA to dynamic visual analogue scale (VAS, 1-no pain; 100- worst pain possible) scores<=40. Side effects were recorded and treated.
RESULTS: Demographic data: mean age=50.5 years, gender=57.3% male, ASA status: I=18.6%, II=42.3%, III=35.9%, IV=3.2%. 49.8% underwent major surgery. Pain relief, vigilance and satisfaction were superior with PCEA (Fig.1, Fig.2, Tab.1). Although no patient required respiratory support a more frequent decrease of respiratory rate (8-12 breaths/min) was observed with PCIA, which additionally resulted in more sedation and nausea (Tab. 1). PCEA required more attention by the APS due to technical problems: PCEA-19.4%, PCIA=10.9%.

*p<.05; **9<.01

Treatment by the APS resulted in costs of 509.580 EURO per year (staff: 1.5 physicians: 79.200; on call service: 150.000; 1 nurse: 36.000 S :260.200 EURO; disposables and drugs: 249.380 EURO). These costs are opposed by savings of 637.000 EURO per year due to reduction of stay on the intensive care unit with PCEA and early extubation as compared to the traditional regimen (Tab. 2)

DISCUSSION: Introduction of the APS resulted in optimal care and cost reduction.
REFERENCES:

1. Brodner et al. Anesth Analg 1998;86:228.34.