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Walayat S, Stadmeyer P, Hameed A, Sarfaraz M, Estrada P, Benson M, Soni A, Pfau P, Hayes P, Kile B, Cruz T, Gopal D. Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol. World J Gastrointest Endosc 2024; 16:413-423. [PMID: 39072249 PMCID: PMC11271719 DOI: 10.4253/wjge.v16.i7.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/22/2024] [Accepted: 06/19/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. AIM To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. CONCLUSION Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.
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Affiliation(s)
- Saqib Walayat
- Department of Gastroenterology, University of Illinois, Peoria, IL 61605, United States
| | - Peter Stadmeyer
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53792, United States
| | - Azfar Hameed
- Department of Internal Medicine, Texas Health Denton, Denton, TX 76201, United States
| | - Minahil Sarfaraz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore 042, Pakistan
| | - Paul Estrada
- Department of Gastroenterology, Texas Tech University Health Services Center, El Paso, TX 79911, United States
| | - Mark Benson
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Anurag Soni
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Patrick Pfau
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Paul Hayes
- Finance Business Partners UW Health, University of Wisconsin, Madison, WI 53792, United States
| | - Brittney Kile
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Toni Cruz
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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Torabi SJ, Tsang C, Patel RA, Nguyen TV, Manes RP, Kuan EC, Trask DK. Medicare volume and reimbursement trends in lingual and hyoid procedures for obstructive sleep apnea. Am J Otolaryngol 2024; 45:104361. [PMID: 38729015 DOI: 10.1016/j.amjoto.2024.104361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVES This study aims to analyze utilization and reimbursement trends in lingual and hyoid surgery for obstructive sleep apnea (OSA). METHODS Annual retrospective data on lingual and hyoid OSA surgeries was obtained from the 2000-2021 Medicare Part B National Summary Datafiles. Current Procedural Terminology (CPT) codes utilized included 21,685 (hyoid myotomy and suspension [HMS]), 41,512 (tongue base suspension [TBS]), 41,530 (radiofrequency ablation of the tongue [RFT]) and 42,870 (lingual tonsillectomy [LT]). RESULTS The number of lingual and hyoid OSA surgeries rose 2777 % from 121 in 2000 to 3481 in 2015, before falling 82.9 % to 594 in 2021. Accordingly, Medicare payments rose 17,899 % from an inflation-adjusted $46,958 in 2000 to $8.45 million in 2015, before falling drastically to $341,011 in 2021. As the number of HMSs (2000: 91; 2015: 84; 2021: 165), TBS (2009: 48; 2015: 31; 2021: 16), and LTs (2000: 121; 2015: 261; 2021: 234) only experienced modest changes in utilization, this change was largely driven by RFT (2009: 340; 2015: 3105; 2021: 179). Average Medicare payments for RFT rose from $1110 in 2009 to $2994 in 2015, before falling drastically to $737 in 2021. CONCLUSION Lingual and hyoid surgery for OSA has overall fallen in utilization among the Medicare population from 2000 to 2021. However, there was a brief spike in usage, peaking in 2015, driven by the adoption (and then quick dismissal) of RFT. The rise and fall in RFT use coincide with the rise and fall in reimbursement.
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Affiliation(s)
- Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Cynthia Tsang
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Rahul A Patel
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Theodore V Nguyen
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - R Peter Manes
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Douglas K Trask
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.
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Pimentel MPT, Chung S, Ross JM, Wright D, Urman RD. Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers. Anesth Analg 2024:00000539-990000000-00814. [PMID: 38640080 DOI: 10.1213/ane.0000000000006700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
BACKGROUND As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs. METHODS Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. RESULTS Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002). CONCLUSIONS This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.
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Affiliation(s)
- Marc Philip T Pimentel
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott Chung
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline M Ross
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Daniel Wright
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, Ohio
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Chen VW, Chidi AP, Rosen T, Dong Y, Richardson PA, Kramer J, Axelrod DA, Petersen LA, Massarweh NN. Case Sampling vs Universal Review for Evaluating Hospital Postoperative Mortality in US Surgical Quality Improvement Programs. JAMA Surg 2023; 158:1312-1319. [PMID: 37755869 PMCID: PMC10535011 DOI: 10.1001/jamasurg.2023.4532] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/04/2023] [Indexed: 09/28/2023]
Abstract
Importance Representative surgical case sampling, rather than universal review, is used by US Department of Veterans Affairs (VA) and private-sector national surgical quality improvement (QI) programs to assess program performance and to inform local QI and performance improvement efforts. However, it is unclear whether case sampling is robust for identifying hospitals with safety or quality concerns. Objective To evaluate whether the sampling strategy used by several national surgical QI programs provides hospitals with data that are representative of their overall quality and safety, as measured by 30-day mortality. Design, Setting, and Participants This comparative effectiveness study was a national, hospital-level analysis of data from adult patients (aged ≥18 years) who underwent noncardiac surgery at a VA hospital between January 1, 2016, and September 30, 2020. Data were obtained from the VA Surgical Quality Improvement Program (representative sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases). Data analysis was performed from July 1 to December 21, 2022. Main Outcomes and Measures The primary outcome was postoperative 30-day mortality. Quarterly, risk-adjusted, 30-day mortality observed-to-expected (O-E) ratios were calculated separately for each hospital using the sample and universal review cohorts. Outlier hospitals (ie, those with higher-than-expected mortality) were identified using an O-E ratio significantly greater than 1.0. Results In this study of data from 113 US Department of Veterans Affairs hospitals, the sample cohort comprised 502 953 surgical cases and the universal review cohort comprised 1 703 140. The majority of patients in both the representative sample and the universal sample were men (90.2% vs 91.1%) and were White (74.7% vs 74.5%). Overall, 30-day mortality was 0.8% and 0.6% for the sample and universal review cohorts, respectively (P < .001). Over 2145 quarters of data, hospitals were identified as an outlier in 11.7% of quarters with sampling and in 13.2% with universal review. Average hospital quarterly 30-day mortality rates were 0.4%, 0.8%, and 0.9% for outlier hospitals identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly 30-day mortality rates were 1.0% at outlier hospitals and 0.5% at nonoutliers. Among outlier hospital quarters in the sample, 47.4% were concurrently identified with universal review. For those identified with universal review, 42.1% were concurrently identified using the sample. Conclusions and Relevance In this national, hospital-level study, sampling strategies employed by national surgical QI programs identified less than half of hospitals with higher-than-expected perioperative mortality. These findings suggest that sampling may not adequately represent overall surgical program performance or provide stakeholders with the data necessary to inform QI efforts.
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Affiliation(s)
- Vivi W. Chen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alexis P. Chidi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Yongquan Dong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Peter A. Richardson
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Laura A. Petersen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta Veterans Affairs Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Latka K, Kołodziej W, Rajski R, Pawuś D, Chowaniec J, Latka D. Outpatient Spine Surgery in Poland: A Survey on Popularity, Challenges, and Future Perspectives. Risk Manag Healthc Policy 2023; 16:1839-1848. [PMID: 37719687 PMCID: PMC10505014 DOI: 10.2147/rmhp.s425465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023] Open
Abstract
Objective This study aimed to investigate the popularity of outpatient spine surgery in Poland, identify factors influencing its adoption, and assess its benefits, challenges, and impact on patient outcomes and healthcare costs. Additionally, the study proposes strategies to improve outpatient spine surgery adoption and ensure its safe implementation in Poland. Materials and Methods An electronic survey was distributed to members of the Polish Spine Surgery Society and the Polish Neurosurgery Society. Data were analyzed using Matlab R2020b statistical software, employing descriptive statistics to summarize the responses. Results The survey indicated that 67% of respondents provide spinal procedures commercially, with 58% performing them on an outpatient basis, showing the growing role of the private sector in providing spinal surgery services in Poland. Root nerve blocks and joint blocks were the most common outpatient procedures, followed by microdiscectomy, endoscopic discectomy, and L-S spinal fusion. The public NHF was the most common payer for outpatient procedures. Conclusion Outpatient spine surgery in Poland is not yet widespread, but improvements can be made to reduce hospital stays and enhance recovery. Changes in reimbursement systems to cover outpatient procedures and addressing physicians' liability concerns, particularly by emphasizing the NO-fault system, are essential. With proper support, outpatient spine surgery could become a valuable addition to Poland's healthcare system.
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Affiliation(s)
- Kajetan Latka
- Department of Neurosurgery, The St. Hedwig’s Regional Specialist Hospital, Opole, Poland
- Center for Minimally Invasive Spine and Peripheral Nerve Surgery neurochirurg.opole.pl, Opole, Poland
| | - Waldemar Kołodziej
- Center for Minimally Invasive Spine and Peripheral Nerve Surgery neurochirurg.opole.pl, Opole, Poland
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Rafal Rajski
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dawid Pawuś
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, Opole, Poland
| | - Jacek Chowaniec
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dariusz Latka
- Center for Minimally Invasive Spine and Peripheral Nerve Surgery neurochirurg.opole.pl, Opole, Poland
- Department of Neurosurgery, Institute of Medical Sciences, University of Opole, Opole, Poland
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Zenilman ME. Managing unknowns in the ambulatory surgery centers. Surgery 2022; 172:9-10. [PMID: 35216823 DOI: 10.1016/j.surg.2021.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Michael E Zenilman
- Department of Surgery, Weill Cornell Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY.
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