Diversity and Similarity of Anesthesia Procedures in the United States During and Among Regular Work Hours, Evenings, and Weekends.

BACKGROUND: Anesthesiologists providing care during off hours (ie, weekends or holidays, or cases started during the evening or late afternoon) are more likely to care for patients at greater risk of sustaining major adverse events than when they work during regular hours (eg, Monday through Friday, from 7:00 AM to 2:59 PM). We consider the logical inconsistency of using subspecialty teams during regular hours but not during weekends or evenings. METHODS: We analyzed data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry (NACOR). Among the hospitals in the United States, we estimated the average number of common types of anesthesia procedures (ie, diversity measured as inverse of Herfindahl index), and the average difference in the number of common procedures between 2 off-hours periods (regular hours versus weekends, and regular hours versus evenings). We also used NACOR data to estimate the average similarity in the distributions of procedures between regular hours and weekends and between regular hours and evenings in US facilities. Results are reported as mean ± standard error of the mean among 399 facilities nationwide with weekend cases. RESULTS: The distributions of common procedures were moderately similar (ie, not large, <.8) between regular hours and evenings (similarity index .59 ± .01) and between regular hours and weekends (similarity index, .55 ± .02). For most facilities, the number of common procedures differed by <5 procedures between regular hours and evenings (74.4% of facilities, P < .0001) and between regular hours and weekends (64.7% of facilities, P < .0001). The average number of common procedures was 13.59 ± .12 for regular hours, 13.12 ± .13 for evenings, and 9.43 ± .13 for weekends. The pairwise differences by facility were .13 ± .07 procedures (P = .090) between regular hours and evenings and 3.37 ± .12 procedures (P < .0001) between regular hours and weekends. In contrast, the differences were -5.18 ± .12 and 7.59 ± .13, respectively, when calculated using nationally pooled data. This was because the numbers of common procedures were 32.23 ± .05, 37.41 ± .11, and 24.64 ± .12 for regular hours, evenings, and weekends, respectively (ie, >2x the number of common procedures calculated by facility). CONCLUSIONS: The numbers of procedures commonly performed at most facilities are fewer in number than those that are commonly performed nationally. Thus, decisions on anesthesia specialization should be based on quantitative analysis of local data rather than national recommendations using pooled data. By facility, the number of different procedures that take place during regular hours and off hours (diversity) is essentially the same, but there is only moderate similarity in the procedures performed. Thus, at many facilities, anesthesiologists who work principally within a single specialty during regular work hours will likely not have substantial contemporary experience with many procedures performed during off hours.

National Perioperative Outcomes for Intrathecal Pump, Spinal Cord Stimulator, and Peripheral Nerve Stimulator Procedures.

BACKGROUND: There is abundant literature on the long-term complications of intrathecal pumps (ITP), spinal cord stimulators (SCS), and peripheral nerve stimulators (PNS) used in the treatment of chronic pain. There is less information, however, on the perioperative complications of these procedures. OBJECTIVE: Exploration of the perioperative outcomes of implantable pain devices. STUDY DESIGN: Observational study. SETTING: University hospitals, community hospitals, specialty hospitals, attached surgery centers, and freestanding surgery centers METHODS: Data were obtained from the National Anesthesia Clinical Outcomes Registry (NACOR) of the Anesthesia Quality Institute (AQI). Information was collected on patient demographics, procedure information, anesthetic administered, diagnosis linked to the procedure, and perioperative outcomes. RESULTS: The search yielded 12,611 ITP, 19,276 SCS, and 15,184 PNS cases from 2010 to 2014. In this sample, the majority of procedures were performed at community hospitals, not university medical centers. The most common diagnosis cited for an ITP was an implant complication (n = 2,570), followed by spasticity, and non-malignant back pain. For SCS, the most common diagnoses were lower back pain (n = 5,515) or radiculopathy (n = 2,398). For PNS, by far the most common diagnosis related to urinary dysfunction (n = 8,745), with painful bladder syndrome a small minority (n = 133). General anesthetics were more often performed for ITP than for SCS and PNS procedures (60.6% vs. 31.8% and 32.2%, respectively). Hemodynamic instability was a common outcome (13.9% for ITP procedures); other common outcomes for all the procedures included case delays, inadequate pain control, and extended PACU stays. LIMITATIONS: Despite the large sample size in this study, not all medical centers transmit their outcome data to NACOR. Furthermore, some institutions do not report clinical outcomes for every case to NACOR, making the sample size of assessing complications smaller and potentially more biased. Finally, procedures identified in the NACOR database using CPT may be similar but not identical and therefore potentially influence outcomes. CONCLUSIONS: Databases such as NACOR can provide rich information on ITP, SCS, and PNS for physicians performing these procedures. In this sample, ITP procedures, performed on the patients with the most severe cormobidities and often-requiring general anesthesia, were the most likely to be associated with hemodynamic instability, inadequate pain control, and extended PACU stays. Complications relating to the ITP are also the most common reason for an operation. These findings underscore the importance of proper patient selection for ITP and other implantable pain devices, in particular for patients with malignant pain or multiple co-morbidities. To identify the root causes of complications, additional information is needed on the procedure performed (e.g., an implant vs a revision), the surgical technique used, and the device implanted, as well as on specific patient comorbidities. Such information will likely become more available as resources like NACOR expand and as electronic medical record systems and coding become more integrated.