Beyond the Sticker Price in Medicine

How far do you expect a hospital to look out from the front doors? Should they focus just on the fancy stuff that happens inside the walls? Should they stretch a few roving tentacles out into the community and kick along some local health programs? Or should they really engage in big public health stuff? It kind of makes sense as a healthier community might drop by the emergency department with the crushing anvil of cardiac death resting on their chest a little less often.

Our local state government seems to have some views on that, particularly in kids’ health. The big kids hospital I drop into when I’m dishing out the happy gas has a designated role in helping provide a beacon for kids’ health across the state. Which is a noble and worthy idea, but it’s harder to see in practice beyond a few small programs. If the role is to get out there and engage with the bigger health issues that will potentially overwhelm all of us, then you’d expect I’d see the results. What I tend to see is levels of management all focussing their gaze deep inside the bellybutton of the hospital beast, trying to figure out which bit of microscopic lint they’ll exercise the tweezers on.

How will I know when they’re getting serious about the bigger picture? When they stop sending me e-mails about the price of a bottle of anaesthetic gas. Perhaps I should explain.

The Price on the Label

There’s a drug committee in the hospital. For the sake of visualisation, lets assume it is run by a group of administrators wielding clipboards who look like they’d suck the joy out of a fairy floss stand at the school fete. Regularly they meet and regularly they complain that the most used anaesthetic gas in our gas cupboard is blowing the hospital budget. ‘Could you use less?’ is the message that comes down the line. I guess they’d like the patients more awake.

Now I could get steamed up because they lack all sense of scale. They quote the total cost on the basis of bottles of gas bought without any reference to how many patients have received the drug. The few drugs up the top of the list are always super expensive stuff splashed in the direction of some very specific patients (and I don’t begrudge them that, but when you’re complaining about relative costs acknowledging that the vapour is used in hundreds of patients a week is relevant).

What actually depresses me is that it’s another example of missing the bigger picture. That picture isn’t that anaesthetists are happy citizens spreading joy and shouldn’t be questioned about piddling items like that. It’s actually about climate change.

Wait, what?

The problem with the cost of this drug sevoflurane shouldn’t be about the bottle price at all. The discussion should be about the real price of what we use in hospitals on a much broader scale than just the health budget. It’s a little like watching an episode of Big Brother – the real cost isn’t the cost of turning on the TV or even the lost time.  The broader impacts of the lost IQ points and steady hollowing out of self-worth should also be part of the accounting.

Likewise, the positive results of a photo of a baby fennec fox linger beyond one minute. [via]

Likewise, the positive results of a photo of a baby fennec fox linger beyond one minute. [via]

Hospitals massively consume, and that is part of the climate change story. In the US, healthcare accounts for 8% of all energy consumption (and the operating suite is 30% of that).  As pointed out here, you can’t just consider climate change as an issue that’s about the environment or even about energy. It’s an everything issue and health is right up there. The Lancet suggested it could be the biggest global health threat of the 21st century, and they base that on the sobering stuff generated by the World Health Organisation who set out a vast array of massive health impacts.

The Real Price of Eggs

So hospitals should start thinking about this stuff. Which brings me back to the price of drugging the population. To really understand the cost of that bottle of sevoflurane, we need to look at all the costs associated with bringing it to the hospital and getting rid of it afterwards. We need to check the whole life cycle of everything we’re using. Need more of an explainer? Then spend 6 minutes or so with Leyla Acaroglu considering the plastic bag.

A team from Yale did exactly that for anaesthetic drugs. They considered the total life cycle cost of sevoflurane, isoflurane, desflurane (all anaesthetic agents in gas form) and propofol (an intravenous anaesthetic agent probably most famous for a grim celebrity client – Michael Jackson). They broke it right down – all the way through manufacture, transport to the hospital, the ways you deliver it, the amount you waste, how you dispose of it and pretty much every other little piece of the process. Then they produced a picture that says it all about how much the gases cost.

The Breakdown with a Bit of Explanation on the Right

The breakdown with a bit of explanation on the right

Seems obvious – ditch the gases and get on the propofol because the real total cost is vastly less, particularly when you include the use of nitrous oxide (aka ‘happy gas’) as a bonus agent. Propofol’s comparative impact is equivalent to a mosquito sneezing in the Amazon river.

Here’s the problem for the hospital. Each vial of propofol costs between $2 and $3 and if you were keeping a 70 kg person asleep you’d use around 4 vials an hour (not including the bit to get them to sleep). You could make one bottle of sevoflurane last all day. So the second we switch to the propofol, you can bet the e-mails will get way more insistent very quickly. Even though the environment might like to quietly beg for a rethink. 

So that’s the depressing bit. I don’t hear any discussion from hospitals about engaging with these really big issues. I don’t hear a discussion about how to start accounting for all our consumables with any eye to the total life cycle costs.

Like any public division, there’s a bit of lip service to sustainability. ‘Lets all photocopy less and turn off the lights in the empty rooms’. That’s not really the inspirational beacon of kids’ health in action is it?

So when will I know that hospitals take this stuff seriously? When they start actually trying to think about the bigger impacts of business as usual and stop assuming the impact of consumption is a problem for everyone else. Maybe they could start by looking out the doors.


The paper this is mostly drawn from is:

Sherman J, Le C, Lamers V and Eckelman M. Life Cycle Greenhouse Gas Emissions of Anesthetic Drugs Anesthesia & Analgesia. 2012;114:1086-90.

There’s a whole theme in that edition on sustainability and anaesthetic practice.


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