Application of cost utility and quality-adjusted life years analyses to monitored anesthesia care for sedation only

Study Objective: To determine how much society should spend to decrease anxiety lasting for the duration of a surgical case. Design: Indications for monitored-anesthesia care (MAC) include: (1) management of an unstable patient, (2) possible induction of general anesthesia, (3) need for the patient to be unconscious for part of the case, and (4) provision of sedation and/or analgesia. The first three indications facilitate quality surgical care. However, MAC solely to decrease anxiety has been criticized on economic grounds. Although MAC for these cases may improve the patient's experience during surgery, it does no facilitate safer surgery. I limited my theoretical analysis to (1) MAC for sedation only and (2) procedures that have an equal outcome with or without an anesthesiologist. Cost-utility analyses compare costs and benefits of technologies by using a common measure of health outcomes. The quality adjusted life year (QALY) gives the expected life years gained from a procedure, with each year weighted to reflect quality of life in that year. Quality of life generally ranges from zero (dead) to one (healthy without distress). Technologies costing more than $75,000 per QALY are usually considered too expensive to justify. I used a deliberately absurd, one unit change in quality of life to calculate the maximum hourly cost of MAC, which lets the cost per QALY be less than $75,000. Measurements and Main Results: Hourly cost must be less than $8.56 per hour. Current Medicare reimbursement corresponds to $876,000 per QALY. Conclusion: MAC for sedation only is a very expensive technology compared with other medical interventions.