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Economics Framework Paper

Pain is a frequent, unpleasant, and terrifying side effect of surgery. Chronic pain has been theorized to result from the unpleasantness and anxiety of pain, even when there are few or no biological findings to account for the patient’s stress level. Because of this, managing pain effectively is crucial to running a successful day surgery clinic. The sensory and mental distress of persistent postoperative pain is well-documented. Postoperative nausea and delirium, length of stay in the Post-Anesthesia Care Unit (PACU), and time spent waiting to be released from the hospital’s outpatient facility are all increased when pain is not managed well. Resuming regular activities may be slowed by inadequate pain management (Althaus et al., 2011). Postoperative pain is inevitable, but it can and should be controlled for faster recovery and fewer complications. Complications like pneumonia and blood clots may be avoided with proper pain management after surgery (Nazari et al., 2022). Postoperative patient satisfaction is related to the level of pain control. This paper discusses the cost per capita quintuple aim of the healthcare delivery system, presenting the cost analysis framework of the use of opioid-free anesthesia in postoperative pain management. Sustainable, high-quality treatment can only be provided if efforts are made to reduce healthcare resource use and costs without compromising on or worsening clinical outcomes.

Project Goal and Desired Outcome

Patients who have persistent pain after surgery incur higher medical and societal expenses. Because of the ongoing pain it produces, it poses a significant threat to public health. Research by Carley et al. (2021) indicated that between 2% and 10% of surgery patients experienced persistent pain. Some 235 million people annually undergo surgery, and millions more suffer from the aftereffects of chronic pain (Carley et al., 2021). Estimates for the prevalence of persistent pain after treatments as diverse as thoracotomy, mastectomy, coronary artery bypass, and hernia repair range from 30-50% (Meissner & Zaslansky, 2019). Once a limb has been amputated, the risk level rises significantly. There are more than 20 known genetic and environmental risk factors, some related to surgery and others to patients’ social situations. Preoperative concerns include anxiety, depression, poor pain regulation, genetic factors, sleep difficulties, and catastrophizing. Surgical technique, nerve injury, and tissue ischemia are all factors that must be considered during surgery and the following recovery. Factors such as postoperative pain hyperalgesia, chemotherapy/radiation treatment, further surgery, and psychological concerns play a role in the more extended postoperative period.

This can happen to patients of any age undergoing any operation. Depending on the extent of tissue damage, the patient may have varied levels of discomfort after surgery. If acute postoperative pain is not treated, it can progress into chronic pain (Althaus et al., 2011). Gelineaun et al. (2018) found that traditional surgical therapies only alleviated pain for between 10 and 60 percent of patients. Nazari et al. (2022) report that over 80% of patients in the United States are not given adequate care for their postoperative pain. This percentage, however, fluctuates based on variables, including the nature of the treatment, the type of anesthetic used, and the length of time needed for recovery. A steady percentage of patients reported severe pain in the first 24 hours following surgery (approximately 20%) throughout the past 30 years (Watts et al., 2017). Postoperative discomfort that persists beyond the first two months is considered chronic. The frequency with which this impact is reported varies significantly across individuals.

Despite the growing understanding of the efficacy of multimodal pain management techniques, opioid monotherapy has long been considered the cornerstone of postoperative pain care. A retrospective study of over 300,000 patients in 380 US hospitals found that 95% of surgical patients received opioids (Watts et al., 2017). Reasons for opioids’ popularity include their ability to alleviate moderate to severe postoperative pain, the lack of a “ceiling effect,” and the availability of many delivery methods. Since opioids have been around for decades, there is much historical data and real-world experience to draw on. Opioid side effects can limit dose or even be fatal, including nausea, vomiting, constipation, oversedation, drowsiness, and respiratory depression. Age, sleep apnea, obesity, and smoking increase the risk of oversedation and respiratory depression (van Boekel et al., 2017). Some individuals may opt to take fewer opioids than prescribed to alleviate the discomfort caused by opioids. There is evidence that adverse events involving opioids increase overall healthcare expenses, lengthen hospital stays, and reduce patient survival rates following in-hospital resuscitation. Because of this, a novel strategy for postoperative pain management is required, and this initiative promotes the use of esmolol as an effective alternative.

This study recommends the integration of Esmolol into the Enhanced Recovery After Surgery (ERAS) protocol as a critical element in perioperative care optimization. The efficacy of esmolol as an opioid-sparing medication has been consistently demonstrated in numerous studies (Gelineau et al., 2018). Its use reduces the necessity for parenteral analgesics during and after surgery, thereby mitigating the adverse effects commonly associated with opioid usage. Incorporating Esmolol into the ERAS framework can optimize patient recovery, accelerate postoperative mobilization, and reduce opioid-associated complications (ElHoshy & El-Din Yacout, 2023). This would be per the fundamental tenets of ERAS and contribute to enhanced patient outcomes.

Esmolol is frequently utilized as an adjunct for perioperative analgesia and anesthesia because it is a highly selective, ultra-short-acting beta-1 blocker. Esmolol can alter the perioperative pain response, increasing the analgesic effect of opioids, decreasing intra-operative anesthetic and opioid requirements, speeding up postoperative recovery, and attenuating the adrenergic response to several perioperative stimuli, among other benefits (Mendonça et al., 2021). Several studies suggest that esmolol can lessen the severity of postoperative pain. However, there is now some contradictory data. The effectiveness of esmolol as an analgesic adjunct in patients having a mastectomy is still unknown, even though its effects have been examined in a wide variety of surgical procedures.

This study aims to introduce a rational conversation about postoperative pain and identify viable pain relief options. After surgical tissue injury, acute pain is present, but it often goes away as the afflicted region recovers. Several elements contribute to the unique ways in which each person experiences pain. Physiological responses, psychological traits, and contextual influences affect how people experience pain differently. The findings provide credence to the use of opioid-free anesthesia for pain relief. Pharmaceutical drugs, both opioid and nonopioid, are often used to alleviate pain after surgery (Gelineau et al., 2018).

While opioids help individuals heal faster and have fewer complications following surgery, they also have many potentially fatal side effects. Because of the significance of reducing perioperative opioid use to the profession of anesthesia, our analysis suggests using esmolol. The project aims to enhance patient outcomes and minimize oral medication costs by decreasing opioid intake. The desired outcome upon implementation includes reduced hospital stays, improved patient experience, and ultimately lower healthcare costs associated with opioid-related complications. This proposal will outline the project’s objective, alignment with the quintuple aim, and the selected cost analysis.

Overview of the Overall Quintuple Aim and the Specific Quintuple Aim Segment

The Triple Aim, created in 2008 to enhance healthcare, emphasized three primary aims. The objectives encompassed the augmentation of population health, improving the care experience for individuals, and reducing the per capita cost of care. In 2014, a decision was made to incorporate an additional aspect that addresses the needs of healthcare providers (Foo et al., 2022). The creation of the Quadruple Aim was a direct response to the need for healthcare improvement. This aspect gained increased attention as the healthcare industry began tackling healthcare worker burnout by addressing the excessive demands on their performance and cognitive load. The Quintuple Aim further develops the Quadruple Aim, incorporating an extra dimension into the healthcare system (Nundy et al., 2022). The significance of optimizing the healthcare system to create health equity is underscored. Within value-based care, the significance of the Quintuple Aim is heightened due to its congruence with the fundamental concepts and objectives of value-based care frameworks.

Promoting health equality within value-based care necessitates cultivating a collaborative and inclusive care team environment. Coordinated efforts across care teams to mitigate health inequities and ensure equitable provision of treatment have the potential to enhance patient outcomes and foster team satisfaction. In addition, acknowledging the influence of social determinants of health on the well-being of individuals can facilitate effective communication and cooperation among healthcare team members, hence facilitating the creation of holistic care strategies that consider each patient’s distinct requirements. According to Itchhaporia (2021), incorporating health equity within the Quintuple Aim can facilitate the advancement of value-based care models, hence fostering the development of a healthcare system characterized by fairness and equality.

Health equality is a crucial factor in enhancing the general health of populations, improving patient experiences, promoting the well-being of healthcare providers, and ensuring equitable access to high-quality healthcare services for all members of the community. Health equality is a multifaceted concept encompassing ethical considerations and practical implications for improving health outcomes and ensuring the long-term viability of healthcare systems. Creating a more sustainable healthcare system may be achieved by implementing value-based care models encompassing all five Quintuple Aim elements (Itchhaporia, 2021). The enhancement of patient outcomes, effective management of population health, cost control, provider engagement, and efficient collaboration across care teams contribute to developing a resilient healthcare system better suited to address the long-term demands of the population.

This project focuses on the specific aspect of cost per capita. One of the principal objectives of value-based care is to effectively manage healthcare expenditures while upholding the provision of services of superior quality. The “Reduce Costs” facet within the Quintuple Aim framework supports this objective by urging healthcare companies to identify areas of inefficiency, minimize wastage, and optimize the allocation of resources. This practice guarantees that the financial benefits derived from value-based care may be used towards enhancing patient care and achieving better results. With the advancing age of the population and the concurrent rise in the need for consistent healthcare services, the imperative to mitigate costs becomes progressively crucial. The lowering of costs in the Quintuple Aim framework has two distinct components. One focus area is identifying strategies for reducing the expenses associated with healthcare services, pharmaceuticals, and therapeutic interventions (Itchhaporia, 2021). Another component contributing to cost reduction is the emphasis on preventive measures. The Quintuple Aim strives to address the healthcare needs of individuals as they age by prioritizing the provision of essential resources for promoting good health.

Overview of the Selected Business Framework

The selected business framework is a cost-benefit analysis. It is standard practice in business to do a cost-benefit analysis to weigh the costs against the potential returns when deciding between competing projects. The first step in a cost-benefit analysis is to sum up all the costs connected with a project or option and then subtract the expected benefits from that total (Schiffmann et al., 2022). The decision should be made if the expected advantages are more significant than the costs. The study will tell the institution whether or not to proceed with the project based on its financial viability. However, if the costs exceed the potential advantages, the institution may wish to reconsider its course of action. Running these assessments before making major organizational decisions can have substantial financial rewards. An organization’s value chain or a project’s Return on Investment (ROI) may be dissected through careful analysis. Cost-benefit analysis is a standard method of data-driven decision-making in businesses of all sizes. One may use the core ideas and framework for making decisions in every area of life, not just business.

Opioid-based and opioid-free anesthesia for postoperative pain management are compared in this study. In modern clinical practice, eradicative medicine is accompanied by a rise in skepticism. One of these is the common practice of administering painkillers during surgery. Opioid-based anesthetic has been used for quite some time as the backbone of analgesia control before, during, and after surgery. Patients undergoing cardiac surgery have often been administered substantial doses of opioids for induction and maintenance (Ozgok & Demir, 2021). However, it eventually became clear that high-dose opioid regimens were associated with adverse outcomes like increased lengths of time spent on mechanical ventilation and in the hospital, gastrointestinal dysfunction, and the potential for opioid addiction.

Before the last two decades, it was proposed to “fast track” patients who had recently undergone cardiac surgery. As a result, the method has evolved, and balanced anesthesia is now the gold standard. Short-acting opioids, nonopioid analgesics, adjuvant medicines, regional blocks, and inhalational anesthetics were utilized in reduced dosages, and patients were also given smaller doses of these medications. The fast-track approach has been demonstrated to reduce the time spent on mechanical ventilation in the critical care unit and the hospital and the associated costs (Ozgok & Demir, 2021). As a result, the technique’s benefits are now readily apparent. Opioid-induced acute tolerance and hyperalgesia present a compelling rationale for opioid usage in the perioperative setting. There then follows a period of elevated vulnerability to addiction. All of these drawbacks became evident over time, and doctors began using opioid-free or reduced-dose anesthetic methods to address them. Opioid-free anesthesia is a method in which multimodal analgesics other than opioids are employed to manage perioperative pain effectively. Opioid-free anesthesia is feasible because of several nonopioid analgesic medicines with reduced reliance potentials and improved adverse effect profiles.

In a comprehensive review and meta-analysis, Motamed (2022) compared the effects of opioid-inclusive anesthesia on postoperative pain and the frequency of nausea and vomiting to those of opioid-free anesthesia. With data from 23 randomized controlled studies encompassing 1304 patients, the researchers showed that the analgesia provided by both anesthetic techniques was equivalent in the postoperative period and for up to 24 hours after surgery. Subgroup analysis using remifentanil as the comparison drug reveals a statistically significant 0.6-point difference in favor of the opioid-free group after two postoperative hours. Results showed that there was a 20% decrease in postoperative nausea and vomiting when opioid-free anesthesia was used.

This finding emphasizes the importance of intra-operative opioid delivery as a risk factor for postoperative nausea and vomiting. Patients rank vomiting as the most undesirable outcome, above surgical pain, despite this side effect being recognized as an unavoidable consequence of opioid-based analgesia. For patients, postoperative nausea and vomiting also negatively impact the healthcare system, leading to more extended hospital stays, higher medical bills, and longer times spent in the recovery room and the hospital overall (Li et al., 2020). Preventing postoperative nausea and vomiting with an opioid-free anesthetic regimen is advantageous and should be addressed, especially in high-risk patients. Cost savings associated with opioid-free anesthesia are of interest in this study. The research attempts to address a range of issues, such as the financial burden of opioid usage and the potential savings from switching to nonopioid treatments.

Rationale for the Framework

The cost analysis framework facilitates the adoption of a systematic methodology to assess a project proposal’s advantages and disadvantages. The cost-benefit analysis provides a framework for evaluating several choices and determining the most effective strategy to attain a desired outcome while also considering potential savings in investment expenditures. Implementing a cost-benefit analysis is vital in promoting the optimal allocation of limited resources towards using planned project resources. Cost–benefit analysis is a form of economic assessment that examines the monetary costs and benefits associated with proposed project initiatives (Schiffmann et al., 2022). The significance of performing a cost-benefit analysis is in comprehending the financial ramifications and determining the viability of pursuing a particular option. This evaluation approach evaluates two feasible possibilities with financial repercussions and emphasizes the importance of exercising caution when making financial decisions without justification.

The utilization of opioids, despite its historical prevalence, has demonstrated notable drawbacks, particularly in terms of financial burdens imposed on both healthcare facilities and individual patients. Therefore, using opioid-free anesthesia is considered an advanced approach to address the difficulties connected with opioid usage. Prolonged hospitalization of patients has been identified as a notable problem associated with opiate usage (Schlosser et al., 2020). According to projections, the implementation of opioid-free anesthesia is expected to result in a reduction in hospitalization duration and a considerable decrease in patient pharmaceutical expenses. Hence, with the implementation of a cost-benefit analysis, one may assess the financial implications of each intervention, thereby facilitating the ability to make well-informed judgments on the most appropriate course of action.

Synthesis of Evidence-Based Peer-Reviewed Literature

Although effective pain management is critical to the health and happiness of patients, opioids come with their risks, including addiction and overdose. Hip and knee arthroplasty patients who take fewer opioids after surgery have shorter hospital stays and fewer readmissions, according to research by Schlosser et al. (2020). It was also shown that the median duration of stay for patients treated with lower dosages of opiates was shorter and that earlier discharge had no detrimental effect on readmission rates. For instance, the median daily dose of morphine milligram equivalent (MME) was significantly lower for patients discharged on day 1. Patients on lower MME/day had a 41.2% greater chance of being discharged on day one than those on higher MME/day Schlosser et al. (2020). Similar results were shown for individuals on lesser dosages of MME/day, with an overall reduction in readmission probabilities of 15.2% Schlosser et al. (2020).

Hardy et al. (2021) found that long-term opioid use was linked to an increased risk of death in the hospital 30 days and a year following intensive care unit admission. The study’s early models showed that opioid usage raised the risk of dying within the next 30 days and the following year by 1.81 and 1.88 times, respectively (Hardy et al., 2021). In addition, the mean hospital stay for patients who were prescribed opioids was 11.62 days, compared to 10.02 days for patients who were not prescribed opioids before admission. After accounting for confounding factors, opioid usage was shown to increase LOS by 1.54 days. Similar results were found in a study by (Schlosser et al., 2020), which showed that both occasional opioid users and those on chronic opioid therapy were more likely to be readmitted to the hospital within 30 days following their initial hospitalization for an acute medical condition. This association persisted in both the partially and fully adjusted models. Preoperative opioid usage has been demonstrated to be an independent risk factor for increased postoperative expenses, length of stay, 30-day readmission rates, and the likelihood of being sent to a rehabilitation center in a subset of patients undergoing surgery.

The evidence suggests that the possibility for more infectious complications with chronic opioid misuse may account for the increased hospital stay and death among chronic opioid users. Research shows that opioid addiction suppresses the immune system by interfering with both the innate and adaptive immune response. Abuse of opioids dramatically increases one’s vulnerability to and severity of bacterial infection. Hardy et al. (2021) showed that morphine therapy causes this effect by reducing the production of interleukins and recruiting neutrophils. These methods might be generalized to the subgroup of the population that consists of individuals who abuse prescription opioids chronically as opposed to illicit opioids.

In a randomized control trial conducted by ElHoshy et al. (2023), it was found that in contrast to the MgSo4 group, the esmolol group demonstrated significantly reduced durations for extubation, spontaneous eye opening, tongue extension, and patient’s ability to recall their names. The esmolol group demonstrated an apparent reduction in both the incidence of regurgitation and the overall quantity of ondansetron ingested in the PACU. However, this study showed no significant difference in pain scores or the recall time for first rescue analgesia between the two groups under investigation. The White-Song scores of individuals in the esmolol group were significantly higher than those in the MgSo4 group at all measurement times except 120 minutes. Therefore, the research study determined that perioperative esmolol infusion has a more favorable and expedited recovery profile than MgSo4 infusion.

In another randomized control trial conducted by Abdelfatah and Amin (2021), the study aim was to evaluate whether the addition of intra-operative esmolol infusion to a Transversus Abdominis Plane (TAP) block can mitigate the limitations of TAP block alone during laparoscopic cholecystectomy, the results indicated that in the context of abdominal laparoscopic cholecystectomy, the utilization of intraoperative esmolol infusion in conjunction with TAP block demonstrated a noteworthy decrease in early postoperative pain scores and a discernible degree of variability in hemodynamics compared to the use of TAP block alone. These results suggest that esmolol is an effective analgesic for postoperative pain management.

The study conducted by Ekstein et al. (2019) on laparoscopic patients in the PACU revealed that for the first four hours following the procedure, pain in these patients was more severe and required 33% more analgesic doses than in those who had undergone laparotomy. Nevertheless, after 24 hours, laparoscopy patients exhibited a relative decrease in pain scores and were discharged from the hospital earlier, expressing greater satisfaction with the technique. The research postulated that the surge in pain ratings during the immediate postoperative phase might be accounted for by “central sensitization,” a phenomenon that prolongs and intensifies pain. This sensitization could potentially be induced by carbon dioxide insufflation alone.

Financial Analysis with Return on Investment (ROI)

ROI measures how profitable an investment is. If the return on investment is substantial, the rewards outweigh the costs. ROI is a performance metric to assess an intervention’s efficacy or compare other treatments’ relative merits. It is an attempt to quantify the rate of profit earned about the initial capital outlay. The computation itself is straightforward and has a wide variety of possible interpretations. If the return on investment is positive, the investment is usually a good idea (Fleßa, 2022). However, these signals might aid investors in eliminating fewer desirable possibilities or choosing the best ones if other chances with greater ROIs are available. Similarly, investors should stay away from ROIs that are negative since that indicates a loss.

The current effort determines the return on investment (ROI) between the costs associated with using opioids and those associated with utilizing opioid-free anesthesia. The financial implications of Opioid use are crucial to grasping this connection. Hospital costs in the United States average $2,883 per day, with California having the highest at $4,181 and Mississippi having the lowest at $1,305 (Skolnick, 2022). A hospitalization typically lasts for 4.6 days and costs $13,262. Hospitals spent an average of $1.94 billion per year treating patients who had overdosed on opioids. Opioid-induced constipation (OIC) was associated with nearly two times the risk of hospitalizations and ED visits over a 12-month observation period compared to those without OIC in a study by Pergolizzi Jr. et al. (2020) that used administrative claims data from an ambulatory patient population with chronic non-cancer pain. Medical and pharmacy costs were significantly higher for those with OIC than those without OIC, and the difference was even more pronounced when using the narrower definition of constipation (Pergolizzi Jr et al., 2020). Opioid abuse is linked to more extraordinary healthcare expenses, as seen by these numbers.

Even with all the innovations in medicine, intravenous (IV) opioid analgesia is still relied on for postoperative pain relief. Opioid analgesics such as morphine sulfate, fentanyl citrate, and hydromorphone hydrochloride are frequently used for moderate to severe postoperative pain. Opioid-related adverse Events (ORAEs) are linked to these drugs and can harm patient health and treatment satisfaction. Pain treatment at the bedside might be jeopardized when adverse reactions occur, limiting the ability to increase the dosage to a level appropriate analgesia is achieved. Patients who encounter ORAEs may have to stay in the hospital longer and incur more significant expenditures (Simpson et al., 2022). The incidence of ORAEs among surgical patients has been reported to range from 1.8% to 13.6%.

A study including 135,379 surgical patients given opioid analgesia found that 14,386 (10.6%) suffered ORAEs, resulting in substantial hospital financial losses. “(Simpson et al., 2022)” After adjusting for patient demographics, clinical risk factors, and surgery type, patients who encountered ORAEs had a mean cost per admission of US$8,225 greater than patients who did not experience ORAEs ($25,599 versus $17,374). Patients who reported ORAEs also had a lengthier average hospital stay than those who did not (6.8 days vs. 5.2 days).

Executive Summary

This initiative proposes strategically incorporating Esmolol, a beta-blocker with a brief duration of action, into the Enhanced Recovery After Surgery (ERAS) protocol to maximize perioperative care. Esmolol, a medication widely recognized for its capacity to avoid the need for opioids during and after surgical procedures, possesses the potential to substantially enhance patient outcomes by mitigating the detrimental effects typically associated with opioid usage. The project implementation is exhaustive, emphasizing staff training, collaborative efforts among healthcare teams, and a steadfast dedication to quality assurance.

It is anticipated that the incorporation of Esmolol into the ERAS protocol will result in numerous advantageous outcomes. Empirical research has consistently shown that this intervention effectively decreases the necessity for intravenous opioids, thereby ameliorating complications associated with opioid use and promoting a more seamless recuperation process. The project aims to improve patient comfort, hasten postoperative mobilization, and shorten patients’ time in the Post-Anesthesia Care Unit (PACU) by using Esmolol. These results are in complete accordance with the principles of the Quantum Aim, specifically regarding enhancing healthcare providers’ well-being, boosting patient experiences, and increasing overall satisfaction.

In order to guarantee the project’s achievement, a comprehensive quality assurance framework will be established. The QA strategy will incorporate dynamic protocol modifications, ongoing staff training, and routine audits as essential components. The initiative seeks to influence all five dimensions, including improving patient outcomes, enhancing patient experiences, reducing costs, optimizing the well-being of healthcare providers, and promoting population health, by focusing on Quintaple Aim principles. Adopting this holistic approach promotes a patient-centered and comprehensive healthcare environment, which is in line with the objectives of ERAS.

The incorporation of esmolol into the ERAS protocol is not only consistent with clinical goals but also provides a persuasive business rationale. The expected decrease in postoperative complications, reduction in PACU stays, and enhancement of patient satisfaction will result in substantial financial savings for the medical facility. The potential for improved patient outcomes and experiences to foster a favorable perception of the hospital could result in increased patient traffic and prospective business partnerships. By employing Esmolol proactively under the ERAS framework, the hospital establishes itself as a frontrunner in perioperative care. It guarantees a favorable return on investment via enhanced operational effectiveness, decreased resource consumption, and a dedication to providing patient-centered, superior care.


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