Objectives: The increasing use of full economic evaluations has led to the development of various instruments to assess their quality. The purpose of this study was to compare the frequently used British Medical Journal (BMJ) check-list and two new instruments: the Consensus Health Economic Criteria (CHEC) list and the Quality of Health Economic Studies (QHES) instrument. The analysis was based on a practical exercise on economic evaluations of the surgical treatment of obesity.

Methods: The quality of nine selected studies was assessed independently by two health economists. To compare instruments, the Spearman rank correlation coefficient was calculated for each assessor. Moreover, the test–retest reliability for each instrument was assessed with the intraclass correlation coefficient (ICC) (3,1). Finally, the inter-rater agreement for each instrument was estimated at two levels: comparison of the total score of each article by the ICC(2,1) and comparison of results per item by kappa values.

Results: The Spearman's rank correlation coefficient between instruments was usually high (rho > 0.70). Furthermore, test–retest reliability was good for every instruments, that is, 0.98 (95 percent CI, 0.86–0.99) for the BMJ check-list, 0.97 (95 percent CI, 0.73–0.98) for the CHEC list, and 0.95 (95 percent CI, 0.75–0.99) for the QHES instrument. However, inter-rater agreement was poor (kappa < 0.40 for most items and ICC(2,1) ≤ 0.5).

Conclusions: The study shows that the results of the quality assessment of economic evaluations are not so much influenced by the instrument used but more by the assessor. Therefore, quality assessments should be performed by at least two independent experts and final scoring based on consensus.

Objectives: The aim of the Consensus on Health Economic Criteria (CHEC) project is to develop a criteria list for assessment of the methodological quality of economic evaluations in systematic reviews. The criteria list resulting from this CHEC project should be regarded as a minimum standard.

Methods: The criteria list has been developed using a Delphi method. Three Delphi rounds were needed to reach consensus. Twenty-three international experts participated in the Delphi panel.

Results: The Delphi panel achieved consensus over a generic core set of items for the quality assessment of economic evaluations. Each item of the CHEC-list was formulated as a question that can be answered by yes or no. To standardize the interpretation of the list and facilitate its use, the project team also provided an operationalization of the criteria list items.

Conclusions: There was consensus among a group of international experts regarding a core set of items that can be used to assess the quality of economic evaluations in systematic reviews. Using this checklist will make future systematic reviews of economic evaluations more transparent, informative, and comparable. Consequently, researchers and policy-makers might use these systematic reviews more easily. The CHEC-list can be downloaded freely from http://www.beoz.unimaas.nl/chec/.

Summary

Background and objective: The randomized, patient- and observer-blinded study was performed in 120 patients undergoing ear, nose and throat surgery to test the hypothesis that intravenous anaesthesia with propofol–remifentanil when compared with a balanced anaesthesia technique using isoflurane–alfentanil improves the speed of recovery, minimizes postoperative side-effects and, thus, leads to an improved quality of recovery without increasing total costs.

Methods: The total costs for each anaesthesia technique were calculated considering drug acquisition costs, personnel costs for the additional time spent in the operating room and the postanaesthesia care unit until fast-tracking eligibility, and the costs to treat the side-effects during and after operation.

Results: The times from the end of surgery to tracheal extubation and the time until leaving the operating room were not different between the two groups. However, more patients receiving intravenous anaesthesia (80 versus 49%) were eligible for fast tracking and thus could bypass the recovery room. This was associated with an average cost saving of €6.00 per patient. However, intravenous anaesthesia was associated with higher total costs (€89 versus €78) mainly because of higher acquisition costs of the anaesthetics (€34.60 versus €16.50). There was no difference in the quality of recovery as measured by a Quality of Recovery score and patient satisfaction between the two groups.

Conclusions: The higher acquisition costs of the intravenous anaesthetics propofol and remifentanil cannot be compensated for by improved speed of recovery. This anaesthesia technique is more cost intensive than balanced anaesthesia using isoflurane and alfentanil.

Background and objective: To evaluate preparation and discharge times as well as the anaesthesia-related costs of out-patient knee arthroscopy performed with a combined sciatic-femoral nerve block, or a propofol-remifentanil general anaesthetic.

Methods: With Ethics Committee approval and written informed consent, 40 healthy patients were premedicated with intravenous midazolam (0.05 mg kg−1) and ketoprofen (50 mg). They were then randomly allocated to receive either a combined sciatic-femoral nerve block with 25 mL mepivacaine 2% (15 mL for the femoral nerve, 10 mL for the sciatic nerve) (PNB group, n = 20), or a general anaesthetic with a continuous intravenous infusion of remifentanil (0.1–0.3 μg kg−1min−1) and propofol (target plasma concentration 2–4 μg mL−1) with a laryngeal mask airway (GA group, n = 20).

Results: The median (range) preparation time was 16 (10–28) min in the PNB group and 13 (8–22) min in the GA group (P = 0.015). Ten PNB patients were directly discharged to the day-surgery unit after the procedure as compared with one GA patient (P = 0.003). Discharge from the postanaesthesia care unit (PACU) required 5 (5–20) min in the PNB group and 23 (7–95) min in the GA group (P = 0.001). Home discharge criteria were fulfilled after 277 (150–485) min in the PNB group and 170 (100–400)min in the GA group (P = 0.005). Costs related to the time spent in the PACU were lower for the PNB group (€1.10, range 0–22) compared with the GA group (€30, range €0–176) (P = 0.0005). There were no differences in total costs: PNB group €158 (range €105–194) versus GA group €160 (range €101–238) (P = 0.61).

Conclusions: In patients undergoing out-patient knee arthroscopy, the length of stay in the PACU can be shorter after a sciatic-femoral nerve block with a small volume of mepivacaine 2% compared with a propofol-remifentanil anaesthetic, and there is an increased likelihood that they will bypass the first phase of the postoperative recovery.

Background and objective: Cost consciousness has become increasingly important in anaesthesia as elsewhere in healthcare. Cost-minimization with uncompromised patient safety and quality requires systematic comparisons of alternative techniques. Inhalation anaesthesia with desflurane or sevoflurane is compared in this study with propofol delivered by the target controlled infusion technique. Directly measured drug consumption and costs and emergence times are compared.

Methods: Consumed anaesthetics were measured during elective arthroscopy of the knee, and costs were calculated for ASA I–II patients (n = 102) randomized to 3 groups: one group received anaesthesia using propofol administered by target controlled infusion, the others inhalation anaesthesia with either desflurane or sevoflurane in combination with nitrous oxide. A partial rebreathing system was used with a laryngeal mask airway. Vaporizers were weighed before and after each anaesthetic.

Results: Aaesthetic duration, postoperative pain and emesis as well as discharge time did not differ between groups. Inhaled anaesthetic techniques with desflurane or sevoflurane were associated with 2–3min shorter emergence times (P < 0.001) and approximately 45% lower cost for consumed anaesthetics as compared with propofol technique based on target controlled infusion. The inclusion of waste costs improved the cost reduction to 55%.

Conclusions: For this patient group, use of inhalation anaesthesia reduced drug costs by half and shortened emergence times compared to target controlled infusion with propofol with equal perioperative patient conditions.

Health care systems throughout the world are faced with continuously rising health care expenditure. In Germany, a fee per capita system will be introduced by 2003 to keep the budgets for hospital care within limits. As a result, numbers of hospital beds and hospitals will be cut in the coming years. On the other hand, more and more patients and health care providers are asking if they are really receiving an adequate value for their money in the treatment they receive. All this will have a strong impact on the anaesthesiologist's work and her/his perception of the different facets of quality.

Quality has various aspects for the anaesthesiologist. The patient as a customer should not incur any detrimental effects after a surgical procedure, and is accompanied by the anaesthesiologist throughout the perioperative setting. The surgeon needs optimal conditions to perform a procedure. The hospital must balance equally costs and income; this requires optimal operating room utilization. Finally, health insurance companies and the government are responsible for covering the cost of treatment according to the quality of the care delivered.

Quality assessment concerning structure, process and outcome has to take these demands into account. Continuous quality improvement in the spirit of Deming's ‘plan-do-check-act cycle’ has to be part of anaesthesiologist's everyday routine. In future, the traditional barriers between the specialities treating a patient will be disrupted when reimbursement for treatment is made according to quality and efficacy of treatment.

Background and aim We evaluated the costs and benefits of total intravenous anaesthesia compared with a balanced anaesthesia regimen.

Methods One-hundred and twenty-four patients undergoing cataract surgery were randomized to either a pro-pofol/remifentanil or an isoflurane/fentanyl group. In the propofol/remifentanil group, both drugs were used for induction and maintenance of anaesthesia; in the isoflurane/fentanyl group, anaesthesia was induced with etomi-date and fentanyl and maintained with isoflurane and fentanyl. All patients received mivacurium for muscle relaxation and the lungs were ventilated mechanically. The use of propofol and remifentanil resulted in a faster emergence and an overall savings per case of € 12.25 due to a reduction in personnel costs which outweighs the higher drug acquisition costs.

Results In the propofol and remifentanil group, more patients were satisfied and would accept the same anaesthetic again.

Conclusion We conclude that propofol and remifentanil is more cost-effective than isoflurane/fentanyl due to its better recovery profile, reduced total direct costs and higher patient satisfaction.