Measuring and Comparing Clinical Productivity of Individual Anesthesiologists.

Measuring and comparing clinical productivity of individual anesthesiologists is confounded by anesthesiologist-independent factors, including facility-specific factors (case duration, anesthetizing site utilization, type of surgical procedure, and non-operating room locations), staffing ratio, number of calls, and percentage of clinical time providing anesthesia. Further, because anesthesia care is billed with different units than relative value units, comparing work with other types of clinical care is difficult. Finally, anesthesia staffing needs are not based on productivity measurements but primarily the number and hours of operation of anesthetizing sites. The intent of this review is to help anesthesiologists, anesthesiology leaders, and facility leaders understand the limitations of anesthesia unit productivity as a comparative metric of work, how this metric often devalues actual work, and the impact of organizational differences, staffing models and coverage requirements, and effectiveness of surgical case load management on both individual and group productivity.

Multivariable Cost Frontiers-Qualitative Financial Analyses Using Operational Metrics From the Implementation of a Surgery Fellowship.

OBJECTIVE: We expand the application of cost frontiers and introduce a novel approach using qualitative multivariable financial analyses. SUMMARY BACKGROUND DATA: With the creation of a 5 + 2-year fellowship program in July 2016, the Division of Vascular Surgery at the University of Vermont Medical Center altered the underlying operational structure of its inpatient services. METHOD: Using WiseOR (Palo Alto, CA), a web-based OR management data system, we extracted the operating room metrics before and after August 1, 2016 service for each 4-week period spanning from September 2015 to July 2017. The cost per minute modeled after Childers et al's inpatient OR cost guidelines was multiplied by the after-hours utilization to determine variable cost. Zones with corresponding cutoffs were used to graphically represent cost efficiency trends. RESULTS: Caseload/FTE for attending surgeons increased from 11.54 cases per month to 13.02 cases per month ( P = 0.0771). Monthly variable costs/FTE increased from $540.2 to $1873 ( P = 0.0138). Monthly revenue/FTE increased from $61,505 to $70,277 ( P = 0.2639). Adjusted monthly reve-nue/FTE increased from $60,965 to $68,403 ( P = 0.3374). Average monthly percent of adjusted revenue/FTE lost to variable costs increased from 0.85% to 2.77% ( P = 0.0078). Adjusted monthly revenue/case/FTE remained the same from $5309 to $5319 ( P = 0.9889). CONCLUSION: In summary, we demonstrate that multivariable cost (or performance) frontiers can track a net increase in profitability associated with fellowship implementation despite diminishing returns at higher caseloads.

Industry-Wide Survey of Academic Anesthesiology Departments Provides Up-to-Date Benchmarking Data on Surgical Anesthesia Productivity.

BACKGROUND: Benchmarking group surgical anesthesia productivity continues to be an important but challenging goal for anesthesiology groups. Benchmarking is important because it provides objective data to evaluate staffing needs and costs, identify potential operating room management decisions that could reduce costs or improve efficiency, and support ongoing negotiations and discussions with health system leadership. Unfortunately, good and meaningful benchmarking data are not readily available. Therefore, a survey of academic anesthesiology departments was done to provide current benchmarking data. METHODS: A survey of members of the Society of Academic Associations of Anesthesiology and Perioperative Medicine (SAAAPM) was performed. The survey collected data by facility and included type of facility, number and type of staff and anesthetizing sites each weekday, and the billed American Society of Anesthesiologists (ASA) units and number of cases over 12 months. The facility types included academic medical center (AMC), community hospital (Community), children's hospital (Children), and ambulatory surgical center (ASC). All anesthesia care billed using ASA units were included, except for obstetric anesthesia. Any care not billed or billed using relative value units (RVUs) were excluded. Percentage of nonoperating room anesthetizing sites, staffing ratio, and surgical anesthesia productivity measurements "per case" and "per site" were calculated. RESULTS: Of the 135 society members, 63 submitted complete surveys for 140 facilities (69 AMC, 26 Community, 7 Children, and 38 ASC). In the survey, overall median productivity for AMC and Children was similar (12,592 and 12,364 total ASA units per anesthetizing site), while the ASC had the lowest median overall productivity (8911 total ASA units per anesthetizing site). By size of facility, in the survey, the smaller facilities (<10 sites, ASC or non-ASC) had lower median overall productivity as compared to larger facilities. For AMC and Children, >20% of anesthetizing sites were nonoperating room anesthetizing sites. Anesthesiology residents worked primarily in AMC and Children. In ASC and Community, residents worked only in 18% and 35% of facilities, respectively. More than half the AMCs reported at least 1 break certified nurse anesthetist (CRNA) each day. CONCLUSIONS: To make data-driven decisions on clinical productivity, anesthesiology leaders need to be able to make meaningful comparisons at the facility level. For a group that provides care in multiple facilities, one can make internal comparisons among facilities and follow measurements over time. It is valuable for leaders to also be compare their facilities with industry-wide measurements, in other words, benchmark their facilities. These results provide benchmarking data for academic anesthesiology departments.

Measuring Clinical Productivity of Anesthesiology Groups: Surgical Anesthesia at the Facility Level.

Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent.

Chronic pain clinic efficiency analysis: optimization through use of the Gantt diagram and visit diagnoses.

OBJECTIVE: The aim of this study is to identify scheduling inefficiencies and to develop a personalized schedule based on diagnosis, service time (face-to-face time between the patient and the provider), and patient wait time using a Gantt diagram in a chronic pain clinic. DESIGN: This is an observational prospective cohort quality improvement (QI) study. SETTING: This study was carried out at a single outpatient multidisciplinary pain management clinic in a university teaching hospital. SUBJECTS: New and established chronic pain patients at the University of Pittsburgh Medical Center (UPMC) Montefiore Chronic Pain Clinic were recruited for this study. METHODS: Time tracking data for each phase of clinic visit and pain-related diagnoses were collected from 81 patients on 5 clinic days in March 2016 for patient flow analysis. RESULTS: A Gantt diagram was created using Microsoft Excel® software. Areas of overbooking and underbooking were identified. Median service times (minutes) differed dramatically based on the diagnosis and were highest for facial pain (23 [IQR, 15-31]) and chronic abdominal and/or pelvic pain (21.5 [IQR, 16-27]) and lowest for myalgia. Abdominal and/or pelvic pain and facial pain median service times consistently exceeded the 15-minute allocation for return visits. CONCLUSION: Schedule efficiency analysis using the Gantt diagram identified trends of overbooking and underbooking and inefficiencies in examination room utilization. A 15-minute appointment for all return patients is unrealistic due to variation of service times for some diagnoses. Scheduling appointments based on the diagnosis is an innovative approach that may reduce scheduling inefficiencies and improve patient satisfaction and the overall quality of care. To the best of our knowledge, this type of scheduling diagram has not been used in a chronic pain clinic.

Measuring Clinical Productivity.

Productivity measurements have been used to evaluate and compare physicians and physician practices. Anesthesiology is unique in that factors outside anesthesiologist control impact opportunity for revenue generation and make comparisons between providers and facilities challenging. This article uses data from the multicenter University of Pittsburgh Physicians Department of Anesthesiology to demonstrate factors influencing productivity opportunity by surgical facility, between department divisions and subspecialties within multispecialty divisions, and by individuals within divisions. The complexities of benchmarking anesthesiology productivity are demonstrated, and the potential value of creating a productivity profile for facilities and groups is illustrated.

Regional Anesthesia Is Cost-Effective in Preventing Unanticipated Hospital Admission in Pediatric Patients Having Anterior Cruciate Ligament Reconstruction.

BACKGROUND AND OBJECTIVES: Published studies have shown a benefit of regional anesthesia (RA) in preventing unplanned hospital admissions (UHAs) and decreasing hospital costs after orthopedic surgeries in adults but not pediatric patients. We performed a retrospective analysis to assess the effect of converting from an opioid to RA-based approach to pain management after pediatric anterior cruciate ligament (ACL) reconstruction. METHODS: The records of patients having ACL reconstruction were reviewed. Two groups, those with (n = 115) and without (n = 39) nerve blocks, were identified. Single-shot blocks or indwelling catheters were performed in the operating room (OR) or a block room. Time to discharge readiness, postoperative opiate and antiemetic consumption, hospital admission or discharge, and complications were recorded. The cost of providing RA, the change in UHA and postanesthesia care unit utilization, and subsequent financial impact were calculated. RESULTS: Regional anesthesia-based pain management was associated with a lower rate of UHA (P = 0.045), less time in postanesthesia care unit phase II (P = 0.013), and a reduction in opioid consumption (P < 0.001). Use of a dedicated RA team with a dedicated block room resulted in cost savings or neutrality, whereas RA catheters placed in the OR were associated with increased direct hospital costs. CONCLUSIONS: Regional anesthesia for pain after ACL repair in pediatric patients facilitated reliable same-day surgery discharge and significantly reduced UHAs. Single-shot blocks and blocks performed outside the OR were the most cost-effective. In addition, nerve block patients required less opioids and were ready for discharge sooner.

A Department-of-Anesthesiology-based management protocol for perioperative corneal abrasions.

INTRODUCTION: Corneal abrasions (CAs) are the most prevalent ocular injuries in the perioperative period. Previously, patients at our community hospital would wait for an ophthalmologist to be available to manage these minor injuries. To decrease this waiting period - and thereby increase patient satisfaction - we developed an anesthesiology-based protocol to manage minor CAs arising in the recovery room. The current study sought to assess this protocol's efficacy as well as further establish the incidence and some risk factors of CA. METHODS: This was a hospital-based, observational study. As per protocol, anesthesiologists saw and diagnosed any patient exhibiting symptoms of CA, after which they initiated a preestablished treatment regimen. To examine the efficacy of this protocol between March 2007 and December 2011, the number of CAs anesthesiologists managed and time to treatment were recorded. Additionally, the frequency of CAs was established along with some of their risk factors. RESULTS: Throughout the study period, there were 91,064 surgical cases, with 118 CAs (0.13% incidence). Anesthesiology alone managed 110 (93.22%) of these cases. The median time between the end of anesthesia to the time of prescribed ophthalmic medication was 156 minutes (first-third interquartile range: 108-219). All patients experienced resolution of symptoms by the morning following their complaint. Compared to the general surgical population, CA patients were older (P<0.01) and underwent longer surgeries (P<0.01). CONCLUSION: Minor CAs can be safely and effectively managed using an anesthesiology-based approach. Advanced age and longer surgery are confirmed as risk factors for these injuries.

Preparing for budget-based payment methodologies: global payment and episode-based payment.

PURPOSE OF REVIEW: Use of budget-based payment methodologies (capitation and episode-based bundled payment) has been demonstrated to drive value in healthcare delivery. With a focus on high-volume, high-cost surgical procedures, inclusion of anaesthesiology services in these methodologies is likely. This review provides a summary of budget-based payment methodologies and practical information necessary for anaesthesiologists to prepare for participation in these programmes. RECENT FINDINGS: Although few examples of anaesthesiologists' participation in these models exist, an understanding of the structure of these programmes and opportunities for participation are available. Prospective preparation in developing anaesthesiology-specific bundled payment profiles and early participation in pathway development associated with selected episodes of care are essential for successful participation as a gainsharing partner. SUMMARY: With significant opportunity to contribute to care coordination and cost management, anaesthesiology can play an important role in budget-based payment programmes and should expect to participate as full gainsharing partners. Precise costing methodologies and accurate economic modelling, along with identification of quality management and cost control opportunities, will help identify participation opportunities and appropriate payment and gainsharing agreements. Anaesthesiology-specific examples with budget-based payment models are needed to help guide increased participation in these programmes.

Sugammadex is effective in reversing rocuronium in the presence of antibiotics.

BACKGROUND: The effectiveness of sugammadex in reversing rocuronium-induced neuromuscular blockade (NMB) in the presence of drugs that may potentiate NMB remains to be fully established. The aim of this post-hoc analysis of data from a Phase III clinical trial (VISTA; NCT00298831) was to investigate the impact of antibiotics on recovery from rocuronium-induced NMB after administration of sugammadex for reversal, and compared the neuromuscular recovery in patients who received antibiotics preoperatively with those who did not. METHODS: A Phase III, multicenter, open-label study designed to reflect potential use of sugammadex in clinical practice was conducted at 19 sites. Data obtained from patients who received antibiotics were compared with the cohort of patients who underwent the same protocol without antibiotics. Each subject received rocuronium 0.6 mg/kg for muscle relaxation, after which tracheal intubation was performed; patients were also permitted to receive maintenance doses of rocuronium 0.15 mg/kg to maintain the desired level of NMB throughout the operation, as required.. At least 15 min after the last rocuronium dose, patients received sugammadex 4.0 mg/kg for reversal. Neuromuscular monitoring was continued until a train-of-four (TOF) ratio of ≥0.9 was achieved or the anesthetic was discontinued. RESULTS: The presence of antibiotics prior to the administration of sugammadex did not affect the recovery time from rocuronium-induced NMB when sugammadex 4.0 mg/kg was administered at least 15 min after the last dose of rocuronium. In the presence of antibiotics, the geometric mean (95% CI) time from administration of sugammadex 4.0 mg/kg to recovery of the TOF ratio to ≥0.9 was 1.6 (1.4-1.9) min (range: 0.7-10.5 min), compared with 2.0 (1.8-2.3) min (range: 0.7-22.3 min) for patients who did not receive antibiotics. CONCLUSIONS: These findings suggest that prophylactic antibiotic use is unlikely to have a major impact on the recovery time from rocuronium-induced NMB with sugammadex reversal. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00298831.

Factors impacting on-time transfer to the operating room in patients undergoing peripheral nerve blocks in the preoperative area.

STUDY OBJECTIVES: To assess the on-time transfer to the operating room (OR) when peripheral nerve blocks (PNBs) are performed prior to surgery. DESIGN: Prospective time motion study. SETTING: Preoperative area of a university medical center. PATIENTS: 650 candidates for PNBs for postoperative analgesia. INTERVENTION: Patients were allocated to two groups: a control group (no PNB performed) and a PNB group (PNBs performed). MEASUREMENT TIME: The time required to perform each of the steps leading to transfer to the OR was recorded. MAIN RESULTS: On-time transfer was achieved in 40% and 49% in the blocked (n = 549) and control groups (n = 101), respectively (P = 0.067, one-sided). Surgery-related delays represented the most important causes of delays (51.9% in the control group and 53.8% in the PNB group). The average time required to perform the blocks was 21 minutes (20-22 min). This time varied with the type and number of blocks performed (12-30 min). Performing PNBs accounted for 15.1% of delays. CONCLUSIONS: Performing PNBs prior to surgery in the preoperative area takes additional time. This time needs to be considered in optimizing on-time transfer to the OR.