HEALTH ECONOMIC

INTRODUCTION

All the steps in the life cycle of a reusable endoscope, from its use, reprocessing, transport through to its repair, are additional items in the long list of expenditure required to maintain these systems.

The financial aspect is often considered first when comparing single-use bronchoscopes with conventional devices. While it is very easy to estimate the cost of using a disposable endoscope, it is much harder to calculate that of a reusable endoscope. Very often, the calculations are partial, only taking into account direct costs (disinfection equipment), but omitting indirect costs (maintenance contracts, depreciation, salaries of staff for reconditioning, etc.).

In order to make an objective comparison, it is necessary to not only cover the direct financial aspects, but to also extend the comparison to all direct and indirect costs:

Cost of repairs
Reprocessing process
Risks and costs of cross-contamination
Consequences of lack of availability

Cost per use of reusable bronchoscope = 294€ ⁽¹⁾

REPAIR

Bronchoscopes are fragile and regularly break. The costs of repair vary depending on the instrument type, but are known to be very onerous.

The problems of breakage are inevitable given the fragility of the systems and the situations in which they are used, with their various functions subject to significant pressure. The use of some instruments, and sometimes their incorrect use, exacerbate the risks of breakage for systems that are regularly weakened by disinfection solutions.

For each repair, the endoscope is unavailable for a long period; no repairs can be performed on-site in the hospital. Hospitals usually have costly maintenance contracts with manufacturers.
This aspect should not be overlooked when comparing single-use and reusable devices.⁽²⁾

$7,262

Average cost per repair

1/167

Use / repair ratio

$49

Average cost per use

The most frequent repairs concern angulation, a damaged insertion tube, a leak, etc. The overall repair process can result in several months of equipment unavailability.

REPROCESSING

An independent study was conducted by an American association (International Association of Healthcare Central Service Materiel Management) grouping together hygiene control service members in order to assess the impact of new guidelines for the disinfection of endoscopes issued following numerous disinfection problems.

Based on different guidelines, the authors carefully recorded the induced costs and time required to perform the various steps necessary for decontamination. The following results emerged, by procedure:

These data are a summary from 14 different American institutions and help estimate the real induced costs in terms of equipment, personnel and immobilization time to perform the processes in accordance with the guidelines. Although the study appears to be very detailed, the authors conclude that additional research is necessary in order to gain a better knowledge of the costs, particularly those related to maintenance.⁽³⁾

Average time = 76 min

Reprocessing step	Minimum cost	Maximum cost
PPE for reprocessing personel	$5.06	$17.78
Bedside pre-cleaning	$4.45	$19.14
Leak testing	$2.27	$5.28
Manual cleaning	$11.12	$37.11
Visual inspection, cleaning verification, and re-cleaning 20% endoscopes	$14.62	$49.69
HLD in an AER	$10.74	$17.21
Drying and storage	$1.88	$6.45
Repairs needed use due to issues identified by reprocessing technicians	$63.93	$128.05
TOTAL	$114.07	$280.71

CROSS-CONTAMINATION

Generally speaking, it is accepted that the risk of cross-contamination related to bronchoscopy is underestimated by the literature since it is under-reported and under-monitored by manufacturers and healthcare establishments.

A study published in 2017 for the first time attempted to quantify the additional cost induced by the risk of cross-contamination and the use of a reusable bronchoscope in the intensive care setting.

In intensive care/resuscitation, the most common infection developed by patients on mechanical ventilation is ventilation-acquired pneumonia (VAP). The immune defences are often weakened in these patients and the introduction of a contaminated device directly into the lungs, crossing the natural barriers (mucosa of the upper airways), regularly results in complications.

Risk of residual
cross-contamination after decontamination of a bronchoscope following the guidellness

21%

Risk of patient developing an infection following the use of a contaminateds reusable broncoscope

$28,383

Additional cost of treatment per patient having contracted VAP

When the risk of developing VAP in a ventilated patient is multiplied by the risk of residual contamination of an endoscope, an infection risk of 0.007% per procedure is obtained. This risk related to the cost of treating VAP leads to an estimated cost of $178 per procedure for the treatment of cross-contamination according to this study.⁽⁴⁾

CONSEQUENCES OF LACK OF AVAILABILITY

An audit was conducted over a one-year period in the United Kingdom by the Royal College of Anaesthetists concerning the management of airways in emergency departments, intensive care/resuscitation units and operating rooms.

The study examined difficult intubations, via 2.9 million anesthetics in the operating room, 20,000 tracheal intubations in emergency departments and 58,000 advanced airway care events in intensive care/ resuscitation units.

In the report, to explain this difference, it was mentioned that access to a fiber-optic endoscope for inspection of the airways or in the event of a difficult intubation was a recurrent problem, as was personnel training in the technique.

184

major events related to
airway managment

deaths were counted related
to airway managment,
including 16 in the operating room,
2 in emergency departments
and 18 in intensive care/resuscitation

Observation

The mortality rate related to the number of patients included in the study is 58 times higher in intensive care/resuscitation settings than in the operating room.

Causes

In the report, to explain this difference, it was mentioned that accessing to a fiber-optic endoscope for inspection of the airways or in the event of a difficult intubation were recurrents problems, as the personnel training was in the technique.

Recommendations

The authors recommend that a fiber-optic endoscope be immediately available and ready to use in intensive care/resuscitation or emergency departments. Personnel should also be better trained in the use of the different devices, including fiber-optic endoscopes, in the event of difficult intubation.
Single-use endoscopes obviate the need for lengthy and costly reprocessing and repair steps. They are always available and sterile and can be easily stored on an emergency intubation cart.⁽⁵⁾

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References to read:

(1) Mouritsen et al. A systematic review and cost effectiveness analysis of reusable vs. single-use bronchoscopes . Anaesthesia, 75: 529-540. https://doi.org/10.1111/anae.14891

(2) High Price of Bronchoscopy – Cost of Maintenance and Repair of Flexible and Ultra-sound Bronchoscopes

(3) A glimpse at the true cost of reprocessing endoscopes: results of a pilot project

(4) Terjesen et al. 2017; Early Assessmen of the Likely Cost Effectiveness of Single-Use Flexible Video Bronchoscopes

(5) NAP4 – 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society.