Aanesthetic Agents for Day Surgery - NIHR Health Technology ...

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214 Appendix 17 TABLE 87 Unit costs of drugs prescribed by a GP Drug prescribed Unit Unit cost (including VAT) (£) ‘Antibiotic cream’, mupiprocin 2% 15 g 4.28 ‘Antibiotics’, amoxicillin 250 mg 15 capsules 2.66 Cefalexin 250 mg 20 capsules 2.77 Ciprofloxacin 250 mg 14 tablets 12.34 Cocodamol 20 tablets 1.80 Codeine phosphate 30 mg 20 tablets 1.80 Codydramol 20 tablets 0.60 Coproxamol 20 tablets 0.40 Diclofenac 50 mg 21 tablets 1.68 Dihydrocodeine 30 mg 20 tablets 1.40 ‘Ear spray’, Sofradex ® 10 mls 6.12 Erythromycin 250 mg 28 tablets 3.62 Flucloxacillin 250 mg 20 capsules 3.03 Hormone replacement therapy, Prempak C ® 0.625 7 tablets 1.01 Ibuprofen 400 mg 21 tablets 1.48 Lignocaine 2% 20 g 1.25 Medroxyprogesterone 10 mg 7 tablets 2.03 Metronidazole 400 mg 21 tablets 5.86 ‘Migraine beta blockers’, Propranolol 40 mg 21 tablets 0.12 Norethisterone 5 mg 21 tablets 1.78 ‘Painkillers’, Co-codamol 20 tablets 1.80 Penicillin V 500 mg 28 tablets 2.40 Ponstan ® 500 mg 21 tablets 2.01 ‘Steroid cream’, hydrocortisone 1% 15 g 0.49 Trimethoprim 100 mg 7 tablets 0.17 TABLE 88 Unit costs of a hospital visit Visit type Unit Unit cost (£) Accident and emergency visit Per outpatient attendance 65.00 Inpatient stay Per inpatient day 223.00 Outpatient attendance Per outpatient attendance 68.00 Phone call to hospital Per phone call (10.8 min) 5.58
Background The empirical study required accurate and detailed information on the quantities of anaesthetic used. For volatile anaesthetics, it is not possible to measure the quantity administered in terms of volume. The carrier gases, normally oxygen and N 2O, pass through an agent-specific vaporiser mounted on the anaesthetic machine in which the liquid anaesthetic agent is vaporised and added to the stream of gases. The combination of gases and anaesthetic vapour is carried to and from the patient’s lungs by a system of tubing known as the ‘breathing system’. The vaporisers used to administer volatile anaesthetics are calibrated to show the percentage concentration of vapour delivered to the breathing system rather than the volume of liquid agent delivered in millilitres. The anaesthetist intermittently varies the concentration of agent delivered to the breathing system by adjusting the dial on the vaporiser according to the needs of the patient. The volume of liquid agent delivered to the patient depends, inter alia, on the flow of carrier gases passing through the vaporiser (known as the ‘fresh gas flow’) and the percentage concentration of vapour set on the vaporiser dial. The type of breathing system is relevant to the economy with which the anaesthetic agent is utilised. There are broadly two types. In a nonre-breathing system, a large flow of anaesthetic gases and vapour is carried to the patient’s lungs. An amount of anaesthetic agent and oxygen is taken up by the patient and the remainder is vented to the atmosphere. In a re-breathing system the ‘waste’ gases and vapour exhaled by the patient are recycled continuously by immediately directing the exhaled breath through a low-resistance carbon dioxide-absorbing canister and thence back to the patient. This system is commonly described as a ‘circle system’. All that has to be added to a circle system is the amount of oxygen (approximately 200 ml/min) and the amount of anaesthetic vapour actually taken up by the patient with each breath. The predominant advantage of reducing the fresh gas flow to a minimum is extreme economy of use. A second © Queen’s Printer and Controller of HMSO 2002. All rights reserved. Appendix 18 Health Technology Assessment 2002; Vol. 6: No. 30 Determining the quantity of the volatile anaesthetic agents used advantage is the considerable reduction in the release of N 2O and anaesthetic halogenated hydrocarbons into the atmosphere. A potential disadvantage is that it is difficult rapidly to vary the amount of anaesthetic agent available to the patient if, for example, the severity of the surgical stimulus suddenly increases and it becomes necessary to quickly deliver more anaesthetic to the patient to avoid excessively light anaesthesia. In these circumstances it is usual to increase the fresh gas flow for a few minutes in addition to increasing the vaporiser setting. During the first few minutes of anaesthesia, the uptake of anaesthetic agent by the patient’s tissues is very high. In order to provide sufficient anaesthetic agent, a relatively high fresh gas flow is required initially and, subsequently, the flow is progressively decreased by the anaesthetist. To ensure that the appropriate anaesthetic concentration is achieved in the circle breathing system, the actual percentage of vapour being delivered to the patient is routinely measured on a breath-by-breath basis throughout each anaesthetic using an accurate monitor. In practice, circle systems are seldom used in their most parsimonious ‘closed’ state and a fresh gas flow is chosen which achieves the best compromise between economy on the one hand and the ability to vary the amount of anaesthetic agent available to the patient on the other. Previous studies have attempted to estimate the cost of anaesthetic agents by simply measuring the volume of liquid agent used. 22 Weighing the vaporiser containing the volatile anaesthetic before and after anaesthesia is the most accurate way to calculate the quantity of volatile anaesthetic agent used. 28 However, this process is logistically demanding and time consuming and was considered on these grounds to be inappropriate for the large numbers of patients recruited to the current study. The Dion formula was developed and has been used in several studies to estimate the quantity and cost of volatile anaesthetic agents administered using machines with no system to allow re-breathing of the vapours. 24,220 The widespread introduction of circle systems into anaesthetic practice 246 has generated some uncertainty in the CESA team of investigators 215
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Which anaesthetic agents are costef
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Which anaesthetic agents are costef
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NHS R&D HTA Programme The NHS R&D H
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Contents Appendix 6 Adult patient-b
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Background The aim of the project w
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• The incidence of PONV was low d
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2 Introduction dizziness or disorie
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4 Introduction a reduced incidence
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6 Introduction willingness to pay f
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8 Literature review included in the
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10 Literature review TABLE 1 Compar
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12 Literature review intermediate a
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18 Literature review Patient-based
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20 Literature review TABLE 5 contd
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22 Literature review No studies fol
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24 Literature review (30%) and meth
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26 Literature review • There are
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28 National survey of anaesthetic p
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36 Economic evaluation methods (inc
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38 Economic evaluation methods The
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40 Economic evaluation methods Tabl
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42 Economic evaluation methods simi
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44 Economic evaluation methods Prob
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Recruitment to the CESA RCT The stu
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Clinical outcome data PONV by anaes
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The findings from the logistic regr
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TABLE 29 The length of stay and pri
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140 120 100 80 60 40 20 0 No. of pa
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250 200 150 100 50 0 No. of patient
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TABLE 37 Deterministic sensitivity
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20 15 10 5 0 -5 Difference in varia
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Patient admitted for day surgery an
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500 400 300 200 100 0 -100 -200 -30
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Recruitment to the CESA RCT The stu
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TABLE 49 The occurrence of any PONV
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60 50 40 30 20 10 0 No. of patients
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a scale effect for scenario A, but
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The mean CVs for avoidance of PONV
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1.80 The new variable cost and tota
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100 90 80 70 60 50 40 30 20 10 0 Su
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The structure and content of this d
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nurses to have an in-depth knowledg
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agent used (see appendix 18). It wa
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Furthermore, anaesthetists operate
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The CESA project was designed to as
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practice, such as the use of midazo
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1. Royal College of Surgeons of Eng
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60. Cheng KI, Chu KS, Fang YR, Su K
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112. Raeder J, Gupta A, Pedersen FM
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162. Viitanen H, Baer G, Annila P.
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220. Rosenberg KM, Bridge P, Brown
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The range of databases interrogated
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24. preferen$.mp. [mp=title, abstra
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110 Appendix 2 TABLE 65 contd Summa
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112 Appendix 3 Quality assessment o
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TABLE 69 Summary of paediatric pati
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TABLE 69 contd Summary of paediatri
Page 177 and 178: TABLE 70 Characteristics of cost or
Page 179 and 180: TABLE 71 Quality of cost or economi
Page 181 and 182: TABLE 71 contd Quality of cost or e
Page 189 and 190: Abbott J, Abbott P. Psychological a
Page 191 and 192: Hall JE, Stewart JIM, Harmer M. Sin
Page 193: Struys M, Versichelen L, Thas O, He
Page 196 and 197: 182 Appendix 11
Page 205 and 206: The aim of this study was to develo
Page 207 and 208: anaesthetics in day surgery, using
Page 209: © Queen’s Printer and Controller
Page 213 and 214: Background The empirical study quan
Page 215 and 216: Satisfaction with care Nearly all (
Page 217 and 218: TABLE 76 Reason given for preferenc
Page 219 and 220: TABLE 79 Comparisons with previous
Page 221 and 222: TABLE 80 Reason given for preferenc
Page 223 and 224: TABLE 81 Reason given for willingne
Page 225 and 226: Background Variable costs account f
Page 227: TABLE 85 Unit costs for the purchas
Page 231 and 232: Ethical approval This was covered b
Page 233 and 234: 20 15 10 5 0 -5 -10 -15 True weight
Page 235: 15 10 5 0 -5 -10 True weight - Dion
Page 238 and 239: 224 Appendix 19 • patients aged o
Page 241 and 242: All staff unit costs were for the y
Page 243: Background Fixed costs account for
Page 246 and 247: 232 Appendix 22 March, Tuesday 15 A
Page 248 and 249: 234 Appendix 23 TABLE 96 Reasons fo
Page 251 and 252: Patients were coded using the OPCS
Page 253 and 254: Q03.4 punch biopsy of cervix Q03.5
Page 255 and 256: This section displays the associati
Page 257 and 258: given in Table 103 confirm the age
Page 259: TABLE 107 Occurrence of PONV by dur
Page 262 and 263: 248 Appendix 27 TABLE 113 Frequency
Page 265 and 266: This section displays the associati
Page 267 and 268: The adverse events observed in the
Page 269 and 270: 262 Health Technology Assessment Pr
Page 271: 264 Health Technology Assessment Pr
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