One of the basic elements of hospital management is budgeting, i.e. planning, execution and control of expenditure of financial resources allotted to hospital activities [1].

The hospital budget is planned for one year and executed by four kinds of units [2]:

1. Task units (TUs) or basic units, which are directly involved in the treatment of patients. Their activity is financed by the National Health Fund (NHF); the financial result is a derivative of the contract value, and the costs incurred. The task units include hospital wards, outpatient clinics, and hospital emergency departments.

2. Cost units (CUs), providing axillary services for TUs. They can also run their own profit activities for patients and external entities. The CUs include diagnostic imaging units, laboratories, endoscopy units, etc.

3. Medical units (MUs) unrelated directly to therapeutic activities, which work for task units, e.g. sterilisation, blood donation, operating theatres.

4. Administrative units (AUs) – hospital administration and management.

Individual units execute their own tasks and budget based on reliable internal information. This is how the hospital current costs are evaluated, expenditures and the real budget for the following period planned and accepted [3]. Monitoring and analysis of hospital costs by the constituting units is the essential element of effective hospital management [4].

The Department of Anaesthesiology and Intensive Therapy forms two separate cost units, i.e. the intensive therapy unit (ITU) belonging to task units and the anaesthesiology unit (CU). 

The costs of ITUs are quite clearly defined. Although there are many controversies regarding the extent and way of financing ITU costs by NHF, there is a well-specified area of ITU basic activities where the individual costs can be analysed in detail.

The costs of anaesthetic activities are defined as costs of a unit providing the auxiliary services for surgical wards. In this extremely general approach, the specificity of anaesthetic activities is not taken into account [5]. 

The surgical wards are mainly concerned with low costs of anaesthetic procedures as these costs burden their budget; at the same time, they expect high quality of services, which the anaesthetic teams are responsible for. Neither the hospital administration nor the employees of surgical wards are interested in the details of anaesthetic activities. The costs of anaesthesia are usually calculated as a percentage of the costs of a surgical procedure or as a percentage of the total costs of the operating theatre. Based on this, the percentage of anaesthetic costs in relation to TU costs, i.e. surgical wards, is calculated.

Such calculations of costs do not include the detailed elements of anaesthetic activities, e.g. the patient’s health condition and risk of anaesthesia, type of surgery and anaesthesia, or duties of an anaesthesiologist outside the operating room.

All the elements mentioned affect significantly the anaesthesia-related costs. Despite the attempts to exclude anaesthetic activities from the total surgical costs in order to manage the costs rationally and calculate them separately, occasionally undertaken by the department of anaesthesiology and intensive therapy, the functioning management patterns are lacking and the hospital administration are not particularly interested in them.

The aim of present study was to describe our attempts to analyse comprehensively the costs of anaesthesia in a multi-profile hospital.

METHODS

The University Hospital in Wrocław is a new institution comprising 837 beds. The anaesthetic procedures are performed in 26 workstations and their number exceeds 1000 a month. Such extensive anaesthetic activities constitute a significant percentage of hospital expenditure.

Until 2009, the costs of anaesthetic activities were traditionally calculated by summing the costs of patient’s stay in the operating suite (the operating theatre and  recovery room). Since January 2009, new principles of anaesthesia-related cost settlements were designed and approved by the hospital authorities. The unit of anaesthesiology became a subject in the structure of task units and the point settlement of anaesthetic activities was introduced. The individual budget of the unit of anaesthesiology enabled to define and monitor the costs incurred for individual anaesthesia-related items, such as drugs, equipment and salaries.

Nine categories of anaesthetic procedures were distinguished and priced in points:

1. Short-term intravenous anaesthesia or sedation with monitoring.

2. Combined anaesthesia for minor surgery in a healthy individual.

3. General anaesthesia for major vascular, urological, neurological, orthopaedic, maxillo-facial, ENT, general and oncologic surgery; ASA IV-V patients, irrespective of the type of surgery, children ≤3 years of age and adults >65 years of age, irrespective of the type of anaesthesia.

4. Epidural and continuous epidural analgesia.

5. Subarachnoid analgesia; patients not listed in point 3.

6. General anaesthesia + continuous epidural analgesia.

7. Total intravenous anaesthesia (TIVA).

8. Anaesthetic surveillance (stand-by) – in the operating room and recovery room.

9. Other anaesthesiological activities not connected directly with the anaesthetic procedure.

The basis for point calculations was a comprehensive analysis of costs of individual categories of anaesthesia in 2008. For instance, in category 2, one hour of anaesthesia was scored 200 pts and each further 30 min – 60 pts. In category 3, one hour of anaesthesia was scored 250 pts and the further 20 min – 75 pts. In the procedure 5, the total anaesthesia equalled 150 pts; the anaesthesia for Caesarean section – 180 pts.

The anaesthetic personnel recorded and summed up the points of procedures for each patient; by the end of each month, the total price of anaesthetic services was scored. The hospital financial services ascribed the Polish zloty values for the particular point sums and charged the individual task units (surgical wards).

In the present paper, we analysed the anaesthesia responsibilities and their costs in the forth quarter of 2008 and compared them with the first quarter of 2010, when the new scoring system was introduced.

RESULTS

Between the forth quarter of 2008 and first quarter of 2010 the number of anaesthetic procedures increased by 20% on average. The increase depended on the organisation of hospital services and changes in the NHF contract and varied in individual departments ranging from 43% in endoscopy and 32 % in laryngology to 7% in neurosurgery (Table 1).

In 2008, the percentage of anaesthetic costs within the costs of surgical wards was calculated on the basis of the work time of the anaesthetic team whereas in 2010 was based on points and increased on average by 12.7%; however, the charges of task units (surgical wards) with the costs of the anaesthesiology unit changed variably (Table 2).

The costs increased due to a higher number of anaesthesias carried out yet in many wards the relation was not proportional, which suggested that other factors were also involved. The comparison of both methods of cost-related calculations showed some correlation yet sometimes varied markedly (Table 3).

The analysis of anaesthesias in individual departments demonstrated what the causes of anaesthesia cost changes were.

In the ENT Department, the costs increased proportionally to the number of procedures. In some departments, despite the higher number of procedures, the anaesthetic costs were clearly reduced. The comprehensive analysis revealed that in the Department of Orthopaedic and Trauma Surgery this decrease was associated with an increase in the percentage of regional anaesthesia and monitored anaesthetic care. In the Department of Neurosurgery, reduced costs at higher number of procedures were related to organisational changes – post-operative patients were admitted to ITU.

The analysis of two departments of general surgery disclosed interesting results. In one of them, the 14% increase in the number of procedures was accompanied by the 8% increase in anaesthesia costs; in the other one, the 22% increase in the number of procedures was accompanied by the 2% decrease in costs. Once the changes were introduced, the decisive factor was the duration of procedures. In one of the departments analysed, the duration of similar surgical procedures was longer.

DISCUSSION

Anaesthesiologists postulate to calculate the costs of their work based on clear and verifiable parameters. For the reasons difficult to define, costs of anaesthetic services are calculated throughout the decade of health care reform as an arbitrarily determined percentage of surgical costs based on various, general and imprecise parameters, e.g. the number of procedures, duration of stay in the operating room, etc.

Such a vague way of cost calculations does not create favourable conditions for control of the quality of anaesthetic services. The detailed evaluation of costs, as in the scoring system suggested in the present paper, enables the analysis of individual elements of anaesthetic care, thus the management changes can be introduced considering the service quality improvement and cost reductions [5, 6]. The possibilities of reducing the costs are multiple; reduced costs can depend on popularisation of regional anaesthesia, routine use of low flow general anaesthesia or shortened time of patients` stay in the recovery room [7]. However, the improvement-related and repair activities will be possible only when all factors affecting the costs of anaesthesia are recognized. The evaluation of treatment costs as a conventional percentage of procedure-related costs does not enable to improve the quality and reduce the costs.

The presented scoring system of anaesthesia costs is only a proposition, which works when the hospital management authorities are eagerly involved. The time has come to formulate the uniform scoring system of anaesthetic services to be accepted as a standard method of cost calculations by the National Health Fund.

CONCLUSIONS

1. The point system of scoring anaesthetic activities makes it possible to diversify the costs according to the type of surgery and anaesthesia, patient’s condition and activities of anaesthesiologists other than the anaesthetic procedure itself.

2. Costs of anaesthetic activities calculated according to the point scoring system differ from the costs defined schematically as a fixed percentage of costs of the surgical procedure.

3. The new scoring system provides the detailed analysis in individual surgical wards and assessment of the quality of anaesthetic services as well as rational regulation of their costs.

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REFERENCES

1.    Zuckerman HS, Dowling WL: Rola zarządzających; w: Podstawy zarządzania opieką zdrowotną. (Red.: Shortell SM, Kaluzny AD), Uniwersyteckie Wydawnictwo Medyczne „Vesalius”, Kraków 2001.

2.    Luke RD, Begun JW: Opracowywanie strategii w organizacjach opieki zdrowotnej; w: Podstawy zarządzania opieką zdrowotną. (Red.: Shortell SM, Kaluzny AD) Uniwersyteckie Wydawnictwo Medyczne „Vesalius”, Kraków 2001.

3.    Gierusz J, Cygańska M: Wprowadzenie do budżetowania, w: Budżetowanie kosztów działań w szpitalu (Red.: Gierusz J, Cygańska M). Ośrodek Doradztwa i Doskonalenia Kadr, Gdańsk 2009.

4.    Gierusz J, Cygańska M: Koncepcja budżetowania kosztów szpitala w oparciu o ABC; w: Budżetowanie kosztów działań w szpitalu (Red.: Gierusz J, Cygańska M). Ośrodek Doradztwa i Doskonalenia Kadr, Gdańsk 2009.

5.    Macario A, Vitez TS, Dum B, McDonald T: Where are the costs of perioperative care? Anesthesiology 1995; 83: 1138-1144.

6.    Johnstone RE, Martinec CI: Costs of anesthesia. Anesth Analg 1993; 76: 840-848.

7.    Kettler D, Crozier T: Cost-effectiveness of anaesthesia. Curr Opin Anaesthesiol 2001; 14: 569-572.

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address:

*Mirosław Gibek
I Klinika Anestezjologii i Intensywnej Terapii
ul. Borowska 213, 50-556 Wrocław
tel.: 48 71 733 23 10, fax: 48 71 733 23 09
e-mail: office@anest.am.wroc.pl

received: 06.04.2011
accepted: 21.07.2011