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Wanderer JP, Nelson SE, Hester DL, Shotwell M, Sandberg WS, Anderson-Dam J, Raines DE, Ehrenfeld JM. Sources of Variation in Anesthetic Drug Costs. Anesth Analg 2019; 126:1241-1248. [PMID: 29256939 DOI: 10.1213/ane.0000000000002732] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Increasing attention has been focused on health care expenditures, which include anesthetic-related drug costs. Using data from 2 large academic medical centers, we sought to identify significant contributors to anesthetic drug cost variation. METHODS Using anesthesia information management systems, we calculated volatile and intravenous drug costs for 8 types of inpatient surgical procedures performed from July 1, 2009, to December 31, 2011. For each case, we determined patient age, American Society of Anesthesiologists (ASA) physical status, gender, institution, case duration, in-room provider, and attending anesthesiologist. These variables were then entered into 2 fixed-effects linear regression models, both with logarithmically transformed case cost as the outcome variable. The first model included duration, attending anesthesiologist, patient age, ASA physical status, and patient gender as independent variables. The second model included case type, institution, patient age, ASA physical status, and patient gender as independent variables. When all variables were entered into 1 model, redundancy analyses showed that case type was highly correlated (R = 0.92) with the other variables in the model. More specifically, a model that included case type was no better at predicting cost than a model without the variable, as long as that model contained the combination of attending anesthesiologist and case duration. Therefore, because we were interested in determining the effect both variables had on cost, 2 models were created instead of 1. The average change in cost resulting from each variable compared to the average cost of the reference category was calculated by first exponentiating the β coefficient and subtracting 1 to get the percent difference in cost. We then multiplied that value by the mean cost of the associated reference group. RESULTS A total of 5504 records were identified, of which 4856 were analyzed. The median anesthetic drug cost was $38.45 (25th percentile = $23.23, 75th percentile = $63.82). The majority of the variation was not described by our models-35.2% was explained in the model containing case duration, and 32.3% was explained in the model containing case type. However, the largest sources of variation our models identified were attending anesthesiologist, case type, and procedure duration. With all else held constant, the average change in cost between attending anesthesiologists ranged from a cost decrease of $41.25 to a cost increase of $95.67 (10th percentile = -$19.96, 90th percentile = +$20.20) when compared to the provider with the median value for mean cost per case. The average change in cost between institutions was significant but minor ($5.73). CONCLUSIONS The majority of the variation was not described by the models, possibly indicating high per-case random variation. The largest sources of variation identified by our models included attending anesthesiologist, procedure type, and case duration. The difference in cost between institutions was statistically significant but was minor. While many prior studies have found significant savings resulting from cost-reducing interventions, our findings suggest that because the overall cost of anesthetic drugs was small, the savings resulting from interventions focused on the clinical practice of attending anesthesiologists may be negligible, especially in institutions where access to more expensive drugs is already limited. Thus, cost-saving efforts may be better focused elsewhere.
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Affiliation(s)
- Jonathan P Wanderer
- From the Department of Anesthesiology, Vanderbilt University, The Vanderbilt Clinic, Nashville, Tennessee.,Departments of Biomedical Informatics
| | - Sara E Nelson
- From the Department of Anesthesiology, Vanderbilt University, The Vanderbilt Clinic, Nashville, Tennessee
| | - Douglas L Hester
- From the Department of Anesthesiology, Vanderbilt University, The Vanderbilt Clinic, Nashville, Tennessee
| | - Matthew Shotwell
- From the Department of Anesthesiology, Vanderbilt University, The Vanderbilt Clinic, Nashville, Tennessee.,Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Warren S Sandberg
- From the Department of Anesthesiology, Vanderbilt University, The Vanderbilt Clinic, Nashville, Tennessee.,Departments of Biomedical Informatics
| | - John Anderson-Dam
- Department of Anesthesiology, UCLA Medical Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Douglas E Raines
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jesse M Ehrenfeld
- From the Department of Anesthesiology, Vanderbilt University, The Vanderbilt Clinic, Nashville, Tennessee.,Biostatistics, Vanderbilt University, Nashville, Tennessee.,Department of Surgery, Vanderbilt University, Nashville, Tennessee
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Kennedy RR, French RA. A Ten-Year Audit of Fresh Gas Flows in a New Zealand Hospital: The Influence of the Introduction of Automated Agent Delivery and Comparisons with Other Hospitals. Anaesth Intensive Care 2019; 42:65-72. [DOI: 10.1177/0310057x1404200112] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- R. R. Kennedy
- Department of Anaesthesia, Christchurch Hospital, Christchurch, New Zealand
- Christchurch Hospital and University of Otago, Christchurch, New Zealand
| | - R. A. French
- Department of Anaesthesia, Christchurch Hospital, Christchurch, New Zealand
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Abstract
Abstract
Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.
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Kolarczyk L, Zvara D. A Value-Based Revolution Afoot. Anesth Analg 2018; 126:1116-1117. [DOI: 10.1213/ane.0000000000002830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Amorin-Woods LG, Losco BE. 'PICO-D Management'; a decision-aid for evidence-based chiropractic education and clinical practice. Chiropr Man Therap 2016; 24:49. [PMID: 27999660 PMCID: PMC5151136 DOI: 10.1186/s12998-016-0130-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 11/10/2016] [Indexed: 12/21/2022] Open
Abstract
Background Various models and decision-making aids exist for chiropractic clinical practice. Results “PICO-D Man” (Patient-Intervention-Comparator-Outcome-Duration Management) is a decision-aid developed in an educational setting which field practitioners may also find useful for applying defensible evidence-based practice. Clinical decision-making involves understanding and evaluating both the proposed clinicalintervention(s) and the relevant and available management options with respect to describing the patient and their problem, clinical and cost effectiveness, safety, feasibility and time-frame. Conclusions For people consulting chiropractors this decision-aid usually requires the practitioner to consider a comparison of usual chiropractic care, (clinical management including a combination of active care and passive manual interventions), to usual medical care usually including medications, or other allied healthmanagement options while being mindful of the natural history of the persons’ condition.
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Affiliation(s)
- Lyndon G Amorin-Woods
- School of Health Professions, Discipline of Chiropractic 90 South St Murdoch, Perth, 6150 Western Australia
| | - Barrett E Losco
- School of Health Professions, Discipline of Chiropractic 90 South St Murdoch, Perth, 6150 Western Australia
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Hakimoglu S, Hancı V, Karcıoglu M, Tuzcu K, Davarcı I, Kiraz HA, Turhanoglu S. Cost-Conscious of Anesthesia Physicians: An awareness survey. Pak J Med Sci 2015; 31:1089-94. [PMID: 26648992 PMCID: PMC4641261 DOI: 10.12669/pjms.315.7520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: Increasing competitive pressure and health performance system in the hospitals result in pressure to reduce the resources allocated. The aim of this study was to evaluate the anesthesiology and intensive care physicians awareness of the cost of the materials used and to determine the factors that influence it. Methods: This survey was conducted between September 2012 and September 2013 after the approval of the local ethics committee. Overall 149 anesthetists were included in the study. Participants were asked to estimate the cost of 30 products used by anesthesiology and intensive care units. Results: One hundred forty nine doctors, 45% female and 55% male, participated in this study. Of the total 30 questions the averages of cost estimations were 5.8% accurate estimation, 35.13% underestimation and 59.16% overestimation. When the participants were divided into the different groups of institution, duration of working in this profession and sex, there were no statistically significant differences regarding accurate estimation. However, there was statistically significant difference in underestimation. In underestimation, there was no significant difference between 16-20 year group and >20 year group but these two groups have more price overestimation than the other groups (p=0.031). Furthermore, when all the participants were evaluated there were no significant difference between age-accurate cost estimation and profession time-accurate cost estimation. Conclusion: Anesthesiology and intensive care physicians in this survey have an insufficient awareness of the cost of the drugs and materials that they use. The institution and experience are not effective factors for accurate estimate. Programs for improving the health workers knowledge creating awareness of cost should be planned in order to use the resources more efficiently and cost effectively,
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Affiliation(s)
- Sedat Hakimoglu
- Sedat Hakimoğlu, MD, Assistant Professor, Department of Anesthesiology and Reanimation, Mustafa Kemal University, Faculty of Medicine, 31100, Serinyol, Antakya, Hatay, Turkey
| | - Volkan Hancı
- Volkan Hancı, MD, Associate Professor, Dept. of Anesthesiology and Reanimation, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Murat Karcıoglu
- Murat Karcıoğlu, MD, Associate Professor, Department of Anesthesiology and Reanimation, Mustafa Kemal University, Faculty of Medicine, 31100, Serinyol, Antakya, Hatay, Turkey
| | - Kasım Tuzcu
- Kasım Tuzcu, MD, AssistantProfessor, Department of Anesthesiology and Reanimation, Mustafa Kemal University, Faculty of Medicine, 31100, Serinyol, Antakya, Hatay, Turkey
| | - Isıl Davarcı
- Isıl Davarcı, MD, Assistant Professor, Department of Anesthesiology and Reanimation, Mustafa Kemal University, Faculty of Medicine, 31100, Serinyol, Antakya, Hatay, Turkey
| | - Hasan Ali Kiraz
- Hasan Ali Kiraz, MD, Assistant Professor, Dept. of Anesthesiology and Reanimation, ÇanakkaleOnsekiz Mart University, Faculty of Medicine, Çanakkale, Turkey
| | - Selim Turhanoglu
- Selim Turhanoğlu, MD, Professor, Department of Anesthesiology and Reanimation, Mustafa Kemal University, Faculty of Medicine, 31100, Serinyol, Antakya, Hatay, Turkey
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Epstein RH, Dexter F, Patel N. Influencing Anesthesia Provider Behavior Using Anesthesia Information Management System Data for Near Real-Time Alerts and Post Hoc Reports. Anesth Analg 2015; 121:678-692. [PMID: 26262500 DOI: 10.1213/ane.0000000000000677] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this review article, we address issues related to using data from anesthesia information management systems (AIMS) to deliver near real-time alerts via AIMS workstation popups and/or alphanumeric pagers and post hoc reports via e-mail. We focus on reports and alerts for influencing the behavior of anesthesia providers (i.e., anesthesiologists, anesthesia residents, and nurse anesthetists). Multiple studies have shown that anesthesia clinical decision support (CDS) improves adherence to protocols and increases financial performance through facilitation of billing, regulatory, and compliance documentation; however, improved clinical outcomes have not been demonstrated. We inform developers and users of feedback systems about the multitude of concerns to consider during development and implementation of CDS to increase its effectiveness and to mitigate its potentially disruptive aspects. We discuss the timing and modalities used to deliver messages, implications of outlier-only versus individualized feedback, the need to consider possible unintended consequences of such feedback, regulations, sustainability, and portability among systems. We discuss statistical issues related to the appropriate evaluation of CDS efficacy. We provide a systematic review of the published literature (indexed in PubMed) of anesthesia CDS and offer 2 case studies of CDS interventions using AIMS data from our own institution illustrating the salient points. Because of the considerable expense and complexity of maintaining near real-time CDS systems, as compared with providing individual reports via e-mail after the fact, we suggest that if the same goal can be accomplished via delayed reporting versus immediate feedback, the former approach is preferable. Nevertheless, some processes require near real-time alerts to produce the desired improvement. Post hoc e-mail reporting from enterprise-wide electronic health record systems is straightforward and can be accomplished using system-independent pathways (e.g., via built-in e-mail support provided by the relational database management system). However, for some of these enterprise-wide systems, near real-time data access, necessary for CDS that generates concurrent alerts, has been challenging to implement.
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Affiliation(s)
- Richard H Epstein
- From the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Anesthesia, University of Iowa, Iowa City, Iowa; and Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Tabing AK, Ehrenfeld JM, Wanderer JP. Limiting the accessibility of cost-prohibitive drugs reduces overall anesthetic drug costs: a retrospective before and after analysis. Can J Anaesth 2015; 62:1045-54. [PMID: 26239665 DOI: 10.1007/s12630-015-0442-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/21/2015] [Accepted: 07/16/2015] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Cost effectiveness is becoming increasingly important in today's healthcare environment. Remifentanil, dexmedetomidine, and desflurane are costly agents that often have suitable alternatives to their use. We sought to identify changes in cost and outcomes following interventions that limited the availability of these drugs. METHODS We calculated anesthetic drug costs for all operating room procedures performed before and after the accessibility interventions. We retrospectively compared drug costs per case and the frequency of agent use before and after the interventions. In addition, we analyzed the incidence of adverse outcomes, including delayed out-of-room times, postoperative nausea and vomiting (PONV), unplanned intubations, use of naloxone, and reintubations. Wilcoxon-Mann-Whitney and Chi square analyses were used to quantify differences in cost, use, and outcomes between cohorts. RESULTS Of the 27,233 cases we identified, 24,201 cases were analyzed. The mean anesthetic drug costs per case were significantly lower after the interventions vs before at ($21.44 vs $32.39, respectively), a cost savings of $10.95 (95% confidence interval, $9.86 to $12.04; P < 0.001). Additionally, a comparison of data after vs before the interventions revealed the following results: remifentanil use was significantly lower (3.5% vs 9.2% of cases; P < 0.001). Dexmedetomidine use did not differ significantly (0.4% vs 0.5% of cases; P = 0.07), and desflurane use was significantly lower (0.6% vs 20.2% of cases; P < 0.001). There was no significant relationship between the interventions and the frequency of delayed out-of-room times (15.5% vs 15.9%; P = 0.41), unplanned intubations (0.02% vs 0.03%; P = 0.60), and reintubations (0.01% vs 0.03%; P = 0.28). Postoperative nausea and vomiting decreased significantly after the interventions (22.8% vs 24.4%; P = 0.003), and naloxone use showed a significant increase (0.22% vs 0.11% of cases; P = 0.04). CONCLUSIONS Reducing the accessibility of these cost-prohibitive agents resulted in significant anesthetic drug cost savings and decreased utilization of remifentanil and desflurane. The interventions had no significant effect on patient recovery time, incidence of unplanned intubations, or incidence of reintubation, but they were associated with a decrease in PONV and an increase in naloxone use.
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Affiliation(s)
- Ariana K Tabing
- Vanderbilt University School of Medicine, 2215 Garland Ave, Nashville, TN, 37232, USA,
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Benhamou D, Constant I, Longrois D, Molliex S, Nouette-Gaulain K, Bull A. Use of volatile anaesthetic agents in anaesthesia: A survey of practice in France in 2012. Anaesth Crit Care Pain Med 2015; 34:205-9. [DOI: 10.1016/j.accpm.2015.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 01/12/2015] [Indexed: 11/16/2022]
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A simple intervention to reduce the anesthetic pharmacy budget; the effect of price list stickers placed on vaporizers. J Clin Anesth 2015; 27:307-10. [DOI: 10.1016/j.jclinane.2015.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 01/28/2015] [Accepted: 03/02/2015] [Indexed: 11/21/2022]
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Bajwa SJS. Amalgamation of management information system into anaesthesiology practice: A boon for the modern anaesthesiologists. Indian J Anaesth 2014; 58:121-6. [PMID: 24963173 PMCID: PMC4050925 DOI: 10.4103/0019-5049.130803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Over the years, traditional anaesthesia record keeping system has been the backbone of anaesthesiology ever since its introduction in the 1890s by Dr. Harvey Cushing and Dr. Ernest A. Codman. Besides providing the important information regarding patients’ vital physiologic parameters, paper records had been a reliable source for various clinical research activities. The introduction of electronic monitoring gadgets and electronic record keeping systems has revolutionised the anaesthesiology practice to a large extent. Recently, the introduction of anaesthesia information management system (AIMS), which incorporates all the features of monitoring gadgets, such as electronic storage of large accurate data, quality assurance in anaesthesia, enhancing patient safety, ensuring legal protection, improved billing services and effecting an organisational change, is almost a revolution in modern-day anaesthesiology practice. The clinical research activities that are responsible for taking anaesthesiology discipline to higher peaks have also been boosted by the amalgamation of AIMS, enabling multicenter studies and sharing of clinical data. Barring few concerns in its installation, cost factors and functional aspects, the future of AIMS seems to be bright and will definitely prove to be a boon for modern-day anaesthesiology practice.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
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Bucx MJL, Landman JJ, van Onzenoort HAW, Kox M, Scheffer GJ. Reducing the cost of anaesthesia. Anaesthesia 2014; 69:525-6. [PMID: 24738822 DOI: 10.1111/anae.12687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M J L Bucx
- Radboud University Medical Centre, Nijmegen, The Netherlands.
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Dexter F, Wachtel RE. Strategies for Net Cost Reductions with the Expanded Role and Expertise of Anesthesiologists in the Perioperative Surgical Home. Anesth Analg 2014; 118:1062-71. [DOI: 10.1213/ane.0000000000000173] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Koçkaya G, Koçkaya PD, Özbağrıaçık Ö, Oba S. Improving cost-efficiency at a hospital by showing the time-saving effect of using different neuromuscular blockers for short operations. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2014. [DOI: 10.1111/jphs.12040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | - Sibel Oba
- Şişli Etfal Government Hospital; Istanbul Turkey
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Bilinski K, Boyages S. Evidence of overtesting for vitamin D in Australia: an analysis of 4.5 years of Medicare Benefits Schedule (MBS) data. BMJ Open 2013; 3:bmjopen-2013-002955. [PMID: 23794593 PMCID: PMC3693422 DOI: 10.1136/bmjopen-2013-002955] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To comprehensively examine pathology test utilisation of 25-hydroxyvitamin D (25(OH)D) testing in each state of Australia to determine the cost impact and value and to add evidence to enable the development of vitamin D testing guidelines. DESIGN Longitudinal analysis of all 25(OH)D pathology tests in Australia. SETTING Primary and Tertiary Care. MEASUREMENTS The frequency of 25(OH)D testing between 1 April 2006 and 30 October 2010 coded for each individual by provider, state and month between 2006 and 2010. Rate of tests per 100 000 individuals and benefit for 25(OH)D, full blood count (FBC) and bone densitometry by state and quarter between 2000 and 2010. RESULTS 4.5 million tests were performed between 1 April 2006 and 30 October 2010. 42.9% of individuals had more than one test with some individuals having up to 79 tests in that period. Of these tests, 80% were ordered by general practitioners and 20% by specialists. The rate of 25(OH)D testing increased 94-fold from 2000 to 2010. Rate varied by state whereby the most southern state represented the highest increase and northern state the lowest increase. In contrast, the rate of a universal pathology test such as FBC remained relatively stable increasing 2.5-fold. Of concern, a 0.5-fold (50%) increase in bone densitometry was seen. CONCLUSIONS The marked variation in the frequency of testing for vitamin D deficiency indicates that large sums of potentially unnecessary funds are being expended. The rate of 25(OH)D testing increased exponentially at an unsustainable rate. Consequences of such findings are widespread in terms of cost and effectiveness. Further research is required to determine the drivers and cost benefit of such expenditure. Our data indicate that adoption of specific guidelines may improve efficiency and effectiveness of 25(OH)D testing.
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Affiliation(s)
- Kellie Bilinski
- Westmead Breast Cancer Institute, Westmead Hospital, Westmead NSW and The University of Sydney, Western Clinical School, Sydney New South Wales, Australia
| | - Steve Boyages
- Department of Endocrinology, Westmead Hospital, The University of Sydney, eHealth NSW Initiative, NSW Health, Westmead, New South Wales, Australia
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Abstract
Anesthetic drugs have the potential to contribute to global warming. There is some debate about the overall impact of anesthetic drugs relative to carbon dioxide, but there is no question that practice patterns can limit the degree of environmental contamination. In particular, careful attention to managing fresh gas flow can use anesthetic drugs more efficiently--reducing waste while achieving the same effect on the patient. The environmental impact of a single case may be minimal, but when compounded over an entire career, the manner in which fresh gas flow is managed by each individual practitioner can make a significant difference in the volume of anesthetic gases released into the atmosphere. The maintenance phase of anesthesia is the best opportunity to reduce fresh gas flow because circuit gas concentrations are relatively stable and it is often the longest phase of the procedure. There are, however, methods for managing fresh gas flow during induction and emergence that can reduce the amount of wasted anesthetic vapor. This article provides background information and discusses strategies for managing fresh gas flow during each phase of anesthesia with the goal of reducing waste when using a circle anesthesia system. Monitoring oxygen and anesthetic gas concentrations is essential to implementing these strategies safely and effectively. Future technological advances in anesthetic delivery systems are needed to make it less challenging to manage fresh gas flow.
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Affiliation(s)
- Jeffrey M Feldman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 34th & Civic Center Blvd., Philadelphia, PA 19104, USA.
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Cost-cutting capital investment proposals in chronic pain management. J Clin Anesth 2012; 24:82-3. [DOI: 10.1016/j.jclinane.2011.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 11/26/2010] [Accepted: 02/22/2011] [Indexed: 11/20/2022]
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Plaud B. Arrêt de la commercialisation du thiopental (Pentothal®) par les laboratoires Hospira™ - France : une mauvaise nouvelle qui en annonce probablement d’autres. ACTA ACUST UNITED AC 2011; 30:617-8. [DOI: 10.1016/j.annfar.2011.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Zamper RPC, Torres MLA, Ferraz JL, Neto SM, Holzhacker R, Shimada V, Carmona MJC. Evaluation of a computerized anesthesia report. Rev Bras Anestesiol 2010; 60:285-301. [PMID: 20682160 DOI: 10.1016/s0034-7094(10)70036-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 01/20/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In Brazil, the use of information systems that allows filling out anesthesia reports automatically is still in its initial stages. The objective of this study was to validate an automated anesthesia record. METHODS This study was approved by the Ethics Commission of the institution; an industry-university partnership (Dixtal, São Paulo, Brazil and Universidade de São Paulo) was developed, and the study received a grant from FINEP (Financiadora de Estudos e Projetos do Ministério de Ciência e Tecnologia). The integration of hospital information systems for recovery of data regarding identification, preoperative evaluation, and laboratorial exams was the premise of this study. The applicability of the final version of the prototype of the automated system was evaluated by applying a semi-structured tool to 33 physicians, residents, and/or anesthesiologists during surgery procedures in 66 patients. Descriptive evaluation of the data was undertaken. RESULTS The computerized system was considered reliable even for large surgeries by 81% of the participants. The majority of the anesthesiologists considered the prototype of great value for future studies and capable of meeting the requirements of anesthesia reports, bringing benefits for anesthesiologists, patients, and hospitals. The full use of the system requires training and some of its aspects can be improved. CONCLUSIONS Validation of this prototype of a computerized system for elaboration of anesthesia reports showed the viability of this type of solution to help anesthesiologists in their daily tasks, increasing the reliability of the data. Besides, when evaluating the applicability, anesthesiologists considered that the prototype could be useful for patients, physicians, and hospitals.
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Affiliation(s)
- Raffael Pereira Cezar Zamper
- Anesthesiology Subject and Anesthesia Division of Instituto Central do Hospital das Clínicas (HC) of Faculdade de Medicina da Universidade de São Paulo (FMUSP), SP
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Merrill DG, Laur JJ. Management by outcomes: efficiency and operational success in the ambulatory surgery center. Anesthesiol Clin 2010; 28:329-351. [PMID: 20488398 DOI: 10.1016/j.anclin.2010.02.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Quality of care and service in health care can benefit from the use of algorithm-driven care (standard work) that integrates literature assessment and analysis of local outcome and process data to eliminate unnecessary variation that causes error and waste. Effective management of an ambulatory surgery center requires that leadership emphasize constant improvement in the processes of care to achieve maximum patient safety and satisfaction, delivered with highest efficiency. Process improvement may be achieved by simple measurement alone (the Hawthorne effect). However, as shown in this article, the authors have successfully used the implementation of regular measurement and open discussion of patients' clinical outcomes and other operational metrics to focus active systems improvement projects in ambulatory surgery centers, with excellent results.
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Affiliation(s)
- Douglas G Merrill
- Outpatient Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Way, Lebanon, NH 03753, USA.
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Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010; 111:120-8. [PMID: 20442260 DOI: 10.1213/ane.0b013e3181da832d] [Citation(s) in RCA: 283] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In this review, we summarize the clinical implications of residual neuromuscular block. Data suggest that residual neuromuscular block is a common complication in the postanesthesia care unit, with approximately 40% of patients exhibiting a train-of-four ratio <0.9. Volunteer studies have demonstrated that small degrees of residual paralysis (train-of-four ratios 0.7-0.9) are associated with impaired pharyngeal function and increased risk of aspiration, weakness of upper airway muscles and airway obstruction, attenuation of the hypoxic ventilatory response (approximately 30%), and unpleasant symptoms of muscle weakness. Clinical studies have also identified adverse postoperative events associated with intraoperative neuromuscular management. Large databased investigations have identified intraoperative use of muscle relaxants and residual neuromuscular block as important risk factors in anesthetic-related morbidity and mortality. Furthermore, observational and randomized clinical trials have demonstrated that incomplete neuromuscular recovery during the early postoperative period may result in acute respiratory events (hypoxemia and airway obstruction), unpleasant symptoms of muscle weakness, longer postanesthesia care unit stays, delays in tracheal extubation, and an increased risk of postoperative pulmonary complications. These recent data suggest that residual neuromuscular block is an important patient safety issue and that neuromuscular management affects postoperative outcomes.
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Affiliation(s)
- Glenn S Murphy
- Department of Anesthesiology, NorthShore University HealthSystem, 2650 Ridge Ave., Evanston, IL 60201, USA.
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Fernández P, Andruskevicius M, Cristiani F. [Use of nitrous oxide in Uruguay]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:71-78. [PMID: 20336997 DOI: 10.1016/s0034-9356(10)70167-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) is a medicinal gas that has been used for anesthesia for over a century and a half. As evidence of the adverse effects of N2O have been contrasted with the good safety profiles of new anesthetic agents, use of the older gas has declined. OBJECTIVE To describe and analyze the use of N2O for anesthesia in the Eastern Republic of Uruguay. To describe the use of other drugs for general anesthesia. METHODS The study had 2 phases. In the first phase, information on the use of N2O and other drugs for general anesthesia was obtained from the medical records of a sample of patients who underwent surgery between November 2007 and November 2008 at nationally important hospitals. In the second phase 80 physician anesthesiologists were surveyed to obtain information on their reported use of N2O for general anesthesia. The respondents were found working during the first half of 2008. RESULTS A total of 104 patients' records were read and 80 anesthesiologists were surveyed. We found that 31 (29.8%) patients received N2O during anesthesia. The survey showed that 62 (77.5%) of the anesthesiologists had used N2O in the last 6 months. Nine (50%) of the anesthesiologists who had not used N2O said their reason was that it was unavailable. The other 9 referred either to the risk of postoperative nausea and/or vomiting (n = 6) or the fact of having better alternatives (n = 9). CONCLUSION This study shows that N2O is little used in current anesthesia practice. The tendency in Uruguay continues to be toward declining use.
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Affiliation(s)
- P Fernández
- Departamento de Farmacología y Terapéutica, Facultad de Medicina, Universidad de la República, Uruguay.
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Management of outcomes in the ambulatory surgery center: the role of standard work and evidence-based medicine. Curr Opin Anaesthesiol 2008; 21:743-7. [DOI: 10.1097/aco.0b013e3283126d0d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Muravchick S, Caldwell JE, Epstein RH, Galati M, Levy WJ, O'Reilly M, Plagenhoef JS, Rehman M, Reich DL, Vigoda MM. Anesthesia Information Management System Implementation: A Practical Guide. Anesth Analg 2008; 107:1598-608. [DOI: 10.1213/ane.0b013e318187bc8f] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kheterpal S, Gupta R, Blum JM, Tremper KK, O'Reilly M, Kazanjian PE. Electronic Reminders Improve Procedure Documentation Compliance and Professional Fee Reimbursement. Anesth Analg 2007; 104:592-7. [PMID: 17312215 DOI: 10.1213/01.ane.0000255707.98268.96] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting. METHODS We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders. RESULTS A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement. CONCLUSIONS The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.
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Affiliation(s)
- Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Vigoda MM, Gencorelli F, Lubarsky DA. Changing Medical Group Behaviors: Increasing the Rate of Documentation of Quality Assurance Events Using an Anesthesia Information System. Anesth Analg 2006; 103:390-5, table of contents. [PMID: 16861422 DOI: 10.1213/01.ane.0000221176.27215.20] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the United States, quality assurance (QA) documentation is required by numerous agencies for each anesthetic performed. The goal of this study was to determine the effect of several interventions on the voluntary completion rate of QA documentation. We hypothesized that optimizing workflow integration would increase both QA completion rates and complication capture rates and promote long-term successful changes in reporting behavior. Whereas electronic scanning of anesthetic records may automate some aspects of QA, there will continue to be a need for anesthesiologists to enter QA documentation that cannot be automated. Starting from a baseline completion rate of 48%, we instituted a series of interventions. We successively increased the completion rate to 55% (education), 68% (workflow integration), and 78% (individual feedback). Each intervention increased the completion rate from the previous intervention (P < 0.001). The increased completion rate suggests better overall data capture, because the percentage of "no complication" entries decreased. After the study period, the completion rate increased to 94%, principally because of the improved workflow integration. As implementation of anesthesia information systems increases, attention to user interface design may be a key component in the functionality and utility of these systems.
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Affiliation(s)
- Michael M Vigoda
- Center for Informatics and Perioperative Management, Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami/Jackson Memorial Hospital, 1611 NW 12th Ave. (C-300), Miami, Florida 33136, USA.
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Vigoda MM, Lubarsky DA. The Medicolegal Importance of Enhancing Timeliness of Documentation When Using an Anesthesia Information System and the Response to Automated Feedback in an Academic Practice. Anesth Analg 2006; 103:131-6, table of contents. [PMID: 16790641 DOI: 10.1213/01.ane.0000221602.90315.49] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Documentation should ideally occur in real time immediately after completion of a service. Although electronic records often do not print the time that documentation notes were entered on the medical record, automated anesthesia record keeping systems store an audit trail that time stamps events entered by all anesthesia providers. As more lawyers become aware of this fact and requisition audit trails, prospective charting of necessary documentation may undermine the integrity of an anesthesia care team accused of malpractice, with potentially significant medicolegal consequences. We changed existing documentation practices of a large academic practice via a three-step process. Educational sessions increased the percentage of cases with correct timing of emergence documentation from 25% to 60% over a 2-mo period. Automated email performance feedback further increased correct note timing to 70%. When combined with personal contact by a member of the billing office and email copy notification of the chair, the percentage increased to >99.5%. The behavioral change was seen in all individuals, as 95% of attendings had < or = 2 records/mo with untimely documentation at the end of the study period. Once the habits were ingrained, further input was rarely necessary over the next 9 mo. This suggests physician behavioral change related to work process flow, unlike that related to patient care, is easily sustained.
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Affiliation(s)
- Michael M Vigoda
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School ofMedicine, Miami, Florida 33136, USA.
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Heidegger T, Gerig HJ, Henderson JJ. Strategies and algorithms for management of the difficult airway. Best Pract Res Clin Anaesthesiol 2005; 19:661-74. [PMID: 16408540 DOI: 10.1016/j.bpa.2005.07.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Management of the difficult airway is the most important patient safety issue in the practice of anaesthesia. Many national societies have developed algorithms and guidelines for management of the difficult airway. The key issues of this chapter are definition of terms, the advantages and disadvantages of the use of guidelines, and a comparison of different algorithms and guidelines for management of the most important clinical airway scenarios. Although there is no strong evidence of benefit for any specific strategy or algorithm for management of the difficult airway, there is strong agreement that a pre-planned strategy may lead to improved outcome.
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Affiliation(s)
- Thomas Heidegger
- Department of Anaesthesiology, Cantonal Hospital St Gallen, Switzerland.
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Schuster M, Standl T, Reissmann H, Kuntz L, Am Esch JS. Reduction of Anesthesia Process Times After the Introduction of an Internal Transfer Pricing System for Anesthesia Services. Anesth Analg 2005; 101:187-94, table of contents. [PMID: 15976230 DOI: 10.1213/01.ane.0000154187.47998.60] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To improve operating room workflow, an internal transfer pricing system (ITPS) for anesthesia services was introduced in our hospital in 2001. The basic principle of the ITPS is that the department of anesthesia receives reimbursement only for the surgically controlled time, not for anesthesia-controlled time (ACT). A reduction in anesthesia process times is therefore beneficial for the anesthesia department. In this study, we analyzed the ACT (with its parts: preparation before induction, induction, extubation, and recovery room transfer) for 3 yr before and 3 yr after the introduction of the ITPS in 55,776 cases. Furthermore, the anesthesia cases were subsegmented into 10 different anesthesia techniques, and the process times were studied. The average total ACT was reduced from 40.4 +/- 23.5 min in 1998 to 34.3 +/- 21.7 min in 2003. The main effect came from reductions in anesthesia preparation time and recovery room transfer time, whereas induction and extubation time changed little. A significant reduction in average ACT was seen in 7 of 10 analyzed anesthesia techniques, ranging from 4 to 18 min. We conclude that transfer pricing of anesthesia services based on the surgically controlled time can be a successful approach to reduce anesthesia process times.
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Affiliation(s)
- Martin Schuster
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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O’Reilly M, Tremper KK, Baumgart P. Anesthesia information management systems: Workflow engineering and return on investment. ACTA ACUST UNITED AC 2004. [DOI: 10.1053/j.sane.2004.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Titler MG, Herr K, Schilling ML, Marsh JL, Xie XJ, Ardery G, Clarke WR, Everett LQ. Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers. Appl Nurs Res 2004; 16:211-27. [PMID: 14608555 DOI: 10.1016/s0897-1897(03)00051-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
This article examines acute pain management practices for patients 65 years of age and older who were hospitalized during 1999 for hip fracture. Data were collected from the medical records of patients (N = 709) admitted to 12 hospitals in the Midwest and from questionnaires on pain practices completed by nurses (N = 172) caring for these patients. The major variables examined were (1). pharmacological and nonpharmacological treatments for acute pain in hospitalized elders, (2). nurses' perceived stage of adoption for avoiding meperidine use and for administering analgesics around-the-clock, and (3). nurses' perceived barriers to optimal treatment of acute pain in elders. Acetaminophen was the most frequently administered analgesic, but administered doses were far less than the maximum daily recommended dose. More than one third (39%) of the nurses reported that they always avoided the use of meperidine, and over half reporting avoiding its use sometimes. However, the majority of patients (56.8%) received at least one dose of meperidine, even though evidence suggests that other analgesic agents are more appropriate for treatment of acute pain in elders. Only 27% of patients received patient-controlled analgesia, and only 22.3% of patients received around-the-clock administration during the first 24 hours after admission of analgesics that had been ordered on a prn basis. The majority of nurses were aware that around-the-clock administration of analgesics was preferable, but only 33.7% were persuaded (believed) that this method should be used. Intramuscular injection was used for 52.2% of patients, even though this route is not recommended for older adults. The most frequently used nonpharmacological intervention was repositioning, followed by use of pressure relief devices and cold application. Nurses reported difficulty contacting physicians and difficulty communicating with them about type and/or dose of analgesics as the greatest barriers to pain management. Findings from this multi-site study show that active and focused "translation" interventions are needed to promote adoption of evidence-based acute pain management practices by health care providers.
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Affiliation(s)
- Marita G Titler
- Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, IA 52242-1009, USA.
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Murphy GS, Szokol JW, Franklin M, Marymont JH, Avram MJ, Vender JS. Postanesthesia Care Unit Recovery Times and Neuromuscular Blocking Drugs: A Prospective Study of Orthopedic Surgical Patients Randomized to Receive Pancuronium or Rocuronium. Anesth Analg 2004; 98:193-200. [PMID: 14693617 DOI: 10.1213/01.ane.0000095040.36648.f7] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
UNLABELLED In this study, we examined the effect of choice of neuromuscular blocking drug (NMBD) (pancuronium versus rocuronium) on postoperative recovery times and associated adverse outcomes in patients undergoing orthopedic surgical procedures. Seventy patients were randomly allocated to a pancuronium or rocuronium group. On arrival to the postanesthesia care unit (PACU) and again 30 min later, train-of-four ratios were quantified by using acceleromyography. Immediately after acceleromyographic measurements, patients were assessed for signs and symptoms of residual paresis. During the PACU admission, episodes of hypoxemia, nausea, and vomiting were recorded. The time required for patients to meet discharge criteria and the time of actual PACU discharge were noted. Forty percent of patients in the pancuronium group had train-of-four ratios <0.7 on arrival to the PACU, compared with only 5.9% of subjects in the rocuronium group (P < 0.001). Patients in the pancuronium group were more likely to experience symptoms of muscle weakness (blurry vision and generalized weakness; P < 0.001) and hypoxemia (10 patients in the rocuronium group versus 21 patients in the pancuronium group; P = 0.015) during the PACU admission. Significant delays in meeting PACU discharge criteria (50 min [45-60 min] versus 30 min [25-40 min]) and achieving actual discharge (70 min [60-90 min] versus 57.5 min [45-61 min]) were observed when the pancuronium group was compared with the rocuronium group (P < 0.001). In conclusion, our study indicates that PACU recovery times may be prolonged when long-acting NMBDs are used in surgical patients. IMPLICATIONS Clinical recovery may be delayed in surgical patients administered long-acting neuromuscular blocking drugs. During the postanesthesia care unit admission, patients randomized to receive pancuronium (versus rocuronium) were more likely to exhibit symptoms of muscle weakness, develop hypoxemia, and require more time to meet discharge criteria.
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Affiliation(s)
- Glenn S Murphy
- *Department of Anesthesiology, Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Evanston, Illinois; and †Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Odin I, Merle JC, Feiss P, Nathan N. Nausées–vomissements postopératoires : avantage et coût d’un programme d’assurance qualité. Partie I : en salle de surveillance post-interventionnelle. ACTA ACUST UNITED AC 2003; 22:697-703. [PMID: 14522388 DOI: 10.1016/s0750-7658(03)00213-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To report the efficiency and direct cost induced by a quality insurance programme (QIP) aimed to reduce the incidence of post-operative nausea and vomiting (PONV) in the post-anaesthesia care unit. TYPE OF STUDY Prospective and descriptive study. METHODS The occurrence and treatment of PONV were prospectively recorded in the post-anaesthesia care unit in a standardised file before and following therapeutic recommendations made by volunteers component of a QIP. Prophylaxis was administered to patients according to a score of risks based on the type of surgery and patient characteristics. The real cost induced by this change of practice was evaluated according to pharmacists' accounts over 1 year. RESULTS The QIP was associated to a 33.5% reduction of PONV relative risk and a 50% increase in prophylactic treatments. When this reduction of PONV was extrapolated to the total number of anaesthesia over 1 year, this QIP avoided PONV in 770 patients each year. The increase of cost reached 3572 as the cost by patient receiving a prophylactic treatment increased from 0.66 to 1. CONCLUSION Despite an increase in the individual cost of PONV prophylaxis, the selection of patients by a "home" score of risk limits the indications of prophylactic treatment. Thus the increase in cost remains in acceptable ranges.
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Affiliation(s)
- I Odin
- Département d'anesthésie-réanimation, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France.
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Olutoye O, Jantzen EC, Alexis R, Rajchert D, Schreiner MS, Watcha MF. A comparison of the costs and efficacy of ondansetron and dolasetron in the prophylaxis of postoperative vomiting in pediatric patients undergoing ambulatory surgery. Anesth Analg 2003; 97:390-396. [PMID: 12873923 DOI: 10.1213/01.ane.0000072706.09194.5e] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Postoperative vomiting (POV) after ambulatory surgery remains a major problem. We designed this study to determine the smallest dose of dolasetron equivalent to the Food and Drug Administration approved dose of ondansetron 100 micro g/kg IV, for the prophylaxis of POV in children undergoing surgery. In this double-blinded controlled study, 204 healthy ASA I-II children aged 2-12 yr, undergoing superficial ambulatory (day-case) surgery, were randomized to receive either ondansetron 100 micro g/kg IV, or dolasetron 45, 175, 350, or 700 micro g/kg IV during a standardized perioperative regimen. The primary end-point was the incidence of complete response, defined as the absence of POV symptoms. Costs were calculated from the perspective of the hospital using a previously described model. The incidence of early (0-6 h) and 24-h emesis was more frequent in the dolasetron 45 micro g/kg group compared with the dolasetron 350 and 700 micro g/kg groups and with the ondansetron group. Repeated POV occurred more often when dolasetron was used in a dose <350 micro g/kg. There were no significant differences in emesis rates between the dolasetron 175, 350, and 700 micro g/kg groups or between these groups and the ondansetron 100 micro g/kg group. The smallest dose of dolasetron with acceptable equivalent efficacy and patient satisfaction scores to ondansetron 100 micro g/kg was 350 micro g/kg. Institutional costs for managing POV were less with dolasetron 350 micro g/kg than with ondansetron. IMPLICATIONS This randomized double-blinded dose-ranging study concluded that dolasetron, 350 micro g/kg IV, was the smallest dose that provided acceptable equivalent efficacy and patient satisfaction scores to ondansetron, 100 micro g/kg IV, for the prophylaxis of postoperative vomiting in children undergoing outpatient surgery. However, with this dose, the costs to the institution for managing postoperative vomiting were less.
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Affiliation(s)
- Olutoyin Olutoye
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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Kashner TM, Carmody TJ, Suppes T, Rush AJ, Crismon ML, Miller AL, Toprac M, Trivedi M. Catching up on health outcomes: the Texas Medication Algorithm Project. Health Serv Res 2003; 38:311-31. [PMID: 12650393 PMCID: PMC1360886 DOI: 10.1111/1475-6773.00117] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To develop a statistic measuring the impact of algorithm-driven disease management programs on outcomes for patients with chronic mental illness that allowed for treatment-as-usual controls to "catch up" to early gains of treated patients. DATA SOURCES/STUDY SETTING Statistical power was estimated from simulated samples representing effect sizes that grew, remained constant, or declined following an initial improvement. Estimates were based on the Texas Medication Algorithm Project on adult patients (age > or = 18) with bipolar disorder (n = 267) who received care between 1998 and 2000 at 1 of 11 clinics across Texas. STUDY DESIGN Study patients were assessed at baseline and three-month follow-up for a minimum of one year. Program tracks were assigned by clinic. DATA COLLECTION/EXTRACTION METHODS Hierarchical linear modeling was modified to account for declining-effects. Outcomes were based on 30-item Inventory for Depression Symptomatology-Clinician Version. PRINCIPAL FINDINGS Declining-effect analyses had significantly greater power detecting program differences than traditional growth models in constant and declining-effects cases. Bipolar patients with severe depressive symptoms in an algorithm-driven, disease management program reported fewer symptoms after three months, with treatment-as-usual controls "catching up" within one year. CONCLUSIONS In addition to psychometric properties, data collection design, and power, investigators should consider how outcomes unfold over time when selecting an appropriate statistic to evaluate service interventions. Declining-effect analyses may be applicable to a wide range of treatment and intervention trials.
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Affiliation(s)
- T Michael Kashner
- Dallas VA Center for Health Services Research, Department of Veterans Affairs, North Texas Health Care System, USA
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Affiliation(s)
- Steven Gayer
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, 1611 NW 12th Avenue Central Building, Room 301, Miami, FL 33136, USA
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Pradervand Mooser M, Gardaz JP, Capt H, Spahn DR. [Relative anesthesia-cost for laparoscopic cholecystectomy: fairly low]. Can J Anaesth 2002; 49:540-4. [PMID: 12067863 DOI: 10.1007/bf03017378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The relative contribution of anesthesia costs to total perioperative costs is not known precisely. The goal of this prospective study was to measure the proportion of anesthesia costs relative to total hospital costs of elective laparoscopic cholecystectomy (LC) for in-patients. METHODS With Institutional approval, the total hospital costs of elective LC for 62 ASA I-III patients were analyzed. All direct and indirect variable costs, including salaries of anesthesia and surgery teams, were obtained for each patient. Data are expressed as mean +/- SEM. RESULTS Intraoperative anesthesia costs as a percentage of the total hospital costs equaled 10.5 +/- 0.3%. Postanesthesia care unit (PACU) cost was 3.1 +/- 0.2%. The largest hospital cost category was the operating room with 37.4 +/- 0.6%. The costs attributed to the ward equaled 31.3 +/- 3%. Other costs were generated by radiology (6.2 +/- 1.1%), laboratory (5.4 +/- 0.7%), admission unit (3.4 +/- 0.2%), pharmacy (2.0 +/- 0.4%) and administration (0.7 +/- 0.1%). CONCLUSION Even if salaries are included, anesthesia and PACU costs (13.6%) represent a small portion only of total hospital costs. Cost savings thus may result from improving operating room efficiency and shortening of hospitalisation rather than programs aiming at lowering anesthesia costs.
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Beaussier M, Decorps A, Tilleul P, Megnigbeto A, Balladur P, Lienhart A. Desflurane improves the throughput of patients in the PACU. A cost-effectiveness comparison with isoflurane. Can J Anaesth 2002; 49:339-46. [PMID: 11927471 DOI: 10.1007/bf03017320] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE In a pharmacoeconomic approach of anesthesia, postanesthesia care unit (PACU) occupancy can be chosen as a criteria of effectiveness to compare two anesthetic drugs with different rates of elimination and different costs of administration. Our objective was to develop a cost-effectiveness approach for the comparison of isoflurane (I) and desflurane (D). METHOD In this prospective observational study, 68 patients aged 18-70 received either D or I for maintenance of anesthesia for inpatient abdominal procedures. Length of stay (LOS) in PACU was collected by a blinded observer. After the relationship between duration of surgery and LOS in PACU had been established in the 68 observed patients, we estimated the PACU occupancy according to duration of surgery and time of admission in PACU using a computer model of 204 consecutive patients, based on the hypothesis of an exclusive use of either D or I. Outcome measures were direct costs of the anesthesia procedure and occupancy of the PACU. RESULTS The direct cost of the anesthetic was significantly higher with D than with I. This represents an increase of CAN$ 2 708 for the 204 patients. PACU occupancy was reduced by at least one patient (out of five beds) during 26.1% of the time with D (P <0.01). DISCUSSION Improving the throughput of patients in PACU by using new halogenated anesthetic agents with faster rates of elimination may outweigh the incremental cost of this strategy. This becomes particularly meaningful in operating theatres experiencing frequent overcrowded periods.
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Affiliation(s)
- Marc Beaussier
- Department of Anesthesia and Intensive Care, St Antoine University Hospital, and the University Paris XIII, Paris, France.
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Plaud B, Debaene B. [From a consensus conference to AMM (authorization to market): succinylcholine as an example]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:247-8. [PMID: 11963394 DOI: 10.1016/s0750-7658(02)00580-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
STUDY OBJECTIVE To complement previous studies that employed indirect methods of measuring anesthesia drug waste. DESIGN Prospective, blinded observational study. SETTING Operating rooms of a single university hospital. SUBJECTS Anesthesia providers practicing in this setting who were completely unaware of the conduct of the study. MEASUREMENTS All opened and unused or unusable intravenous (IV) anesthesia drugs left over at the end of each workday were collected over a randomly selected typical 2-week period. MAIN RESULTS 166 weekday cases were performed. Thirty different drugs were represented in the 157 syringes and 139 ampoules collected. Opioid waste as well as opened vials that became outdated were counted in the tally. Based on actual hospital drug acquisition costs, $1,802 of drugs were wasted during this 2-week period ($300/OR), amounting to an average cost per case of $10.86. On a cost basis, six drugs accounted for three quarters of the total wastage: phenylephrine (20.8%), propofol (14.5%), vecuronium (12.2%), midazolam (11.4%), labetalol (9.1%), and ephedrine (8.6%). Because incompletely used syringes or vials that were discarded in the trash were not measured in this analysis, the results may underestimate the total cost of drug wastage at this institution by up to 40%. CONCLUSIONS The results of this study are similar to those of previous studies that employed electronic record keeping techniques to calculate drug waste. Intravenous drugs that are prepared but unused may be a significant cost of intraoperative anesthesia care. Methods to reduce the amount of drug wasted are proposed.
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Affiliation(s)
- M B Weinger
- Department of Anesthesiology, University of California, San Diego, CA 92161, USA.
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Imasogie N, Chung F. Effect of return hospital visits on economics of ambulatory surgery. Curr Opin Anaesthesiol 2001; 14:573-8. [PMID: 17019150 DOI: 10.1097/00001503-200110000-00020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This review examines the effect of unanticipated admission, return hospital visits and readmission on the economics of ambulatory surgery. The overall rate of unanticipated admission was approximately 1% and the overall rate of readmission to hospital was approximately 1%. Ambulatory surgery allows total cost savings of 20-50% when compared with inpatient surgery. If 98% of ambulatory surgery patients experience uneventful recovery, the decrease in cost savings caused by unanticipated admission and return hospital visit is very small. Modifications of anesthesia and surgical technique can help to further reduce the incidence of unanticipated admission or readmission to hospital.
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Affiliation(s)
- N Imasogie
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Splinter WM, Isaac LA. The Pharmacoeconomics of Neuromuscular Blocking Drugs: A Perioperative Cost-Minimization Strategy in Children. Anesth Analg 2001. [DOI: 10.1213/00000539-200108000-00020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Splinter WM, Isaac LA. The pharmacoeconomics of neuromuscular blocking drugs: a perioperative cost-minimization strategy in children. Anesth Analg 2001; 93:339-44 , 3rd contents page. [PMID: 11473856 DOI: 10.1097/00000539-200108000-00020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED The purpose of this investigation was to compare the costs of intermediate-acting neuromuscular blocking drugs in children during routine ambulatory surgery. We studied 200 healthy, 2-10-yr-old children undergoing elective dental restorative surgery. During Part 1 of the study, children received an inhaled anesthetic with halothane and nitrous oxide, whereas in Part 2, the anesthetic was IV propofol with nitrous oxide. The study drugs were atracurium, cisatracurium, mivacurium, rocuronium, and vecuronium. Patients were initially administered 2x the effective dose for 95% of the study drug. After recovery to 10% of baseline neuromuscular function, the neuromuscular blockade was rigidly maintained with an infusion of the study drug at about 10% of baseline function. Neuromuscular drug costs were approximated as drug usage x cost/unit. The initial drug costs were not substantially different for both Parts 1 and 2, but over time, mivacurium became the most expensive drug and cisatracurium the least expensive. In conclusion, based on current costs, cisatracurium is the least expensive intermediate-acting neuromuscular drug. IMPLICATIONS For children undergoing minor ambulatory procedures of 1-2 h, and continuous intraoperative neuromuscular blockade is indicated, cisatracurium currently is the least expensive drug.
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Affiliation(s)
- W M Splinter
- Department of Anaesthesia, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1.
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Gan TJ, Lubarsky DA. Whose Value is it Anyway? Anesth Analg 2001. [DOI: 10.1213/00000539-200108000-00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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