This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by Schuster, M. Articles by Standl, T. Search for Related Content PubMed PubMed Citation Articles by Schuster, M. Articles by Standl, T. Related Collections Economics and Health Care Research Anesthetic Techniques Regional Anesthesia

---

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH

A Retrospective Comparison of Costs for Regional and General Anesthesia Techniques

Martin Schuster, MD, MA^*, André Gottschalk, MD^*, Jürgen Berger, PhD, and Thomas Standl, MD^*

*Department of Anesthesiology and Institute for Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

Address correspondence and reprint requests to Martin Schuster, MD, MA, Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Address e-mail to m.schuster{at}uke.uni-hamburg.de.

	Abstract

Top Abstract Introduction Methods Results Discussion Appendix 1. References

 
In this retrospective study, we compared the costs for three different regional anesthesia techniques with the costs of general anesthesia (GA). A total of 1587 anesthesia cases which were performed for orthopedic and trauma patients over a 1-yr period in a tertiary level, university hospital setting were analyzed. The anesthesia technique-related costs were determined calculating case-specific costs for personnel, supplies, and drugs. The techniques were compared on the basis of anesthesia costs and surgical procedure duration. As a result, we found that the costs per surgical minute largely depend on the surgical procedure duration. Based on the regression function, the cost advantage of spinal anesthesia over GA can be estimated to be 13% for a 50-min case, 9% for a 100-min case, and 5% for a 200-min case. The cost disadvantage of brachial plexus anesthesia over GA can be estimated to be 19% for a 50-min case, 8% in a 100-min case, and 1% for a 200-min case. We found no difference in costs between epidural and GA. We concluded that cost comparisons of anesthesia techniques largely depend on the surgical duration of the cases studied. Even in a teaching hospital setting, spinal anesthesia has economic advantages over GA. Especially for short cases, brachial plexus block is more expensive in this setting.

	Introduction

Top Abstract Introduction Methods Results Discussion Appendix 1. References

 
There is still debate regarding the advantages and disadvantages of regional versus general anesthesia (GA) technique. A meta-analysis suggests that regional anesthesia techniques probably reduce postoperative morbidity and mortality (1). However, there have been concerns that regional anesthesia techniques consume too much time to be performed and are hence more costly than GA (2). There have been several studies regarding time and cost aspects of regional anesthesia versus GA for a variety of specific indications including hernia repair (3,4), hand surgery (4), hysterectomy (6), cesarean delivery (7), arthroscopy (8,9), and others. However, most studies have focused only on drugs, supplies, and recovery room costs and neglected the anesthesiologists and anesthesia nurses personnel costs during the case. The effect of case duration on the average cost and on the cost comparison of techniques has not been studied. Our hypothesis was that shorter procedures favor GA compared with regional anesthesia techniques, because the increased time to perform regional anesthesia may outweigh the reduced material and drug costs for regional anesthesia.

We present a retrospective analysis of 1587 anesthesia cases from the orthopedic and trauma service comparing the anesthesia technique-related costs for spinal anesthesia (SPA), brachial plexus block (BPB), and epidural anesthesia (EDA) with those of GA.

	Methods

Top Abstract Introduction Methods Results Discussion Appendix 1. References

 
From October 2002 through September 2003, 3098 anesthesia cases were performed in the orthopedic and trauma service of our hospital. With approval of our Ethics Committee, we retrospectively compared anesthesia technique-related costs for four different types of anesthesia: SPA, BPB, EDA, and GA. To minimize selection bias, we excluded all cases in which there were time delays or increased drugs and supply costs unrelated to the anesthesia technique. The exclusion criteria were: age of patient <18 yr, placement of central venous catheters, arterial lines, Foley catheters, or double-lumen endotracheal tube, use of fiberoptic intubation technique, planned combination of GA and regional anesthesia technique, and cases that were transferred preoperatively or postoperatively from or to the intensive care unit. Because of the typical case mix of a university hospital, approximately 50% of all cases were excluded based on the above-mentioned criteria. The remaining 1587 anesthesia cases were included in the study. Cost analysis was assessed by intention-to-treat. Hence, cases planned for regional anesthesia that required GA because of treatment failure or change in surgical procedure remained in the initial treatment group for the cost analysis.

The anesthesia record system used in our hospital is a scanner-based system. The initial documentation is done on paper but is later scanned and analyzed electronically. Plausibility checks are run on the created file and, among others, the information regarding process times and drugs and supply usage is transferred into the central anesthesia record database. Aggregated data are later transferred to the hospital accounting and controlling database. All anesthesia-related times are documented in the anesthesia record during the procedure by the anesthesiologist in fractions of 5 min. The following time spans regarding staff involvement during the anesthesia cases were extracted from the anesthesia records: patient preparation and positioning by the anesthesiologist before induction of anesthesia (preparation time), anesthesia induction period which ends when the patient is ready to be positioned for the operation by the surgical staff (induction time), the procedure time including surgical positioning and preparation, surgery, and dressing (surgical procedure time), the period after the end of the surgery until the end of the anesthesia (postsurgical time/extubation), and the transfer time to the recovery room (recovery room transfer time). The time definitions used are identical in the whole hospital and the time spans and time points have been agreed upon by all services and the hospital administration. The time documentation in the anesthesia chart is the central time documentation for operating room (OR) management and is used both for statistical and billing purposes. The time the patients spent in the recovery room (recovery room time) was also recorded but not used for the cost calculation. The two services analyzed in this study each have their own recovery room staffed with one nurse. Therefore, the costs for the recovery room are fixed costs and reduction in recovery room time would not necessarily translate in reduced costs. For this reason, we did not include these costs in our calculation.

In Germany, anesthesia nurses do not perform anesthesia by themselves, but rather support anesthesiologists, e.g., during the induction period and prepare medications, medical devices, and anesthesia machines. In our department, in each anesthesia service, two or three residents are medically directed by one attending anesthesiologist. Because residents frequently rotate through the different services, residents with all levels of experience, from first to fifth year, participated in the services during the study period. Personnel costs per case were calculated based on the total case time (begin patient preparation to end recovery room transfer) using average calculatory costs for anesthesiologists and anesthesia nurses in the 2 subspecialty services, based on an average yearly total compensation of 79,200 Euro per anesthesiologist and 53,000 Euro per anesthesia nurse (1 Euro equals approximately 1.20 United States [US] $). The personnel costs used for calculation are the actual average costs for anesthesiologists and anesthesia nurses in our hospital including social security and health insurance. Both anesthesiologists and anesthesia nurses are employees of the hospital.

The calculatory costs were determined dividing the total staff costs per service (including all overtime charges) with the total case time per service during a 6-mo period.

Because the study population reflected the actual clinical practice in our hospital, a large variety of different drugs was used both for GA and for regional anesthesia. There was no major change in practice pattern regarding anesthesia techniques, drugs, or supplies over the study period. However, case mix and patient population might vary over the year both in trauma and in orthopedic cases. We therefore used a full year of data to exclude the influence of seasonal changes. Approximately 60% of the GA group received a balanced anesthesia with isoflurane, sevoflurane, or desflurane as volatile anesthetic and sufentanil or remifentanil as opioids. The remaining 40% received a total IV anesthesia with propofol in combination with sufentanil or remifentanil. Propofol or etomidate were used to induce anesthesia, and rocuronium, cisatracurium, and succinylcholine were used as neuromuscular blocking drugs. Airway management was achieved by intratracheal intubation (70%) or laryngeal masks (30%). Reusable laryngeal masks were used. However, cost for device replacement which occurred during the study period was included in the cost calculation. In most cases with intratracheal intubations a plain tracheal tube was used. Spiral tubes were used for prone, lateral, and beach chair positions. The most frequently used drug for SPA was bupivacaine 0.5%, but in some instances hyperbaric mepivacaine 4% was also used. EDA was always catheter-based and ropivacaine 0.75% or bupivacaine 0.5% was used as the local anesthetic during the operation. BPB was performed as a single-dose technique and a combination of prilocaine 1% and ropivacaine 0.75% was administered. For all regional anesthesia techniques, prepared sets with the necessary equipment were available. In our department, drugs and supplies are neither prepared nor charged separately for each case. Drugs and supplies are used by the anesthesiologists from common storage. However, the use of specific drugs and supplies is recorded on the anesthesia record. For this study, we have retrospectively calculated the drug and supply cost per case using a method that has been previously described for cost calculation for scanner-based anesthesia record systems (10). For supplies, such as spinal sets or endotracheal tubes, the total costs for this supply type during the study period was divided by the number of documented uses for all cases performed in the OR suite during the study period. For drugs, either cost per case (e.g., induction drugs) or cost per anesthesia minute (e.g., volatile anesthetics) was calculated based on the total cost in the OR and the documented use in all cases performed in the OR suite during the study period. The costs for drugs and supplies we used for cost calculation in our study represent the average pharmacy acquisition cost in our hospital for each item during the study period. The department of anesthesiology has to pay for all drugs and supplies used in its service according to these prices. We have added the items used for cost calculation in Appendix 1. Approximately 500 different items of drugs and supplies were used in the two OR suites during the study period. However, very few make up for the vast majority of cost. In the first step, we have therefore identified those items that account for 85% of the total costs for drugs and supplies; the large number of items that accounted for the remaining 15% were not further studied. Economically, the most important drugs and supplies, which accounted for 85% of the costs, were divided into 2 groups: those related to the anesthesia technique (for example, endotracheal tube, volatile anesthetics, neuromuscular blocking drugs for GA and spinal set and the local anesthetics for SPA) and those unrelated to the specific technique (for example, gloves or forced air warming device). For the cost comparison, only the anesthesia technique-related drugs and supply costs were included. For all anesthesia cases included in the study, the personnel, drug, and supply costs were calculated separately. Case-specific costs were determined as cost per surgical minute, dividing the total case costs by the surgical procedure time. We compared the four groups based on the best fit regression lines between surgical duration and anesthesia cost per surgical minute.

The data were extracted from the hospital’s central anesthesia record database (Medlinq®, Hamburg, Germany) and downloaded in a Microsoft Excel worksheet (Microsoft Corp., Redmond, WA) and analyzed with SPSS 11.5 (SPSS, Chicago, IL). If not otherwise stated, mean ± sd are displayed. A P value < 0.05 was considered significant. For the comparison of process times, a Mann-Whitney test was used. Each regional anesthesia group was independently compared with the GA group. Despite using the natural logarithm of cost, the relationship between ln(cost) and duration was not linear. We therefore fitted separately for each of the four anesthesia techniques nonlinear regressions of the general form ln(cost) = a * (surgical time)^b. Based on coefficient estimates and its standard error of mean, we tested whether two regression lines were statistically different or not. The coefficients b contain the information concerning how fast the cost declines with the surgical duration by anesthesia technique. For the decision if the coefficients b_x of SPA, BPB, or EDA are statistically different from the coefficient b_total of GA, we calculated the approximated standard normal distributed test value z = (|b_x – b_total|)/[var(b_total) + var(b_x)]^1/2. The graphical solution help to decide where the differences are most pronounced. However, the nature of this test procedure does not allow any statement regarding any exact point from which one technique is superior to the other technique.

	Results

Top Abstract Introduction Methods Results Discussion Appendix 1. References

 
Of the 3098 anesthesia cases, 1511 had to be excluded based on the exclusion criteria described above. Patient characteristics of the included 1587 cases are displayed in Table 1. Table 2 summarizes the relevant anesthesia time spans. The anesthesia-controlled time, defined as the sum of preparation, induction, postsurgical time/extubation, and recovery room transfer, was similar between SPA and GA. BPB and EDA had almost 50% longer anesthesia-controlled times. The surgical-controlled time also differed considerably among the groups, whereas the recovery room times were quite similar.

Figure 1a–d display the nonlinear regression between anesthesia technique-related costs (calculated per surgical minute) and surgical time for each technique. As described above, the costs were transformed using the natural logarithm and the best fit regression was sought using the general form ln(cost) = a * (surgical time)^b. The direct comparison of each regional anesthesia group with the GA group is shown in Figure 2a–c. The coefficients received for the best fit regression line and the standard error of mean, which are the basis for the statistical testing, are given in Table 3. Also in Table 3, the P values for each comparison between regional and GA technique are displayed. A small but statistically significant cost advantage was found for the SPA group compared with the GA group. Based on the regression function, the cost advantage of SPA over GA can be estimated to be 13% for a 50-min case, 9% for a 100-min case, and 5% for a 200-min case. The anesthesia-related costs for BPB were significantly more than for GA cases. Again, this difference was small and was most pronounced for shorter cases. The cost disadvantage of BPB over GA can be estimated to be 19% for a 50-min case, 8% in a 100-min case, and 1% for a 200-min case. No statistically significant difference was found comparing EDA and GA.

View larger version (32K): [in this window] [in a new window]   Figure 1. Cost regression for each anesthesia technique. Anesthesia costs and surgical duration are displayed for each group separately. Each dot represents one anesthesia case. The anesthesia cost is displayed for statistical reasons as the natural logarithmic of the actual value in Euro per surgical minute. For each group, a nonlinear regression was fitted and the R2 value is displayed.

View larger version (29K): [in this window] [in a new window]   Figure 2. Cost comparison of regional anesthesia techniques with general anesthesia (GA). The graphs from Figure 1 are used for direct comparison of the techniques. As in Figure 1, the regional anesthesia cases have black dots and gray regression lines; the GA cases have gray dots and a black regression line. The costs for spinal anesthesia cases are significantly less than for GA cases, whereas costs for brachial plexus blocks are significantly more than for GA. No significant difference was found between epidural and GA. For details of test statistics, see Methods section and Table 3.

	Discussion

Top Abstract Introduction Methods Results Discussion Appendix 1. References

 
The hypothesis of our study was that regional anesthesia techniques are more expensive for short cases, but are cost efficient for longer cases. Comparing the anesthesia technique-related costs of SPA, BPB, EDA, and GA we found that our hypothesis was true for BPB, but for EDA the cost did not differ from that for GA, and for SPA the cost was less both for short and for longer cases. In general, the cost differences among techniques for longer cases were minimal.

Several issues regarding the study design deserve further comment. First, this study focused only on direct costs. There is no intention to suggest that the techniques analyzed for this issue can be used alternatively in all cases. The three regional anesthesia techniques are very different, and it is obvious that a BPB can never be used alternatively to SPA. Moreover, each technique has specific advantages and disadvantages for particular groups of patients, e.g., with specific comorbidities. Catheter-based EDAs are performed for different purposes in our department in comparison to a single-dose SPA, because the EDA technique is preferentially used in those cases with anticipated postoperative pain management (11). The only link among the three treatment groups is that all are frequently used in clinical practice as an alternative to a GA. Second, our cost comparison is based on retrospective and nonrandomized data. We wanted to study costs in normal clinical practice with regional anesthesia also performed by residents using a variety of drugs because it is still the common practice in many hospitals. Even though our study population was quite large, selection bias regarding the anesthesia techniques used in the different cases might have influenced our results. We took several steps to minimize potential selection bias. We focused only on those costs that could be directly attributed to the anesthesia technique and we excluded all cases that included intrinsically larger cost because of the need of more invasive monitoring or because prolonged preoperative or postoperative time for patient preparation or transportation was required, such as pediatric patients or critically ill patients. This led to a large percentage of excluded cases. The intention in this study was to compare costs in the same sort of simple, uncomplicated, straightforward anesthesia cases. A complex case, such as anesthesia for major tumor limb surgery, in which the patient receives an epidural catheter together with GA and additionally central venous catheters and arterial line are placed, could neither be grouped in the EDA group nor in the GA group. Furthermore, if we would not have excluded all cases with intrinsically increased process times, such as central venous catheter placements or fiberoptic intubations, the process times for the GA would have been much longer. However, we would have compared very different groups of cases.

A variety of time spans were used to calculate cost and measure process efficiency, including induction times (5,6,12), total anesthesia times (3,4,13,14) or OR turnover times (7,8). The different time spans used make comparisons among studies quite difficult. In general, our data from a teaching hospital setting are consistent with published trials that induction periods and anesthesia-controlled time for GA and SPA are similar, whereas EDA and peripheral nerve blocks take longer. In our experience, process times for regional anesthesia techniques are more dependent on the anesthesiologists' skill level than process times for GA techniques. Therefore, it is likely that a cost comparison in a teaching hospital, as in our study, favors GA.

To calculate case-specific costs retrospectively based on the anesthesia record has some limitations because a cost average per documented item is used and not the actual costs, and recording errors might occur. But the cost average approach also has advantages, because the waste of drugs and supplies is already included in the calculated costs. Moreover, anesthesiologists in training are less likely to be as efficient in using drugs and supplies as more experienced anesthesiologists. With the cost-average method, these additional training costs are distributed more evenly among the cases. It is important to keep in mind that all drugs and supplies account for only 22% of the total cost. Half of these costs are not anesthesia technique-related costs, such as gloves, syringes, cell saver supplies, forced air warming devices, and monitoring sets. Because only anesthesia technique-related drugs and supplies were included in the analysis, these drugs and supplies account for only 11% of the total costs in the final analysis. The influence of different methods to allocate material costs will therefore be limited.

We did not include the recovery room costs in our calculation for the following reason: It is very difficult to translate reduction of recovery room times into real cost savings. Recovery room costs are up to 98% personnel costs, which means they are semifixed costs, not variable costs. Peak staffing requirements depend much more on OR scheduling (15) and transport logistics (16) than on recovery room times. Reduction in recovery room times will only have an economic effect in large recovery rooms with many nurses, with a large decrease in recovery room times and an optimized transfer to the wards or, for ambulatory cases, to the step down, predischarge unit. In our hospital, recovery rooms are small and adjunct to the OR suite and we would not expect any economic effect from changes in recovery room times.

It is a general limitation of most cost studies that institution-specific costs for personnel and drugs and supplies are used and these costs might be very different in other institutions and especially in other countries. For example, compared with our cost assumptions, costs in the US are more both for drugs and supplies and for personnel. Based on the costs listed in the published studies (4,7), the drug and supply costs are approximately 30%–50% less in Germany. The total personnel cost for an anesthesiologist in our hospital (including overtime and on-call compensations) is approximately 80,000–90,000 Euro per year, which is less than half of the 200,000–280,000 US dollars for academic and private-practice anesthesiologists in the US. Also, anesthesia nurses earn about 30% less in Germany compared with nurse anesthetists in the US (17,18). However, anesthesia residents and fellows in Germany earn only 10%–15% less than board-certified anesthesiologists, causing more expense for the hospital than their US counterparts (19). In summary, both personnel and drug and supply costs are about 30%–50% less in Germany. But this increased US cost level applies to all techniques in the same way. Because anesthesia technique-related costs account for only 11% of the total costs in the study, only a large shift of these costs would alter the comparison of the techniques. We therefore believe that our conclusions regarding the cost comparison for the different techniques can also be applied in the US.

In our study, the SPA had a cost advantage compared with the GA group, even in short procedures. The reason for this is that the anesthesia-controlled time for the SPA cases was comparable to GA cases. Moreover, the larger fixed costs for induction of GA, such as costs for induction drugs, endotracheal tubes, and neuromuscular blocking drugs, become more pronounced in short procedures. Compared with these fixed costs, the variable costs in short cases are relatively small (20). The BPB technique had longer induction periods. Therefore, this single-dose technique has the expected economic disadvantages in shorter cases. In addition, patients requiring GA because of treatment failures or changes of the surgical procedure increased the cost in this treatment group. The EDA was the smallest of the three groups. More cases had to be excluded from this group, because most patients undergoing total hip and knee replacements, major tumor operations of the lower extremities, or amputations received a planned combination of continuous EDA and GA, with epidural catheters mainly placed for preemptive analgesia and postoperative pain management. These specific indications also explain why the surgical times in the EDA groups were much longer than for the other regional anesthesia groups. No significant differences were found between the cost for EDA and GA, but there may have been too few short cases in the EDA group to see a cost disadvantage of the EDA technique.

Approximately 78% of the total costs were personnel costs. It is important to note that only the smaller part of the total procedure time is influenced by the anesthesiologist—preparation, induction, postsurgical time/extubation, and recovery room transfer time. This has led to the concept of anesthesia versus surgically controlled time (21). There may be considerable differences in induction times using different techniques. However, whether this difference is economically relevant depends largely on the case duration. Moreover, case duration has a direct impact on anesthesia costs. For example, the reduction of the surgically controlled time by 10 minutes in a 100-minute case reduces the anesthesia cost by approximately 7%. The change from GA to SPA in the same case reduces this cost by 9%. However, the important question for clinical practice is which measure can be realized more easily.

Cost aspects should never be the main focus when an anesthesia technique is chosen. However, as cost becomes increasingly important, our study may help anesthesiologists to understand the economic implications of these different techniques.

We thank Joachim A. Wagner, Dpl. Ing., for assistance in data extraction from the central anesthesia record database.

	Appendix 1.

Top Abstract Introduction Methods Results Discussion Appendix 1. References

 

	References

Top Abstract Introduction Methods Results Discussion Appendix 1. References

1. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493–7.[Abstract/Free Full Text]
2. Wattwil M. General or regional anaesthesia: pro general. Acta Anaesthesiol Scand Suppl 1997;110:54–5.[Medline]
3. Kendell J, Wildsmith JA, Gray IG. Costing anaesthetic practice: an economic comparison of regional and general anaesthesia for varicose vein and inguinal hernia surgery. Anaesthesia 2000;55:1106–13.[Web of Science][Medline]
4. Song D, Greilich NB, White PF, et al. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000;91:876–81.[Abstract/Free Full Text]
5. Chan VW, Peng PW, Kaszas Z, et al. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis. Anesth Analg 2001;93:1181–4.[Abstract/Free Full Text]
6. Tessler MJ, Kardash K, Kleiman S, Rossignol M. A retrospective comparison of spinal and general anesthesia for vaginal hysterectomy: a time analysis. Anesth Analg 1995;81:694–6.[Abstract]
7. Riley ET, Cohen SE, Macario A, et al. Spinal versus epidural anesthesia for cesarean section: a comparison of time efficiency, costs, charges, and complications. Anesth Analg 1995;80:709–12.[Abstract]
8. Mulroy MF, Larkin KL, Hodgson PS, et al. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy. Anesth Analg 2000;91:860–4.[Abstract/Free Full Text]
9. Williams BA, Kentor ML, Williams JP, et al. Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology 2000;93:529–38.[Web of Science][Medline]
10. Uhrlau Ch, Schäff M, Plötz J. Calculation of anaesthesia-related costs by using a scanner-based documentation system. Anaesth Intensivmed 2001;42:691–6.
11. Schuster M, Gottschalk A, Freitag M, Standl T. Cost drivers in patient controlled epidural analgesia for postoperative pain management after major surgery. Anesth Analg 2004;98:708–13.[Abstract/Free Full Text]
12. Lennox PH, Chilvers C, Vaghadia H. Selective spinal anesthesia versus desflurane anesthesia in short duration outpatient gynecological laparoscopy: a pharmacoeconomic comparison. Anesth Analg 2002;94:565–8.[Abstract/Free Full Text]
13. Nordin P, Zetterstrom H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet 2003;362:853–8.[Web of Science][Medline]
14. Li S, Coloma M, White PF, et al. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology 2000;93:1225–30.[Web of Science][Medline]
15. Dexter F, Tinker JH. Analysis of strategies to decrease postanesthesia care unit costs. Anesthesiology 1995;82:94–101.[Web of Science][Medline]
16. Marcon E, Kharraja S, Smolski N, et al. Determining the number of beds in the postanesthesia care unit: a computer simulation flow approach. Anesth Analg 2003;96:1415–23.[Abstract/Free Full Text]
17. Tremper KK, Barker SJ, Gelman S, et al. A demographic, service, and financial survey of anesthesia training programs in the United States. Anesth Analg 2003;96:1432–46.[Abstract/Free Full Text]
18. Abouleish AE, Dexter F, Epstein RH, et al. Labor costs incurred by anesthesiology groups because of operating rooms not being allocated and cases not being scheduled to maximize operating room efficiency. Anesth Analg 2003;96:1109–13.[Abstract/Free Full Text]
19. Franzini L, Berry JM. A cost-construction model to assess the total cost of an anesthesiology residency program. Anesthesiology 1999;90:257–68.[Web of Science][Medline]
20. Rowe WL. Economics and anaesthesia. Anaesthesia 1998;53:782–8.[Medline]
21. Dexter F, Coffin S, Tinker JH. Decreases in anesthesia-controlled time cannot permit one additional surgical operation to be reliably scheduled during the workday. Anesth Analg 1995;81:1263–8.[Abstract]

This article has been cited by other articles:

				C. Gonano, U. Leitgeb, C. Sitzwohl, G. Ihra, C. Weinstabl, and S. C. Kettner Spinal Versus General Anesthesia for Orthopedic Surgery: Anesthesia Drug and Supply Costs Anesth. Analg., February 1, 2006; 102(2): 524 - 529. [Abstract] [Full Text] [PDF]

				E. L. Bloomfield Costs Are Not the Only Thing We Should Be Concerned with in Anesthesia Anesth. Analg., November 1, 2005; 101(5): 1562 - 1562. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by Schuster, M. Articles by Standl, T. Search for Related Content PubMed PubMed Citation Articles by Schuster, M. Articles by Standl, T. Related Collections Economics and Health Care Research Anesthetic Techniques Regional Anesthesia