Reduction of Anesthesia Process Times After the Introduction of an Internal Transfer Pricing System for Anesthesia Services

Estimating anesthesia time using the medicare claim: a validation study

INTRODUCTION

Procedure length is a fundamental variable associated with quality of care, though seldom studied on a large scale. The authors sought to estimate procedure length through information obtained in the anesthesia claim submitted to Medicare to validate this method for future studies.

METHODS

The Obesity and Surgical Outcomes Study enlisted 47 hospitals located across New York, Texas, and Illinois to study patients undergoing hip, knee, colon, and thoracotomy procedures. A total of 15,914 charts were abstracted to determine body mass index and initial patient physiology. Included in this abstraction were induction, cut, close, and recovery room times. This chart information was merged to Medicare claims that included anesthesia Part B billing information. Correlations between chart times and claim times were analyzed, models developed, and median absolute differences in minutes calculated.

RESULTS

Of the 15,914 eligible patients, there were 14,369 for whom both chart and claim times were available for analysis. For these 14,369, the Spearman correlation between chart and claim time was 0.94 (95% CI 0.94, 0.95), and the median absolute difference between chart and claim time was only 5 min (95% CI: 5.0, 5.5). The anesthesia claim can also be used to estimate surgical procedure length, with only a modest increase in error.

CONCLUSION

The anesthesia bill found in Medicare claims provides an excellent source of information for studying surgery time on a vast scale throughout the United States. However, errors in both chart abstraction and anesthesia claims can occur. Care must be taken in the handling of outliers in these data.

Status quo and current trends of operating room management in Germany

PURPOSE OF REVIEW

Ongoing healthcare reforms in Germany have required strenuous efforts to adapt hospital and operating room organizations to the needs of patients, new technological developments, and social and economic demands. This review addresses the major developments in German operating room management research and current practice.

RECENT FINDINGS

The introduction of the diagnosis-related group system in 2003 has changed the incentive structure of German hospitals to redesign their operating room units. The role of operating room managers has been gradually changing in hospitals in response to the change in the reimbursement system. Operating room managers are today specifically qualified and increasingly externally hired staff. They are more and more empowered with authority to plan and control operating rooms as profit centers. For measuring performance, common perioperative performance indicators are still scarcely implemented in German hospitals. In 2008, a concerted time glossary was established to enable consistent monitoring of operating room performance with generally accepted process indicators. These key performance indicators are a consistent way to make a procedure or case - and also the effectiveness of the operating room management - more transparent.

SUMMARY

In the presence of increasing financial pressure, a hospital's executives need to empower an independent operating room management function to achieve the hospital's economic goals. Operating room managers need to adopt evidence-based methods also from other scientific fields, for example management science and information technology, to further sustain operating room performance.

Influence of resident training on anaesthesia induction times

BACKGROUND

The effect of resident training in anaesthesiology on operating room (OR) economics is an issue of debate. Comparisons of anaesthesia process times between residents and consultants might be systematically skewed by interactions of anaesthesia technique and patient factors.

METHODS

In this prospective, observational study, we analysed anaesthesia process times in 599 cases performed for four different surgical services in a University hospital. The following factors were recorded for each case and used in multivariate analyses of process times: age, American Society of Anesthesiologist (ASA) status, BMI, emergency status, the educational level of the anaesthetist, and the anaesthesia technique.

RESULTS

In the non-adjusted comparison, only for two of seven anaesthetic techniques did resident cases have statistically significant longer induction times than consultant cases: general anaesthesia with placement of a central venous catheter [mean (sd) anaesthesia time for resident cases 38.2 (17.0) vs 22.3 (10.0) min for consultant cases, P=0.001] and general anaesthesia with a laryngeal mask airway [resident cases 11.3 (5.5) vs consultant cases 7.3 (5.0) min, P=0.003]. Anaesthetic technique had the greatest effect on anaesthesia induction time. Educational level of the anaesthetist and age of the patients had small, but significant effects.

CONCLUSIONS

Anaesthesia cases performed by residents have in some, but not in all, anaesthesia techniques increased process times compared with cases performed by consultants. This limits a possible negative impact on OR economics by resident education. Patient-based factors including ASA status, BMI, and emergency status have minimal or no effect on anaesthesia process times.

[Utilization rates and turnover times as indicators of OR workflow efficiency]

BACKGROUND

In many hospitals operating room (OR) utilization rates and turnover times (the time from the end of the previous surgical procedure to the beginning of the next) are used as indicators of OR workflow inefficiency. However, there have been no detailed studies to determine whether these indicators really provide an adequate picture of avoidable wasting of time in the OR.

METHODS

All relevant OR processes in a busy surgical suite with nine ORs were studied in detail over an 8-week period. Productive OR processes, and also reasons for unused times, were recorded by independent observers at 5-minute intervals; they were able to code for 10 different productive activities and 20 different reasons for unused time. Unused time in the OR, the OR utilization rate and the average perioperative turnover times were calculated for each day and a correlation analysis was performed.

RESULTS

In all, 3,501 OR hours and 790 surgical cases were studied. Productive processes accounted for 85.7% of the total OR time; the unused times were times with no scheduled cases (7.7%) and waiting times that arose for many different reasons (6.6%). Correlation analysis showed that there was no close correlation between waiting time and OR utilization (Spearman's r(s) 0.104 and r(s) 0.233). The correlations between total unused time (r(s) 0.718 and r(s) 0.745) and time with no scheduled cases (r(s) 0.706 and r(s) 0.620) and utilization were more robust, but for any given OR utilization rate the range of corresponding unused time or time without scheduled cases per day was considerable. The correlation between waiting time and perioperative turnover times was negligible (r(s) 0.185 and r(s) 0.175). When different definitions of utilization rate or perioperative turnover were used the results obtained were virtually identical.

CONCLUSIONS

Utilization rate and perioperative turnover time cannot be used as indicators of OR workflow efficiency, since they cannot identify the days during which avoidable waiting times occur. If the aim is to identify underused OR time and factors that hamper workflow efficiency, waiting times and times without scheduled cases need to be recorded directly and separately.

[Key performance indicators of OR efficiency. Myths and evidence of key performance indicators in OR management]

A variety of different key performance indicators, both for process and financial performance, are used to evaluate OR efficiency. Certain indicators like OR utilization and turnover times seem to become common standard in many hospitals to evaluate OR process performance. Despite the general use and availability of these indicators in OR management, the scientific evidence behind these data is relatively low. These process indicators are strongly influenced by artefacts and depend on planning process, resource allocation and documentation. Direct financial indicators become more important with increasing autonomy of OR management. Besides budgetary compliance the focus is set on the net results of internal transfer pricing systems. By taking part in an internal transfer pricing system, OR management develops from a mere passive cost center to an active shaper of perioperative processes. However, detailed knowledge of the origin of costs and pitfalls of internal transfer pricing systems is crucial. The increased transparency due to the free accessibility of diagnosis-related-groups (DRG) cost breakdown data can help to develop tools for economic analysis of OR efficiency.

OP-Management im KTQ-Zertifizierungsprozess eines Schwerpunktkrankenhauses

We report the results of our study concerning the organisation of operating room (OR) capacity planned 1 year in advance. The use of OR is controlled using 2 global controlling numbers: a) the actual time difference between the expected optimal and previously calculated OR running time and b) the punctuality of starting the first operation in each OR. The focal point of the presented OR management concept is a consensus-oriented decision-making and steering process led by a coordinator who achieves a high degree of acceptance by means of comprehensive transparency. Based on the accepted running time, the optimal productivity of OR's (OP_A(%) can be calculated. In this way an increase of the overall capacity (actual running time) of ORs was from 40% to over 55% was achieved. Nevertheless, enthusiasm and teamwork from all persons involved in the system are vital for success as well as a completely independent operating theatre manager. Using this concept over 90% of the requirements for the new certification catalogue for hospitals in Germany was achieved.

Cost drivers in anesthesia: manpower, technique and other factors

PURPOSE OF REVIEW

This article reviews the recent literature on cost drivers in anesthesia with respect to staff, techniques and drug costs, and with special focus on anesthesia workflow in the postanesthesia care unit. Moreover, the costs of post-operative pain management provided by an acute pain service are highlighted.

RECENT FINDINGS

Staff costs represent the main contributor to anesthesia costs in all studies. Therefore, many studies address the reduction of personnel costs, e.g. by using fast-tracking procedures which allow the patients to bypass the postanesthesia care unit. However, postanesthesia care unit bypassing and replacement of anesthesiologists by certified anesthesia nurses were not able to significantly decrease anesthesia costs. If anesthesiologists are reimbursed by surgically controlled time, this time is the main determinator for anesthesia costs and should be carefully monitored. Regional anesthesia techniques can help to reduce costs in the ambulatory setting because of reduced post-operative side-effects and earlier home readiness of the patients. Low gas flow and modern electroencephalographic monitoring can contribute to decreased drug-related costs. Acute pain services are mainly run by anesthesia staff thus increasing the costs in anesthesia departments. However, an acute pain service can reduce costs of surgical procedures significantly.

SUMMARY

Clear definition of the meaning of cost drivers and of criteria which allow assessment of patients' condition, and peri-operative standard operating procedures are warranted to ensure comparability of economic data in anesthesia.

Die Nutzung der Erlösdaten der „DRGs“ für ein externes Benchmarking der anästhesiologischen und intensivmedizinischen Leistungserbringung

Measurement and assessment of the economic efficiency of clinical departments is still an unresolved, yet important problem in hospital management. Benchmarking with other providers can help to evaluate one's own efficacy in anaesthesia and intensive care services. In this article we describe a method for using the diagnosis-related-groups (DRG) cost breakdown data, to achieve a case mix adjusted comparison of own costs for anaesthesia and intensive care services with the average costs in German hospitals. On the basis of 19,401 cases from 10 different surgical departments, we compared our own costs with the German-wide benchmark. Major factors for profit optimisation are discussed. Special attention is given to the close interaction of surgical, anaesthesiological and intensive care process performance and costs and its impact on benchmarking studies.