A Primer on Population Health Management and Its Perioperative Application.

The movement toward value-based payment models, driven by governmental policies, federal statutes, and market forces, is propelling the importance of effectively managing the health of populations to the forefront in the United States and other developed countries. However, for many anesthesiologists, population health management is a new or even foreign concept. A primer on population health management and its potential perioperative application is thus presented here. Although it certainly continues to evolve, population health management can be broadly defined as the specific policies, programs, and interventions directed at optimizing population health. The Population Health Alliance has created a particularly cogent conceptual framework and interconnected and very useful population health process model, which together identify the key components of population health and its management. Population health management provides a useful rationale for patients, providers, payers, and policymakers to move collectively away from the traditional system of individual, siloed providers to a more integrated, coordinated, team-based approach, thus creating a holistic view of the patient population. The goal of population health management is to keep the targeted patient population as healthy as possible, thus minimizing the need for costly interventions such as emergency department visits, acute hospitalizations, laboratory testing and imaging, and diagnostic and therapeutic procedures. Population health management strategies are increasingly more important to leaders of health care systems as the health of populations for which they care, especially in a strong cost risk-sharing environment, must be optimized. Most population health management efforts rely on a patient-centric team approach, coordination of care, effective communication, robust outcomes data analysis, and continuous quality improvement. Anesthesiologists have an opportunity to help lead these efforts in concert with their surgical and nursing colleagues. The Triple Aim of Healthcare includes (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing per-capita costs of care. The Perioperative Surgical Home essentially seeks to transform perioperative care by achieving the Triple Aim, including improving the health of the surgical population. Many health care delivery systems and many clinicians (including anesthesiologists) are just beginning their population health management journeys. However, by doing so, they are preparing to navigate a much greater risk-sharing landscape, where these efforts can create greater financial stability by preventing major financial loss. Anesthesiologists can and should be leaders in this effort to add value by improving the comprehensive continuum of care of our patients.

The anesthesiologist and the law: the criminal liability of midwives and anesthesiologists for epidural anesthetic reinjection in obstetrics.

The issue whether an anesthesiologist can be criminally condemned for a mistaken injection by the midwife of a mixture of local anesthetics with calcium chloride into the epidural space was examined by the Criminal tribunal of Dendermonde and confirmed by the Court of Appeal of Ghent. Liability was asserted not only against the negligent midwife who did the erroneous reinjection, but also against the resident anesthesiologist who followed the rules of the anesthesia department and ordered the replacement of the syringe by telephone. The midwife was condemned not because she performed the technical act of an epidural reinjection, but because she made an obvious error in making the solution by confusing of diluting solution. The anesthesiologist was condemned because she did not directly control the midwife while she was performing her task. The current medico-legal situation in Belgium is paradoxical and even greatly inconsistent in that patients with no medical or nursing qualifications perform acts under the safety limits of the patient controlled epidural analgesia (PCEA) technique, acts which nurses or midwives are not legally permitted to perform. The author suggests that the law should be changed, allowing epidural reinjections and the replacements of the syringe of continuous epidural analgesia infusion by nurses or midwives on condition that the physician remains responsible for training and selecting his collaborators and that the injected dose does not exceed the safety limits of a spinal dose of the same anesthetic.

[Use of local anesthetics in dentistry: medico-legal aspects]. / L'impiego degli anestetici locali in odontoiatria: aspetti medico-legali.

The Authors consider the problem of the clinical use of local anaesthetics in dentistry with a view to establishing possible adverse reactions, of which they provide a schematic analysis and an up to date pathogenetic survey; they thus make their observations on case historics taken from the sector of forensic medicine in Siena, and in conclusion make a jurisprudential digression in the form of a discussion on the responsibility of the practitioner in the strait of anaesthesiology, emphasizing by the same, an ever increasingly harmonizing evolution with regular judicial procedure in common law countries.

Dental hygiene licensure specifications on pain control procedures.

State boards of dentistry of the 51 licensure jurisdictions and 51 constituent hygiene presidents were sent identical surveys to obtain current information about dental hygiene licensure specifications for nitrous oxide analgesia, and infiltration, block, and topical anesthesia. The response rate was 72% (N = 37) from boards and 90% (N = 46) from constituent presidents. Results showed that western states are more likely to allow delegation of pain control functions. Of the four functions, topical anesthesia is the most and nitrous oxide analgesia is the least delegated. Most states that allow delegation of pain control procedures did so in the 1970s and 1980s. A majority of states where pain control functions are legal specify direct or indirect supervision and certification through board-approved courses. Percentages of hygienists certified in functions ranged from a low of 0% to a high of 100%. Boards and presidents agreed closely on functions allowed, certification requirements, and year of legalization. Agreement was lower on the type of supervision required for all procedures except nitrous oxide analgesia. No reports of patient reactions to or formal complaints about pain control procedures provided by hygienists were known to state boards or constituent presidents.