To the Editor:--Macario et al. derived cost equations from the best available monetary estimates of variables thought to be associated with the use of face masks, laryngeal mask airways, and endotracheal tubes. Their analysis detects the primary determinants of costs with different airway management techniques and explains possible cost tradeoffs among such variables as neuromuscular blocking drugs, laryngeal mask reuse rates, durations of surgery, and airway complications. This type of cost analysis is a good tool for evaluating clinical practices, but it is a surrogate for actual cost experience. The best evaluations should result from determining and comparing actual costs in large patient populations. Many hospitals and integrated health-delivery networks are accumulating detailed cost data, including direct, indirect, total, and activity-based costs. Examining these databanks may allow us to value our anesthetic practices by knowing their associated outcomes and total costs.

Cost experiences can differ from expectations, especially as we broaden our point of view from the individual to the health-delivery network or society as a whole. For instance, laparoscopic techniques for cholecystectomy were expected to reduce the costs for surgical treatment of gall bladder disease but have increased them overall. Perhaps with accumulated cost data, Macario et al. will find that the average cost for aspiration pneumonia exceeds their estimate of $1,330; our average hospital cost associated with this diagnosis (ICD-9 code 50700) is $16,088. If the costs of complications associated with one technique are very high, it will not be the best value. As Orkin observed in his description of value-based anesthesia care, no costs are obvious ; The outcomes and costs of our anesthetic choices should be measured. When the insights provided by theoretical analyses such as that done by Macario et al. are combined with actual cost experiences, anesthesiologists will be closer to knowing which clinical practices are worth their costs and to delivering value-based anesthesia care.

Robert E. Johnstone, M.D., Professor and Interim Chair, Department of Anesthesiology, West Virginia University, Morgantown, West Virginia 26506.

Macario A, Chang PC, Stempel DB, Brock-Utne JG: A cost analysis of the laryngeal mask airway for elective surgery in adult outpatients. ANESTHESIOLOGY 83:250-257, 1995.
Legorreta AP, Silber JH, Constantino GN, Kobylinski RW, Zatz SL: Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA 270:1429-1432, 1993.
Orkin FK: Moving toward value-based anesthesia care. J Clin Anesth 5:91-98, 1993.