Laboratory-based respiratory virus surveillance pilot project on select cruise ships in Alaska, 2013-15.

BACKGROUND: Influenza outbreaks can occur among passengers and crews during the Alaska summertime cruise season. Ill travellers represent a potential source for introduction of novel or antigenically drifted influenza virus strains to the United States. From May to September 2013-2015, the Alaska Division of Public Health, the Centers for Disease Control and Prevention (CDC), and two cruise lines implemented a laboratory-based public health surveillance project to detect influenza and other respiratory viruses among ill crew members and passengers on select cruise ships in Alaska. METHODS: Cruise ship medical staff collected 2-3 nasopharyngeal swab specimens per week from passengers and crew members presenting to the ship infirmary with acute respiratory illness (ARI). Specimens were tested for respiratory viruses at the Alaska State Virology Laboratory (ASVL); a subset of specimens positive for influenza virus were sent to CDC for further antigenic characterization. RESULTS: Of 410 nasopharyngeal specimens, 83% tested positive for at least one respiratory virus; 71% tested positive for influenza A or B virus. Antigenic characterization of pilot project specimens identified strains matching predominant circulating seasonal influenza virus strains, which were included in the northern or southern hemisphere influenza vaccines during those years. Results were relatively consistent across age groups, recent travel history, and influenza vaccination status. Onset dates of illness relative to date of boarding differed between northbound (occurring later in the voyage) and southbound (occurring within the first days of the voyage) cruises. CONCLUSIONS: The high yield of positive results indicated that influenza was common among passengers and crews sampled with ARI. This finding reinforces the need to bolster influenza prevention and control activities on cruise ships. Laboratory-based influenza surveillance on cruise ships may augment inland influenza surveillance and inform control activities. However, these benefits should be weighed against the costs and operational limitations of instituting laboratory-based surveillance programs on ships.

A matrix model for valuing anesthesia service with the resource-based relative value system.

BACKGROUND: The purpose of this study was to propose a new crosswalk using the resource-based relative value system (RBRVS) that preserves the time unit component of the anesthesia service and disaggregates anesthesia billing into component parts (preoperative evaluation, intraoperative management, and postoperative evaluation). The study was designed as an observational chart and billing data review of current and proposed payments, in the setting of a preoperative holing area, intraoperative suite, and post anesthesia care unit. In total, 1,195 charts of American Society of Anesthesiology (ASA) physical status 1 through 5 patients were reviewed. No direct patient interventions were undertaken. RESULTS: Spearman correlations between the proposed RBRVS billing matrix payments and the current ASA relative value guide methodology payments were strong (r=0.94-0.96, P<0.001 for training, test, and overall). The proposed RBRVS-based billing matrix yielded payments that were 3.0%±1.34% less than would have been expected from commercial insurers, using standard rates for commercial ASA relative value units and RBRVS relative value units. Compared with current Medicare reimbursement under the ASA relative value guide, reimbursement would almost double when converting to an RBRVS billing model. The greatest increases in Medicare reimbursement between the current system and proposed billing model occurred as anesthetic management complexity increased. CONCLUSION: The new crosswalk correlates with existing evaluation and management and intensive care medicine codes in an essentially revenue neutral manner when applied to the market-based rates of commercial insurers. The new system more highly values delivery of care to more complex patients undergoing more complex surgery and better represents the true value of anesthetic case management.