Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data.

STUDY OBJECTIVE: The aim of this study is to provide a contemporary medicolegal analysis of claims brought against anesthesiologists in the United States for events occurring in the post-anesthesia care unit (PACU). DESIGN: In this retrospective analysis, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database. SETTING: Claims closed between January 1, 2010 and December 31, 2014 were included for analysis if the alleged damaging event occurred in a PACU and anesthesiology was named as the primary responsible service. PATIENTS: Forty-three claims were included for analysis. Data regarding ASA physical status and comorbidities were obtained, whenever available. Ages ranged from 18 to 94. Patients underwent a variety of surgical procedures. Severity of adverse outcomes ranged from temporary minor impairment to death. INTERVENTIONS: Patients receiving care in the PACU. MEASUREMENTS: Information gathered for this study includes patient demographic data, alleged injury type and severity, operating surgical specialty, contributing factors to the alleged damaging event, and case outcome. Some of these data were drawn directly from coded variables in the CRICO CBS database, and some were gathered by the authors from narrative case summaries. RESULTS: Settlement payments were made in 48.8% of claims. A greater proportion of claims involving death resulted in payment compared to cases involving other types of injury (69% vs 37%, p = 0.04). Respiratory injuries (32.6% of cases), nerve injuries (16.3%), and airway injuries (11.6%) were common. Missed or delayed diagnoses in the PACU were cited as contributing factors in 56.3% of cases resulting in the death of a patient. Of all claims in this series, 48.8% involved orthopedic surgery. CONCLUSIONS: The immediate post-operative period entails significant risk for serious complications, particularly respiratory injury and complications of airway management. Appropriate monitoring of patients by responsible providers in the PACU is crucial to timely diagnosis of potentially severe complications, as missed and delayed diagnoses were a factor in a number of the cases reviewed.

Cost-utility analyses in spine care: a qualitative and systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: A systematic review was performed to identify US-based cost-utility analyses (CUA) studies in spine care and to critically evaluate the quality of the available literature. SUMMARY OF BACKGROUND DATA: There has been a recent trend in the United States toward increased publication of economic analyses in spine care. The cost-effectiveness of spine interventions and the quality of published literature is not well understood. METHODS: A MEDLINE search was conducted to identify cost analyses in spine care. Articles were excluded on the basis of the following criteria: nonspine care, nonoperative, non-US based, nonclinical, and not CUA. Of the 424 screened articles, 20 met inclusion criteria. Quality of studies was assessed using the Quality of Health Economic Studies instrument. RESULTS: Evidence for the cost-effectiveness of operative spinal intervention is varied. The majority of available studies report favorable cost-effectiveness ratios, however, a few studies suggest that certain operative interventions are not cost-effective. Average Quality of Health Economic Studies score of all included studies was 75.1 (60-93). The quality of evidence is variable and there are a number of weaknesses in the available literature, most significant of which is that few studies adopt a long-term time horizon or have sufficient follow-up (N = 3/20). High Quality of Health Economic Studies scoring studies were more likely to have sensitivity analysis (P = 0.016), societal cost perspective (P = 0.014), and a funding disclosure (P = 0.03). CONCLUSION: There is a small but rapidly growing body of US-based CUA in spine care. The quality of CUA evidence is variable but there are significant opportunities to strengthen future CUA studies in spine. This study highlights the need for more attention to CUA research and the quality of these studies in spine care.