Impact of changes in anaesthesia staff assignments on billing compliance, financial margins, and costs of anaesthesia services: development and application of a margin-cost estimation tool.

BACKGROUND: The US Centers for Medicare and Medicaid Services provide guidelines for the coverage of anaesthesia residents and certified registered nurse anaesthetists (CRNAs) by anaesthesiologists. We tested the hypothesis that changes in the anaesthesia staffing model increase billing compliance. METHODS: We analysed 13 926 anaesthesia cases performed between September 2019 and November 2019 (baseline), and between September 2020 and November 2020 (after change in staff model) at a US academic medical centre using an estimation tool. The intervention was assignment of additional 12-h weekday CRNAs plus an additional anaesthesiologist who covered weekdays after 17:00, weekends, and holidays. The proportion of cases with billing compliant coverage (covered either by solo anaesthesiologist or anaesthesiologist covering two or fewer residents or four or fewer CRNAs) was analysed using logistic and segmented regression analyses. RESULTS: The change in staff model was associated with a decrease in non-optimal anaesthesia staff assignments from 4.2% to 1.2% of anaesthesia cases (adjusted odds ratio 0.25; 95% confidence interval [CI] 0.20-0.32; P<0.001) and an increase in billable anaesthesia units of 0.6 per anaesthesia case (95% CI 0.4-0.8; P<0.001). An increased revenue margin associated with optimal staffing levels would only be achieved with salary levels at the 25th percentile of relevant benchmark compensation levels. Total staff overtime for all anaesthesia providers decreased (adjusted absolute difference -4.1 total overtime hours per day; 95% CI -7.0 to -1.3; P=0.004). CONCLUSIONS: Implementation of a change in anaesthesia staffing model was associated with improved billing compliance, higher billable anaesthesia units, and reduced overtime. The effects of the anaesthesia staff model on revenue and financial margin can be determined using our web-based margin-cost estimation tool.

Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study.

BACKGROUND: Dexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects. METHODS: We analysed data from paediatric patients (aged 0-12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID). RESULTS: Among 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0-21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3-40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835-1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16-1.39; P<0.001), and higher odds of heart rate below 100 beats min-1 (ORadj 1.32; 95% CI: 1.21-1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04-2.68; P=0.034). CONCLUSIONS: Intraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers.

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.

Pragmatic sedation strategies to prevent secondary brain injury in low-resource settings.

Traumatic brain injury is the alteration in brain function due to an external force. It is common and affects millions of people worldwide annually. The World Health Organization estimates that 90% of global deaths caused by injuries occur in low- and middle-income countries, with traumatic brain injury contributing up to half of these trauma-related deaths. Patients with traumatic brain injury in low- and middle-income countries have twice the odds of dying compared with their counterparts in high-income countries. Sedation is a key element of care in the management of traumatic brain injury, used for its neuroprotective effects and to prevent secondary brain injury. While sedatives have the potential to improve outcomes, they can be challenging to administer and have potentially dangerous complications. Sedation in low-resource settings should aim to be effective, safe, affordable and feasible. In this paper, we summarise the indications for sedation in traumatic brain injury, the choice of sedative drugs and the pragmatic management and monitoring of sedated traumatic brain injury patients in low-resource settings.

Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study.

BACKGROUND: The growing demand for cancer surgery has placed a global strain on health systems. In-depth analyses of the global demand for cancer surgery and optimal workforce requirements are needed to plan service provision. We estimated the global demand for cancer surgery and the requirements for an optimal surgical and anaesthesia workforce, using benchmarks based on clinical guidelines. METHODS: Using models of benchmark surgical use based on clinical guidelines, we estimated the proportion of cancer cases with an indication for surgery across 183 countries, stratified by income group. These proportions were multiplied by age-adjusted national estimates of new cancer cases using GLOBOCAN 2018 data and then aggregated to obtain the estimated number of surgical procedures required globally. The numbers of cancer surgical procedures in 44 high-income countries were divided by the actual number of surgeons and anaesthetists in the respective countries to calculate cancer procedures per surgeon and anaesthetist ratios. Using the median (IQR) of these ratios as benchmarks, we developed a three-tiered optimal surgical and anaesthesia workforce matrix, and the predictions were extrapolated up to 2040. FINDINGS: Our model estimates that the number of cancer cases globally with an indication for surgery will increase by 5 million procedures (52%) between 2018 (9 065 000) and 2040 (13 821 000). The greatest relative increase in surgical demand will occur in 34 low-income countries, where we also observed the largest gaps in workforce requirements. To match the median benchmark for high-income countries, the surgical workforce in these countries would need to increase by almost four times and the anaesthesia workforce by nearly 5·5 times. The greatest increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries (from 28 000 surgeons to 58 000 surgeons; 107% increase), followed by lower-middle-income countries (from 166 000 surgeons to 277 000 surgeons; 67% increase). INTERPRETATION: The global demand for cancer surgery and the optimal workforce are predicted to increase over the next two decades and disproportionately affect low-income countries. These estimates provide an appropriate framework for planning the provision of surgical services for cancer worldwide. FUNDING: University of New South Wales Scientia Scholarship and UK Research and Innovation Global Challenges Research Fund.

Comparative Cost Effectiveness of Reflux-Based and Reflux-Independent Strategies for Barrett's Esophagus Screening.

INTRODUCTION: Minimally invasive tests for Barrett's esophagus (BE) detection have raised the prospect of broader nonreflux-based testing. Cost-effectiveness studies have largely studied men aged 50 years with chronic gastroesophageal reflux disease (GERD) symptoms. We evaluated the comparative cost effectiveness of BE screening tests in GERD-based and GERD-independent testing scenarios. METHODS: Markov modeling was performed in 3 scenarios in 50 years old individuals: (i) White men with chronic GERD (GERD-based); (ii) GERD-independent (all races, men and women), BE prevalence 1.6%; and (iii) GERD-independent, BE prevalence 5%. The simulation compared multiple screening strategies with no screening: sedated endoscopy (sEGD), transnasal endoscopy, swallowable esophageal cell collection devices with biomarkers, and exhaled volatile organic compounds. A hypothetical cohort of 500,000 individuals followed for 40 years using a willingness to pay threshold of $100,000 per quality-adjusted life year (QALY) was simulated. Incremental cost-effectiveness ratios (ICERs) comparing each strategy with no screening and comparing screening strategies with each other were calculated. RESULTS: In both GERD-independent scenarios, most non-sEGD BE screening tests were cost effective. Swallowable esophageal cell collection devices with biomarkers were cost effective (<$35,000/QALY) and were the optimal screening tests in all scenarios. Exhaled volatile organic compounds had the highest ICERs in all scenarios. ICERs were low (<$25,000/QALY) for all tests in the GERD-based scenario, and all non-sEGD tests dominated no screening. ICERs were sensitive to BE prevalence and test costs. DISCUSSION: Minimally invasive nonendoscopic tests may make GERD-independent BE screening cost effective. Participation rates for these strategies need to be studied.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola.

BACKGROUND: The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). METHODS: Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible. RESULTS: Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided. CONCLUSIONS: Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

Differential Index-Hospitalization Cost Center Impact of Enhanced Recovery After Surgery Program Implementation.

BACKGROUND: Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals. OBJECTIVE: The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections. DESIGN: We performed a single-institution retrospective, nonrandomized, preintervention (2013-2014) and postintervention (2015-2017) analysis of hospital costs. SETTING: This study was conducted at an academic medical center. PATIENTS: A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/comorbidities) were selected. MAIN OUTCOME MEASURES: The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses. RESULTS: Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111 ($19,285-$28,658) compared to $21,896 ($17,477-$29,179) in the enhanced recovery after surgery group, p = 0.01. Total median cost for diagnosis-related group 331 in the pre-enhanced recovery after surgery group was $19,268 ($17,286-$21,858) compared to $18,444 ($15,506-$22,847) in the enhanced recovery after surgery group, p = 0.22. When assessing cost changes after enhanced recovery after surgery implementation for diagnosis-related group 330, operating room costs increased (p = 0.90), nursing costs decreased (p = 0.02), anesthesia costs increased (p = 0.20), and pharmacy costs increased (p = 0.08). For diagnosis-related group 331, operating room costs increased (p = 0.001), nursing costs decreased (p < 0.001), anesthesia costs increased (p = 0.03), and pharmacy costs increased (p = 0.001). LIMITATIONS: This is a single-center study with a pre- and postintervention design. CONCLUSIONS: The returns on investment at the hospital level for enhanced recovery after surgery implementations in colorectal surgery result largely from cost savings associated with decreased nursing expenses. These savings likely offset increased spending on operating room supplies, anesthesia, and medications. See Video Abstract at http://links.lww.com/DCR/B204. IMPACTO DE LA IMPLEMENTACIÓN DEL PROTOCOLO DE RECUPERACIÓN MEJORADA DESPUÉS DE CIRUGÍA EN EL COSTO DE LA HOSPITALIZACIÓN ÍNDICE EN CENTROS ESPECÍFICOS: La mayoría de los hospitales en los Estados Unidos son reembolsados por la colectomía a través de un paquete de pago basado en el grupo de diagnóstico asignado. Se ha demostrado que los programas de recuperación después de la cirugía mejoran el valor de la cirugía colorrectal, pero se sabe poco sobre las compensaciones financieras granulares que se requieren en los hospitales individuales.El objetivo de este estudio es analizar el impacto del índice de hospitalización en centros de costos específicos asociados con la implementación de RMDC para grupos relacionados con el diagnóstico comúnmente asignados a pacientes que se someten a resecciones de colon.Realizamos un análisis retrospectivo, no aleatorio, previo (2013-2014) y posterior a la intervención (2015-2017) de los costos hospitalarios de una sola institución.Centro médico académico.Un total de 1. 297 pacientes con diagnóstico relacionado con el grupo 330 (colectomía con complicaciones/comorbilidades) y 331 (colectomía sin complicaciones/comorbilidades).El resultado primario fue el índice total de costos de hospitalización. Los resultados secundarios incluyeron gastos específicos del centro de costos.El costo medio total para el grupo relacionado con el diagnóstico de 330 en el grupo de recuperación pre-mejorada después de la cirugía fue de $24,111 ($19,285- $28,658) en comparación con $21,896 ($17,477- $29,179) en el grupo de recuperación mejorada después de la cirugía, p = 0.01. El costo medio total para DRG 331 en el grupo de recuperación pre-mejorada después de la cirugía fue de $19,268 ($17,286- $21,858) en comparación con $18,444 ($15,506-$22,847) en el grupo de recuperación mejorada después de la cirugía, p = 0.22. Al evaluar los cambios en los costos después de una recuperación mejorada después de la implementación de la cirugía para el grupo 330 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.90), los costos de enfermería disminuyeron (p = 0.02) los costos de anestesia aumentaron (p = 0.20) y los costos de farmacia aumentaron (p = 0.08). Para el grupo 331 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.001), los costos de enfermería disminuyeron (p < 0.001) los costos de anestesia aumentaron (p = 0.03) y los costos de farmacia aumentaron (p = 0.001).Este es un estudio de un solo centro con un diseño previo y posterior a la intervención.El retorno de la inversión a nivel hospitalario para una recuperación mejorada después de la implementación de la cirugía en la cirugía colorrectal se debe en gran parte al ahorro de costos asociado con la disminución de los gastos de enfermería. Es probable que estos ahorros compensen el aumento de los gastos en suministros de quirófano, anestesia y medicamentos. Consulte Video Resumen en http://links.lww.com/DCR/B204. (Traducción-Dr. Gonzalo Hagerman).

Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

Effectiveness of Hysteroscopic Techniques for Endometrial Polyp Removal: The Italian Multicenter Trial.

STUDY OBJECTIVE: To compare the effectiveness and safety of different techniques of hysteroscopic polypectomy. DESIGN: Multicenter, prospective observational trial (Canadian Task Force classification II-2). SETTING: Nineteen Italian gynecologic departments (university-affiliated or public hospitals). PATIENTS: Consecutive patients suffering from endometrial polyps (EPs). INTERVENTIONS: Hysteroscopic polypectomy, as performed through different techniques. MEASUREMENTS AND MAIN RESULTS: Included in the study were 1404 patients (with 1825 EPs). The setting was an ambulatory care unit in 40.38% of the cases (567 women), of whom 97.7% (554) did not require analgesia/anesthesia. In the remaining 59.62% of women (837 women), the procedures were performed in an operating room under mild sedation, local or general anesthesia. Minor complications occurred in 32 patients (2.27%), without significant differences between the techniques used (p = ns). Uterine perforation occurred in 14 cases, all performed in the operating room with some kind of anesthesia, only 1 with a vaginoscopic technique and the remaining during blind dilatation (odds ratio [OR], 19.98; 95% confidence interval [CI], 1.19-335.79; p = .04). An incomplete removal of EPs was documented in 39 patients. Logistic regression analysis showed that a higher risk of residual EPs was associated with the use of a fiber-based 3.5-mm hysteroscope (OR, 6.78; 95% CI, 2.97-15.52; p <.001), the outpatient setting (OR, 2.17; 95% CI, 1.14-4.14; p = .019), and EPs located at the tubal corner (OR, 1.98; 95% CI, 1.03-2.79; p = .039). No association between incomplete EP removal and EP size or number was recorded (p = ns), as well as with the other variables evaluated. CONCLUSION: Outpatient polypectomy was associated with a minimal but significantly higher risk of residual EPs in comparison with inpatient polypectomy. Conversely, inpatient polypectomy was associated with a considerably higher risk of uterine perforation and penetration in comparison with office hysteroscopy. Because of lower intraoperative risks and higher cost-effectiveness, office hysteroscopy may be considered, whenever possible, as the gold standard technique for removing EPs.

Does an enhanced recovery after surgery protocol change costs and outcomes of single-level lumbar microdiscectomy?

OBJECTIVEEnhanced recovery after surgery (ERAS) is a multimodal approach that aims to improve perioperative surgical outcomes. The aim of this study was to evaluate the benefits of ERAS in terms of cost-effectiveness and postoperative outcomes in single-level lumbar microdiscectomy.METHODSThis study was a single-center retrospective comparing costs and outcomes before and after implementation of the ERAS pathway. Data were collected from the electronic medical records of patients who had undergone single-level lumbar microdiscectomy during 2 time periods-during the 2 years preceding implementation of the ERAS pathway (pre-ERAS group) and after implementation of the ERAS pathway (ERAS group). Each group consisted of 60 patients with an American Society of Anesthesiologists (ASA) Physical Status Classification of class 1. Patients were excluded if their physical status was classified as ASA class II-V or if they were younger than 18 years or older than 65.Groups were compared in terms of age, sex, body mass index (BMI), perioperative hemodynamics, operation time, intraoperative blood loss, intraoperative fluid administration, intraoperative opioid administration, time to first oral intake, time to first mobilization, postoperative nausea and vomiting (PONV), difference between preoperative and postoperative visual analog scale (VAS) scores, postoperative analgesic requirements, length of hospital stay, and cost of anesthesia.RESULTSThe ERAS and pre-ERAS groups were comparable with respect to age, sex, and BMI. Operation time, intraoperative blood loss, intraoperative opioid administration, and intraoperative fluid administration were all less in the ERAS group. First oral intake and first mobilization were earlier in the ERAS group. The incidence of PONV was less in the ERAS group. Postoperative analgesic requirements and postoperative VAS scores were significantly less in the ERAS group. The length of hospital stay was found to be shorter in the ERAS group. The ERAS approach was found to be cost-effective.CONCLUSIONSERAS had clinical and economic benefits and is associated with improved outcomes in lumbar microdiscectomy.

Precise anesthesia in thoracoscopic operations.

PURPOSE OF REVIEW: The current review focuses on precise anesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. RECENT FINDINGS: VATS has become an established and widely used minimally invasive approach with broad implementation on a variety of thoracic operations. In the current environment of enhanced recovery protocols and cost containment, minimally invasive VATS operations suggest adoption of individualized tailored, precise anesthesia. In addition to a perfect lung collapse for surgical interventions with adequate oxygenation during one lung ventilation, anesthesia goals include a rapid, complete recovery with adequate postoperative analgesia leading to early discharge and minimized costs related to postoperative inpatient services. The components and decisions related to precise anesthesia are reviewed and discussed including: letting patients remain awake versus general anesthesia, whether the patient should be intubated or not, operating with or without muscle relaxation, whether to use different separation devises, operating with different local and regional blocks and monitors. CONCLUSION: The determining factors in designing a precise anesthesic for VATS operations involve consensus on patients' tolerance of the associated side effects, the best practice or techniques for surgery and anesthesia, the required postoperative support, and the care team's experience.

ECONOMIC EFFECTIVENESS OF DIFFERENT METHODS OF ANESTHESIA OF CURETTAGE OF UTERINE CAVITY.

Anesthesia of curettage of uterine cavity (CUC) at postoperative period causes additional expenses. Preventive intraoperative anesthesia makes it possible to reduce these expenses and provide significant positive economic effect on state budget. The objective of this research is determination of influence of different methods of anesthesia of CUC on cash value of anesthetic maintenance of CUC and the possibility of saving of budgetary funds. 128 women took part in the research. They underwent the procedure of CUC. Anesthetic maintenance was performed using different medicamental combinations and their dosages. Mathematical calculation of the cost of each CUC stage was done considering the cost of consumables, medical preparations and value of labor of medical staff. In the course of this research, it was proven that a combination of additional use of dexketoprofen (at the stage of premedication of CUC) and performing preventive intraoperative applicational anesthesia with bupivacaine solution can save 130 452,26UAH of wage fund per year and general budget savings within the confines of a state can each 9 954 617,67UAH per year.

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System.

BACKGROUND & AIMS: Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. METHODS: We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. RESULTS: The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. CONCLUSIONS: In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.

Ablation of paroxysmal atrial fibrillation using a second-generation cryoballoon catheter or contact-force sensing radiofrequency ablation catheter: A comparison of costs and long-term clinical outcomes.

INTRODUCTION: Although noninferiority of cryoballoon ablation (CBA) and radiofrequency catheter ablation for antral pulmonary vein isolation (APVI) has been reported in patients with paroxysmal atrial fibrillation (PAF), it is not clear whether contact force sensing (CF-RFA) and CBA with the second-generation catheter have similar procedural costs and long-term outcomes. The objective of this study is to compare the long-term efficacy and cost implications of CBA and CF-RFA in patients with PAF. METHODS AND RESULTS: A first APVI was performed in 146 consecutive patients (age: 63 ± 10 years, men: 95 [65%], left atrial diameter: 42 ± 6 mm) with PAF using CBA (71) or CF-RFA (75). Clinical outcomes and procedural costs were compared. The mean procedure time was significantly shorter with CBA than with CF-RFA (98 ± 39 vs. 158 ± 47 minutes, P < 0.0001). Despite a higher equipment cost in the CBA than the CF-RFA group, the total procedure cost was similar between the two groups (P = 0.26), primarily driven by a shorter procedure duration that resulted in a lower anesthesia cost. At 25 ± 5 months after a single ablation procedure, 51 patients (72%) in the CBA, and 55 patients (73%) in the CF-RFA groups remained free from atrial arrhythmias without antiarrhythmic drug therapy (P = 0.84). CONCLUSIONS: The procedure duration was approximately 60 minutes shorter with CBA than CF-RFA. The procedural costs were similar with both approaches. At 2 years after a single procedure, CBA and CF-RFA have similar single-procedure efficacies of 72-73%.

Antiemetic Prophylaxis as a Marker of Health Care Disparities in the National Anesthesia Clinical Outcomes Registry.

BACKGROUND: US health care disparities persist despite repeated countermeasures. Research identified race, ethnicity, gender, and socioeconomic status as factors, mediated through individual provider and/or systemic biases; little research exists in anesthesiology. We investigated antiemetic prophylaxis as a surrogate marker for anesthesia quality by individual providers because antiemetics are universally available, indicated contingent on patient characteristics (gender, age, etc), but independent of comorbidities and not yet impacted by regulatory or financial constraints. We hypothesized that socioeconomic indicators (measured as insurance status or median income in the patients' home zip code area) are associated with the utilization of antiemetic prophylaxis (as a marker of anesthesia quality). METHODS: We tested our hypothesis in several subsets of electronic anesthesia records from the National Anesthesia Clinical Outcomes Registry (NACOR), fitting frequentist and novel Bayesian multilevel logistic regression models. RESULTS: NACOR contained 12 million cases in 2013. Six institutions reported on antiemetic prophylaxis for 441,645 anesthesia cases. Only 173,133 cases included details on insurance information. Even fewer (n = 92,683) contained complete data on procedure codes and provider identifiers. Bivariate analysis, multivariable logistic regression, and our Bayesian hierarchical model all showed a large and statistically significant association between socioeconomic markers and antiemetic prophylaxis (ondansetron and dexamethasone). For Medicaid versus commercially insured patients, the odds ratio of receiving the antiemetic ondansetron is 0.85 in our Bayesian hierarchical mixed regression model, with a 95% Bayesian credible interval of 0.81-0.89 with similar inferences in classical (frequentist) regression models. CONCLUSIONS: Our analyses of NACOR anesthesia records raise concerns that patients with lower socioeconomic status may receive inferior anesthesia care provided by individual anesthesiologists, as indicated by less antiemetics administered. Effects persisted after we controlled for important patient characteristics and for procedure and provider influences. Findings were robust to sensitivity analyses. Our results challenge the notion that anesthesia providers do not contribute to health care disparities.

Anesthesia for Cesarean Delivery: A Cross-Sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe.

BACKGROUND: Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe. METHODS: In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization. RESULTS: The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were <5%. The estimated institutional maternal mortality ratio was 573 (provincial), 251 (district), and 211 (mission hospitals) per 100,000 live births. Basic monitoring equipment (oximeters, electrocardiograms, sphygmomanometers) was reported available in theatres. Several unsafe practices continue: general anesthesia without a secure airway, shortage of essential drugs for spinal anesthesia, inconsistent use of recovery area or use of table tilt or wedge, and insufficient blood supplies. Postoperative analgesia management was reported inadequate. CONCLUSIONS: This study identified areas where anesthetic provision and care could be improved. Provincial hospitals, where district/mission hospitals refer difficult cases, did not have the higher level anesthesia expertise required to manage these cases. More intensive mentorship and supervision from senior clinicians is essential to address the shortcomings identified in this survey, such as the implementation of evidence-based safe practices, supply chain failures, high maternal morbidity, and mortality. Training of medical officers and NAs should be strengthened in leadership, team work, and management of complications.

Improving Anesthesia Safety in Low-Resource Settings.

The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the "Bellwether Procedures" (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.

Global Surgery System Strengthening: It Is All About the Right Metrics.

Progress in achieving "universal access to safe, affordable surgery, and anesthesia care when needed" is dependent on consensus not only about the key messages but also on what metrics should be used to set goals and measure progress. The Lancet Commission on Global Surgery not only achieved consensus on key messages but also recommended 6 key metrics to inform national surgical plans and monitor scale-up toward 2030. These metrics measure access to surgery, as well as its timeliness, safety, and affordability: (1) Two-hour access to the 3 Bellwether procedures (cesarean delivery, emergency laparotomy, and management of an open fracture); (2) Surgeon, Anesthetist, and Obstetrician workforce >20/100,000; (3) Surgical volume of 5000 procedures/100,000; (4) Reporting of perioperative mortality rate; and (5 and 6) Risk rates of catastrophic expenditure and impoverishment when requiring surgery. This article discusses the definition, validity, feasibility, relevance, and progress with each of these metrics. The authors share their experience of introducing the metrics in the Pacific and sub-Saharan Africa. We identify appropriate messages for each potential stakeholder-the patients, practitioners, providers (health services and hospitals), public (community), politicians, policymakers, and payers. We discuss progress toward the metrics being included in core indicator lists by the World Health Organization and the World Bank and how they have been, or may be, used to inform National Surgical Plans in low- and middle-income countries to scale-up the delivery of safe, affordable, and timely surgical and anesthesia care to all who need it.