Mubarak M F A Kerim MBBS MCh Orth FRCS FRSM FICS AANA

Consultant Orthopaedic Surgeon

SUCCESS IS A JOURNEY.

NOT A DESTINATION

A good surgeon knows how to operate

A better surgeon knows when to operate

The best surgeon knows when not to operate

A good surgeon knows how to operate

A better surgeon knows when to operate

The best surgeon knows when not to operate

Understand some basic principles behind economic considerations in surgical practice

Recognize the potential conflict between clinical freedom ,medical ethics and the logic of health economics

Examine areas where surgeons ,by good clinical practice ,can influence the costs of surgery.

Key point: clinical freedom allows you to choose the best treatment for a patient based on clinical knowledge and understanding but this choice should be tempered by an appreciation of the resources available.

In simple terms as synonymous with economics

The cost of surgery is not just monetary but also personal and social.

For the patient there is pain,suffering,time spent in hospital and the economic consequences of the disease ,hospitalization and time off work.

Clinicians are unfamiliar with measuring cost effectiveness

Direct cost :due to dealing with the disease,(born with the health care system,community,and family in directly addressing the problem

Indirect :loss of productivity due to the illness and operation

Intangible (pain,suffering,anxiety and grief

In the event of a death after surgery the cost of the life is often considered ,in health economic language as an intangible loss

Will Economic Arguments Take Over And Conflict With Good Patient Care Or Can Good Economic Strategies Mean Better Patient Care?

Using resources inefficiently or inappropriately.

Using investigative or operative techniques which are out-dated.

Not acting on the patient’s intersts but perhaps in the interest of academia or research.

High complication rates .

The poorly considered introduction of new techniques which demand expensive technological back-up or instrumentation for unproved gain.

1-Cost Savings.

2-Effectiveness In Improving Health Care.

3-Cost Savings With an Equal or Better Health Outcome.

4-Having an Additional Benefit Worth The Additional Cost

The first can be considered as avoided cost this involves estimation of costs caused by the disease process which are avoided by surgical intervention, example appropriate treatment for venous insuffiency in the leg ,thus avoiding burdensome and costly venous ulceration in the patient later .

The third option requires no compromise by accountants, or clinicians ,it is a (a win-win)situation.

One method is to Calculate Quality-life-years.

The Benefits Include;

1-Cure

2-Increase In Life Expectancy

3-Increased Quality Of Life

Cost-benefit & Cost-effective Analyses measure & compare The Significant Gains And Lossesassociated With different methods of patient management.

It equates the value in Financial Terms, of a year of Healthy Life.

1-Medical & Surgical Risks

2-Operative or hospital mortality

3-Disability

4-Pain & Suffering

5-Financial Cost

1-Day Surgery is Low-cost/High-output Service, it reduces the cost of procedures without increased morbidity.

2-Short-stay Wards & Low-dependancy Units or hotels reduce cost without detriment to the patient.

3-Preadmission Clinics May Avoid Last Minute Cancellations.

The detection of metastases in malignant disease must be analysed carefully and the value of commonly performed procedures questioned, is there a proven benefit?

Similarly playing (hunt the primary) may be of no value to the patient in terms of palliation or survival, while having a considerable cost implication for the health care.

Staging for ovarian ca involves high cost,but has great clinical value when properly performed.it is inappropriate if done routinely.

Projectile vomiting in infancy, a clinical finding of hypertrophic pyloric stenosiswould be a low-cost/high-yield diagnosiswhere as duodenal atresia might be a high-cost/low-yield condition

Breast Ca

Ca Colon

Aortic Aneurism

Ca Prostate

Can these produce better survival figures & quality of life for the patients?

Can the health care cope with the increased elective work load?

Some procedures are of low benefit with slight chance of

cure,e.g.oesophageal ca .however the palliative benefits may be

high.

The open surgery of adult inguinal hernia is an example of a well

accepted low-cost/high-yield treatment with an accumulative

economic importance in view of the disease frequency.

Laparascopic surgery for the same disease may not have the same

benefits .

The is a high-cost/high-yield procedure.

In emergency surgery(appendicitis)costs can be minimized by

avoiding negative laparotomies & complications.

The effectiveness of a test is a measure of how the test findings influnce the subsequent diagnostic or surgical strategy.

-Routine tests for all admissions are an example of uncritical & inefficient use of lab. tests.

-Many tests are expensive & overlap others .

The best is to order few tests in an appropriate order that will provide the speediest diagnosis

Try to become familiar with the sensitivity & specificity & broad costs of the tests.

1-FNAC

2-High-cost/High-yield procedures for the Management Of Certain Conditions eg Pouch surgery for Uc & angioplasty for peripheral & coronary disease, they improve The Quality Of Life.

3-Lapchole & Other Laparoscopic Surgeries.

4-Develop Local Protocols

Postoperative complications are expensive and can spoil any attempt to improve the cost effectiveness of surgery.

Measures To Reduce Complications;

1-Clinical Audit

2-Specialization

3-Abandoning Out-dated Unproved Procedures.

4-Prophylactic Regimes(antibiotics &Thromboembolic Prophlaxis)

5-Adopting New Proven Techniques

Waste Inappropriate investigations Inappropriate operations Rationing Cost Containments Ethics These are very important questions when

considering economics in medical practice.

WASTE INAPPROPRIATE INVESTIGATIONS INAPPROPRIATE OPERATIONS RATIONING COST CONTAINMENTS ETHICS THESE ARE VERY IMPORTANT QUESTIONS

WHEN COSIDERING ECONOMICS IN MEDICAL PRACTICE.

The response to these questions need to be well thought and workable

It is easy (to do something )particularly when faced with an individual patient ,but perhaps we should stand back ,take a broader view and consider whether an action for the individual patient is appropriate and/or cost effective

A multitude of tests and procedures does not necessarily produce an accurate or speedy diagnosis ,a lower morbidity or mortality or (better )health care

Professional guidelines and clinical audit may sometimes help us when it is necessary to say (no)

We have not found all answers yet,but you must begin to address these difficult questions

Eistman B,Stahlgeen L, cost-effective surgical management, Sounders Philadelphia

Gray AJ ,Hoile R W,NCEPOD

Nicks N R 1994 Some observations on attempts to measure appropriateness of care,BMJ

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Sudan is rich in agricultural resources ,animal resources and oil.