To the Editor:-We are not convinced that the savings reported by Lubarsky et al.  are as great or as real as suggested. The authors conclude that their pharmaceutical practice guidelines, once implemented, resulted in an annual saving of almost 1 million dollars. The institution of this practice was associated with several other effects, including an increase of 3 min on average in the time from the end of surgery to arrival in the postanesthesia care unit (PACU) for each anesthetized patient. Although the authors state that they did not believe this increase was clinically significant, nor that operating rooms would be forced to cancel or delay cases, the fact remains that additional time equates to additional costs. The statement that overtime and associated increases in pay would not result from such increases in workload does not reflect the reality of many operating room environments.
What is relevant and appropriate for the cost analysis used in this report is to quantify the added cost related to this increase in time, which was reported to be statistically significant. Why this was not performed is unclear. Sperry  points out that it is essential for every economic study to identify which costs are counted and which are excluded. Conservative estimates of operating room costs are at least $8.13/min but can range much higher.  For simplicity sake, using an estimate of $10/min as the cost of operating room time, increases of 3 min per case, for a total of 27,728 cases per yr (the number reported to be the annual volume at Duke University Medical Center), equates to an increased cost of $831,840. This amount actually exceeds the annualized savings of $647,000 that the authors attributed directly to the implementation of their pharmaceutical practice guidelines. Such a result is consistent with what Lubarsky et al. noted others to report: that such guidelines can increase, not decrease, costs.  Although other costs were discussed, such as the cost of implementing the particulars of the pharmaceutical practice guidelines, readers were left with the impression that savings were substantial and that the guidelines were an overwhelming success.
Additional costs can also be attributed to unplanned PACU admissions. If PACU costs are estimated to be one fourth of the operating room rate, the increase in unplanned PACU admissions that followed the implementation of the pharmaceutical guidelines, if annualized, would result in additional expenditures of $91,900. We recognize that this and the above calculations are simplistic. However, they illustrate that several different assertions can be made, depending upon which pieces of the puzzle one focuses. Without a more complete analysis, the report by Lubarsky et al. and, in particular, its strong conclusions can be misleading.
Other issues that such analyses do not and maybe cannot address involve other potentially negative effects that such practice guidelines may have on practitioners or patients. Just a few serious negative outcomes could easily eliminate all possible savings. Guidelines that mandate clinicians change one or several components of their practice, such as the anesthetic agents with which they are familiar and are expert at administering, cannot fully consider how such changes might negatively impact the care they give and patient outcome. Although frustrating, it may be that “all that counts cannot be counted”. 
One premise underlying the restriction of choice of opioids suggested by the authors is that all micro-agonists are pharmacodynamically without much difference. However, under many circumstances, different effects result from the administration of one opioid versus another. Often, these differences can be attributed to a combination of pharmacodynamic and pharmacokinetic properties, which distinguish each agent.
The following serves as a simple but common example. Before the induction of general anesthesia, opioids are frequently administered to control the hemodynamic response to tracheal intubation. With fentanyl, frequently neither an adequate dose (3–7 micro gram/kg)[5,6] of fentanyl is administered, nor is enough time (5 min) allowed to pass before stimulation, for optimal hemodynamic control with this opioid. In contrast, the added drug costs of alfentanil or remifentanil when used in the same setting may be offset by taking advantage of the reduced time (1 min) to their maximal effect compared with fentanyl.  In addition, the use of alfentanil and propofol in combination allows tracheal intubation with very good conditions without the use of muscle relaxants.  The use of reversal agents is thus avoided, as are their possible attendant side effects. An analysis of the cost of such an anesthetic, we would argue, may support the use of the more expensive agents.
Although Lubarsky et al. have undertaken a difficult task, we are concerned with the message of their report. The conclusions of such cost analyses remain oversimplifications of our complex world. As such, they paint a picture that some will find appealing and that others will use to achieve certain ends. We are not of the former, and we fear the latter.
Peter L. Bailey, M.D.
Talmage D. Egan, M.D.
Department of Anesthesiology; University of Utah Health Sciences Center; 50 North Medical Drive; Salt Lake City, Utah 84132
(Accepted for publication July 29, 1997.)