Maxillofacial surgery: the economic aspect

British Journal

ofOral

and Marillofuciinl Surgery (1990) 28, 1619

@ 1990The British Association of Oral and Manillofacial Surgeons

Maxillofacial

surgery: the economic aspect

J. C. Lowry Department of Maxillofacial and Oral Surgery, Bolton General Hospital, Bolton

SUMMARY. Fifteen years ago when the expenditure on the National Health Service was 3?2600 million annually, an economic survey of the then more common procedures carried out by oral and maxillofacial surgeons in the UK was undertaken. After three reorganisations of the NHS with a fourth pending the overall cost has escalated to $21.6 billion. The specialty has also seen significant change with a broader spectrum of work being carried out and a greater proportion of major cases being undertaken. The paper shows how previously costed procedures have changed; for example with increasing use of day care facilities and internal fixation techniques, before moving on to consider castings for the more advanced operations now being carried out on a regular basis. In an era of resource management with progressive stringency of funding in the acute sector it has been suggested that some procedures are uneconomical and others possibly should not take high priority. Under these circumstances it has become especially important to justify all facets of practice of the specialty and this aspect is considered in terms of the cost to the National Health Service, the quality of life of the patient and the cost to the economy as a whole in Social Security benefits and loss of productivity.

Reorganisati?ns

INTRODUCTION

Following three reorganisations of the NHS with a fourth pending the annual cost has escalated to 221.6 billion which represents 5.7% of the Gross Domestic Product in contrast to the 5% of 1972/73 when the costs were increasing at a mere &lOOmper year. It is salutory to ‘note that in the 40th year of the HealthService it is the third largest employer in the World after the Red Army and the Indian State Railways. Despite this Britain is relatively low down the list of comparable countries in the proportion of finance devoted to health care. Figures from the’ Organisation for Economic Cooperation and Development (OECD) for countries with a Gross Domestic Product of approximately $11 000 per head of population show France at the top of the list spending 9.4%. In countries outside this group the USA which is currently spending $81.6bn representing 10.8% of GDP and Greece at 4.2% are at the extremes of the scale. Following the introduction of Medicare and Medicaid in 196.5 the US government has made several attempts to hold back the costs and these have significantly altered the health care system in that country. It is interesting to note that during the past decade some european countries with different systems of finance have also introduced controls because of spiralling costs and some, for example Germany, France, Belgium and the Netherlands have extended cost sharing by increasing the contributions made by patients. With progressive advances in medical science both the aspirations of the practitioner and the expectations of the patient have grown. In the United Kingdom it has been estimated by the Department

The economics of health care are currently under scrutiny throughout the World. Not only is there a requirement to reduce the period of pre and postoperative hospital stay but also the number of investigations. Newer techniques in maxillofacial surgery have resulted in reduced morbidity in many conditions and also fewer in-patient days but nevertheless the increasing complexity of operative procedures is expensive in both technical and manpower terms. Background

Fifteen years ago when the -expenditure on the National Health Service was &2600 million annually an economic survey of the then more common procedures in oral and maxillofacial surgery was carried out (Lowry, 1974). This included comparisons of costs for dento- alveolar surgery, maxillofacial trauma and orthognathic operations in regional maxillofacial units, peripheral acute hospitals and in teaching hospitals. At that time, patients undergoing excision of impacted third molars stayed in hospital for just under 4 days at a cost of approximately &68, while those admitted with maxillofacial injuries stayed as in-patients on average 7 days (range 2-29) and expended between &96 and &121. The costs for a patient having orthognathic surgery, most frequently single jaw procedures at that stage, staying as an inpatient for 11 days was between &162 and &198; the 25% higher figure relating to treatment in a teaching hospital. 16

Maxillofacial

of Health and Social Security (1988) that the latter has increased the demand for treatment by 1.2%,per annum over the past 6 years while demographic changes have added another 0.55% annually; a figure which is projected to further rise by 0.78% per year up to 1991/92. Advances

Craniomaxillofacial and oral surgery has taken enormous strides over the past 30 years as the scope of the specialty has expanded into areas covered previously by other disciplines. Progressive experience gained in the management of military and civilian trauma, the victims of which now have an improved survival rate as a result of on-site resuscitation and rapid evacuation to increasingly advanced treatment centres, has led in turn to further evolution in orthognathic surgery and a revolution in the surgical management of head and neck malignancy. Figures by Shepherd and Jones (1986) have confirmed a significant demand for our services and Williams (1987) has shown that a greater proportion of major cases is now being carried out by generalist maxillofacial surgeons (those not confining their practice to a single facet of the specialty for example the surgery of craniofacial deformity or of neoplastic disease) throughout the United Kingdom. For example, parotidectomy and resections for malignancy are now firmly entrenched as part and in some Units the major part, of the routine workload of our specialty. Now with the move progressively towards continental European practice the primary treatment of cleft lip and palate is logically being added. In addition the pattern of management of the type of cases the costs for which were assessed in 1972/73 has changed. For example much of the dentoalveolar work where patients were previouslyformally admitted is now carried out on a day care-basis, often under sedation and analgesia rather than a general anaesthetic. This allows a proportionate reduction in bed occupancy and relative cost. Yet the treatment, in hospital, is concentrated and manpower intensive, costing approximately &307 for such a procedure in contrast to &51 in 1972/73. This rises by &7.5to &382 if the patient is formally admitted. The treatment of maxillofacial injuries has also changed. Although it can be argued that in the light of seat-belt and crash helmet legislation as well as rapid rescue/on-scene resuscitation techniques, we are seeing more severly injured patients surviving who require lengthy in-patient care, many of the more common injuries can be managed in a more cost efficient manner. It is not unknown for the Friday-night inebriate with a depressed malar, to catch his plane to the Costa Blanca as planned on Saturday night after simple hook elevation under ‘a light anaesthetic or midazolamalfentanyl sedationanalgesia. ~Likewise the relatively uncomplicated manidbular fracture may be treated by techniques such as miniplating or’ lag-screwing ‘which’ avoid intermaxillary fixation thus permiting a shorter hospi-

surgery: the economic aspect

tal stay and usually an earlier return to work.

17

/

Current castings

Expenditure on a patient with relatively straight forward injuries requiring an hour or less in the operating theatre and an in-patient stay of 2 days is in the region of ‘~E73-3which includes a day-care attendance for plate or screw removal at a later date. Taking inflation over the intervening years into consideration the costs for such a patient in 1972 would have increased to around f.500. However it is generally understood that medical costs have increased by twice the rate of inflation (Havard, 1988) and on this basis the expected figure would have been in the region of &990. The actual costs calculated are &250 less than this thereby suggesting that the changed treatment policy is being economically successful. In a similar manner one can show that dentoalveolar and orthognathic operations (Lowry, 1974; 1975) have risen far less (by 82% and 50% respectively) than medical and surgical procedures generally; thus confirming that our specialty is performing at a high level of efficiency. Miniplating and other techniques of osteosynthesis have been one facet of an explosion of multisegment osteotomies of the facial skeleton and of course there have also been significant advances in craniofacial surgery building upon the pioneering work of Tessier (1967). In addition, developments in myocutaneous and fasciocutaneous flap construction together with microvascular anastomosis after early work by Jacobson and Suarez (1960) has allowed improved functional reconstruction after resection for orocervical malignancy. Bainton (1988) has recently highlighted the improved mastication and speech achieved by microvascular free flaps in a series of 30 consecutive patients when compared with a previous group 6 years earlier in which reconstruction was largely by distant pedicle flaps. These forms of treatment are of course expensive. Taking as an example the management of a child with a craniostenostic deformity and running through treatment-planning with the full team approach, early frontal advancement and subsequent treatment including orthodontics and later orthognathic surgery, the overall costs at current prices are around &5900. (Table 1). For a patient presenting with orocervical malignancy admitted for presurgical cisplatin chemotherapy and later resection, the costs allowing for intensive care and a return to the operating theatre in the event of vascular occlusion in a free flap are around &4850. (Table 2) This figure does not include any subsequent radiotherapy which may add a further 2800 with conventional fractionation over a 3-week period. Newer techniques utilising for example Continuous Hyperfractionation Accelerated Radiotherapy (CHART) (Michael & Hance, 1988) ;may reduce the overall time to 12 days. However .as this requires treatment throughout the day and night the manpower expenditure may cancel the saving in bed

18 British Journal of Oral and MaxiUofacialSurgery Table1 - Castings for craniofacial surgery

(Correction of craniostenotic deformity) New outpatient attendance Outpatient review for planning Investigations: CT scan radiography haematology/biochemistry Operation: 4 h x 103/h

f UK

EUK

118 254 120 113 104 (412)

1236 Operation: 12 h “x’103/h Intensive care unit supplement: 399 3 days x 133lday 1050 In-patient stay: 14 days X 75lday 132 Outpatient review attendances: 6 X 22 (2702) Sub-total: if 4 h operation if 12 h operation PLUS. (if requiring early frontal advancement and later orthodontics): 440 Orthodontics: 20 visits X 22 120 Further investigations: CT scan 58 radiograph/photographs 618 Operation: 6 h X 103/h Intensive care unit supplement: 399 3 days x 133lday 721 In-Patient stay: 7 days X 103/day

DISCUSSION

3526

Sub-total

2356

Total

5882

NB: These figures represent procedures separated in some cases by several years and are costed at current prices ie: excluding effects of variable annual inflation. Table 2 -

Castings for resection and reconstruction of head and neck malignancy including presurgical chemotherapy and postoperative radiotherapy $UK New outpatient attendance: Investigations: histology haematology & biochemistry Radiography & CT scan: Review for joint consultation: Admissions for cytotoxic chemotherapy: Review radiography Review haematology (X-match) & biochemistry: Operation: 8 h X 103/h Intensive care unit supplement: 3 days x 133lday Early reoperation: 4 h X 103 In-patient stay: 19 x 75lday Outpatient review: 6 x 22iattendance Sub-total for surgical treatment Plus average allowance for radiotherapy treatment

for in-patient days, averages have been taken for some facets of the indirect costs ascribed to each patient irrespective of diagnosis or department attended. However it has been possible to achieve greater accuracy with direct costs which include such items as cost per unit time in the operating theatre.

&UK

118 20 29

175 22 1171 30 104 824 399 412 1425 132 4861 800

occupancy although obviously more patients may be treated within the same facility. The castings have been calculated from management accounts compiled by two district health authorities and although derived in a similar manner to those of the 1972 study, in some aspects lack precision when compared with data currently being obtained in those hospitals where Resource Management Initiative studies are being carried out. For example in new out-patient costs and those

Despite more sophisticated treatment modalities figures from all over the World show that there has been no significant improvement in the survival rate from head and neck cancer over the past 25 years. It is postulated by Stell(1987) that any improvement attributable to treatment techniques is unlikely to be more than 10% and that progress beyond this must lie in earlier diagnosis to allow, in particular if surgery is to be considered, intervention before extracapsular rupture of involved lymph nodes has occured. We have available to us advanced investigation techniques which in some aspects of our work are helpful in diagnosis and treatment planning. For example CT scanning and MRI used judiciously can in the opinion of many radiologists save both time and money by avoiding numerous conventional and often diagnostically unhelpful films. However the routine use of three dimensional reconstruction and now even the milling of models of the facial and cranial sekelton using the same computer software has a value that is doubted by some specialist craniofacial surgeons. In addition when considering the management of trauma it has been suggested that the visualisation of fractures on CT scans especially around the orbit may have led to operations that would not otherwise have been carried out and with a questionable improvement in the outcome. It is important in any specialty to be able to justify expenditure and this we muSt do in terms of outcome. One would be in great difficulty if asked to balance in economic terms nearly 55000 spent in the management of advanced malignancy against benefit measured by an early return to work and a contribution to increased national productivity. If such a balance were to be imposed the relative merits of cardiac transplantation programmes and emotive fields such as advanced paediatric cardiovascular surgery, both extremely expensive with high mortality rates or the 227 000 per year spent in the later treatment of a patient with AIDS or ARC would also have to be considered. Clearly this to caring professionals is unthinkable and must on humanitarian grounds be resisted. However in doing SO one must be seen to be credible and to be practicing our specialty in as economical manner as possible. Spin-,offs achieved as a result of experience with major ‘procedures in m,axillofacial surgery can be me!sured in economic terms as well as the Quality Adltisted Life Years or QUALY concept introduced by Williams (1985). The latter aims to measure the success or otherwise of treatment modalities in terms of life expectancy and quality of life measured by RosSer’s Classification of Disability and Distress.

Maxillofacial surgery: the economic aspect Table 3 - Example of costing for management

temporomandibular

of joint arthrosis with relatively early surgery fUK

New outpatient attendance: Outpatient review attendances: 4 x f22 Radiography including arthrogram Arthroscopy: day-care procedure Operation: 1.5 x fl03/hour In-patient stay: 2 x f75lday Outpatient review: 2 x f2Uattendance Total: on short term-review basis

118 88 158 109 154 150 44 821

19

References Bainton, R. (1988). An analysis of morbidity following major head and neck surgery and subsequent free flap reconstruction. Paper read and abstracted in proceedings of the Autumn Meeting of the British Association of Oral and Maxillofacial Surgeons. Black, D. (1988) Hospital Doctor. Department of Health and Social Security (1988). Social Services Select Committee: Public expenditure on the social services. London: HMSO. Havard, J. (1988). Does the US know best? B&i.& Medical Associarion News Review, 14, 7.

Jacobsen, J. H. & Suarcz, E. L. (1960). Microsurgery in anastomosis of small vcsscls. Surgery Forum, 11, 243. Lowry, J. C. (1974). Some economic aspects of oral surgery.

In temporomandibular joint arthrosis early surgery at a cost of approximately f820 can reduce the necessity for frequent hospital attendances, with time off-work and continuing morbidity also associated with loss of production and payment of social security benefits (Table 3). Currently statutory sick pay is payable up to f49 per week contributing to an annual Social Security expenditure of f44.5 billion. In the management of trauma, osteosynthesis dispensing with the need for intermaxillary fixation can allow an earlier return to work and hopefully contribute to a further economy in public expenditure. In conclusion it is worth quoting Professor Sir Douglas Black (1988) who in response to those who ask why health care is so expensive care stated that instead of looking at the conspicuously high cost of certain procedures, one should look at the frequency with which they are justifiably carried out and the extent to which they influence what matters most to the patient . . . the outcome.

Acknowledgements I would like to thank the Directors of Finance and their ofticers for assistance in providing topics of the clinical managcmcnt accounts of both the Bolton & Blackburn and Hyndburn & Ribble Valley Health Authorities.

British Journal

of Oral Surgery,

11,249.

Lowry, J. C. (1975). Hospital oral surgery and the patient: some financial aspects. Dental Update, Jan/Feb, 17. Michael, B. D. & Hance, M. A. (1988). The Gray Laboratory Annul Reporr, pp. 155-158. London: Cancer Research Campaign. Shepherd, J. & Jones, G. M. (1987). Trends in oral surgery practice. British Dental Journal, 163, 237. Stell, P. M. (1987) Personal Communication. In: President’s Lecture to British Association of Oral and Maxillofacial Surgeons, Spring Meeting in Liverpool. Tessier, P. (1967). Osteotomies totalcs de la face, syndrome de Crouzon, syndrome d’Apert, oxycephalies, scaphycephalics, turricephalies. Anna1e.s Chirurgie Plastiques, 12, 273.

Williams, A. (1985) The value of QUALYS. Health and Social Services Journal, 94,905.

Williams, J. LI. (1987) In: Report of consultants’ discussion group of the Faculty of Dental Surgery of the Royal College of Surgeons of England. Britkh Dental Journal, 162,240.

The Author Mr John C. Lowry MB ChB, BDS, FDSRCS, FRCS

Consultant Oral Surgeon Department of Maxillofacial and Oral Surgery Bolton General Hospital Minerva Road Farnworth Bolton BL4 OJR Paper received 31 March 1989 Accepted 14 October 1989