Understanding the Economic Impact of an Essential Service: Applying Time-Driven Activity-Based Costing to the Hospital Airway Response Team.

BACKGROUND: As the United States moves toward value-based care metrics, it will become essential for anesthesia groups nationwide to understand the costs of their services. Time-driven activity-based costing (TDABC) estimates the amount of time it takes to perform a clinical activity by dividing complex tasks into process steps and mapping each step and has historically been used to estimate the costs of various health care services. TDABC is a tool that can be adapted for variable staffing models and the volume of service provided. Anesthesia departments often provide staffing for airway response teams (ART). The economic implications of staffing ART have not been well described. We present a TDABC model for ART activation in a tertiary-care center to estimate the cost incurred by an anesthesiology department to staff an ART. METHODS: Pages received by the Brigham and Women's Hospital ART over a 24-month time period (January 2019 to December 2020) were analyzed and categorized. The local administrative database was queried for the Current Procedural Terminology (CPT) code used to bill for emergency airway placements. Sessions were held by multiple members of the ART to create process maps for the different types of ART activations. We estimated the staffing costs using the estimated time it took for each type of ART activation as well as the data collected for local ART activations. RESULTS: From the paging records, we analyzed 3368 activations of the ART. During the study period, 1044 airways were billed for with emergency airway CPT code. The average revenue collected per airway was $198.45 (95% CI, $190-$207). For STAT/Emergency airway team activations, process maps and non-STAT airway team activations were created, and third subprocess map was created for performing endotracheal intubation. Using the TDABC, the total staffing costs are estimated to be $218,601 for the 2-year study period. The ART generated $207,181 in revenue during the study period. CONCLUSIONS: Our analysis of ART-activation pages suggests that while the revenue generated may cover the cost of staffing the team during ART activations, it does not cover consumable equipment costs. Additionally, the current fee-for-service model relies on the team being able to perform other clinical duties in addition to covering the airway pager and would be impossible to capture using traditional top-down costing methods. By using TDABC, anesthesia groups can demonstrate how certain services, such as ART, are not fully covered by current reimbursement models and how to negotiate for subsidy agreements.As the transition from traditional fee-for-service payments to value-based care models continues in the United States, improving the understanding and communication of medical care costs will be essential. In the United States, it is common for anesthesia groups to receive direct revenue from hospitals to preserve financial viability, and therefore, knowledge of true cost is essential regardless of payer model.1 With traditional payment models, what is billable and nonbillable may not reflect either the need for or the cost of providing the service. As anesthesia departments navigate the transition of care from volume to value, actual costs will be essential to understand for negotiations with hospitals for support when services are nonbillable, when revenue from payers does not cover anesthesia costs, and when calculating the appropriate share for anesthesia departments when bundled payments are distributed.

The monthly operating cost of an institutional COVID-19 airway response team: A financial model and sensitivity analysis based on experience at an academic medical center.

BACKGROUND: Coronavirus disease 2019 (COVID-19) airway response teams concentrate equipment and expertise while minimizing the number of providers exposed to aerosol generating procedures. These airway teams were implemented in various hospitals around the world to respond to the acute increase of critical ill patients requiring ventilatory support. We created a financial model to estimate the costs for staffing and maintaining a dedicated COVID-19 airway response team based on the experience at an urban academic hospital in the Northeastern United States between March and June of 2020. METHODS: The institutional review board at Brigham and Women's Hospital approved this protocol and the requirement for informed consent was waived. The average reimbursement for 125 COVID-19 airway consultations was measured. Our team estimated the costs of consumable items for each airway based on previously published recommendations for equipment and personal protective equipment. A sensitivity analyses was performed for variable numbers of monthly airway consults and different staffing patterns based on a literature review of available COVID-19 airway team structures. RESULTS: Based on the average reimbursements and estimates of the consumable costs, each airway procedure represented a net loss of $34 to the institution. The overall estimated cost of staffing a dedicated airway team was between $109,472 and $204,575 per month. CONCLUSIONS: Development and implementation of a dedicated COVID-19 airway response teams represents a significant institutional expense. Institutions should establish necessary cost sharing, consider volume and team structure, and identify reimbursement opportunities that mitigate the necessary expense associated with airway response programs.

Resident-Driven Quality Improvement Project in Perioperative Hand Hygiene.

OBJECTIVES: The goal of the project was to improve hand hygiene compliance in the perioperative setting while involving anesthesia residents in quality improvement. To achieve this goal, we facilitated direct trainee participation on patient safety and quality improvement initiatives. The result was a project for perioperative hand hygiene improvement conceived and led by anesthesiology residents. METHODS: Anesthesiology residents contributed project ideas and participated in problem-based learning discussions to develop several interventions for improving perioperative hand hygiene compliance. Interventions included electronic and laminated posters, reminder cards, monthly aggregated performance feedback, and a simulation-based hand hygiene workshop. Monthly hand hygiene compliance data were gathered during unannounced observations for a 29-month period. Run chart analysis and χ test were used to determine the impact of these interventions on compliance rates. RESULTS: A total of 1122 hand hygiene observations were made for 29 months. Run chart analysis showed a nonrandom shift and increasing trend during the postintervention period. The baseline hand hygiene rate was 68% (95% CI [65%-72%], n = 661), which increased to 79% post-intervention (95% CI [76%-83%], n = 461, P < 0.01). CONCLUSIONS: Our resident-led hand hygiene program used a multifaceted approach to drive sustained increases in perioperative hand hygiene compliance, while directly engaging house staff in quality improvement initiatives.

Description of a multidisciplinary initiative to improve SCIP measures related to pre-operative antibiotic prophylaxis compliance: a single-center success story.

BACKGROUND: The Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created due to recognition of the impact of proper perioperative prophylaxis on an estimated annual one million inpatient days and $1.6 billion in excess health care costs secondary to preventable surgical site infections (SSIs). An internal study was conducted to create low cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration. METHODS: We assessed the impact of auditing and notifying providers of SCIP errors on overall compliance with inpatient antibiotic guidelines and on net financial gain or loss to a large tertiary center between March 1st 2010 and September 31st 2013. We hypothesized that direct physician-to-physician feedback would result in significant compliance improvements. RESULTS: Through physician notification, our hospital was able to significantly improve SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for re-investment in patient care initiatives. CONCLUSIONS: Provider education and direct notification of SCIP prophylactic antibiotic dosing errors resulted in improved compliance with national patient improvement guidelines. There were differences between the anesthesiology and surgery department feedback responses, the latter likely attributed to diverse surgical department sub-divisions, frequent changes in resident trainees and supervising attending staff, and the comparative ability. Provider notification of guideline non-compliance should be encouraged as standard practice to improve patient safety. Also, the hospital experienced increased revenue for re-investment in patient care as a secondary result of provider notification.

Process measures to improve perioperative prophylactic antibiotic compliance: quality and financial implications.

The Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created because of recognition of the impact of proper perioperative prophylaxis on an estimated annual 1 million inpatient days and $1.6 billion in excess health care costs that are secondary to preventable surgical site infections. There is a need to create low-cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration. The impact of interventions on provider compliance with SCIP inpatient antibiotic guidelines and net financial gain or loss to a large tertiary center were assessed. A single hospital was able to significantly improve their SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for reinvestment in patient safety initiatives. Low-cost interventions aimed at educating providers that utilize existing infrastructure result in improved SCIP compliance and patient safety. As a secondary gain, there were hundreds of thousands of dollars in annual cost savings. The impact of compliance on infection rates is inferred but requires further study.

Increased perioperative b-type natriuretic peptide associates with heart failure hospitalization or heart failure death after coronary artery bypass graft surgery.

BACKGROUND: Heart failure (HF) is a leading cause of hospitalization and mortality. Plasma B-type natriuretic peptide (BNP) is an established diagnostic and prognostic ambulatory HF biomarker. We hypothesized that increased perioperative BNP independently associates with HF hospitalization or HF death up to 5 yr after coronary artery bypass graft surgery. METHODS: The authors conducted a two-institution, prospective, observational study of 1,025 subjects (mean age = 64 ± 10 yr SD) undergoing isolated primary coronary artery bypass graft surgery with cardiopulmonary bypass. Plasma BNP was measured preoperatively and on postoperative days 1-5. The study outcome was hospitalization or death from HF, with HF events confirmed by reviewing hospital and death records. Cox proportional hazards analyses were performed with multivariable adjustments for clinical risk factors. Preoperative and peak postoperative BNP were added to the multivariable clinical model in order to assess additional predictive benefit. RESULTS: One hundred five subjects experienced an HF event (median time to first event = 1.1 yr). Median follow-up for subjects who did not have an HF event = 4.2 yr. When individually added to the multivariable clinical model, higher preoperative and peak postoperative BNP concentrations each, independently associated with the HF outcome (log10 preoperative BNP hazard ratio = 1.93; 95% CI, 1.30-2.88; P = 0.001; log10 peak postoperative BNP hazard ratio = 3.38; 95% CI, 1.45-7.65; P = 0.003). CONCLUSIONS: Increased perioperative BNP concentrations independently associate with HF hospitalization or HF death during the 5 yr after primary coronary artery bypass graft surgery. Clinical trials may be warranted to assess whether medical management focused on reducing preoperative and longitudinal postoperative BNP concentrations associates with decreased HF after coronary artery bypass graft surgery.

Partial anterior leaflet valvuloplasty to avoid systolic anterior motion after mitral valve repair.

Systolic anterior motion (SAM) of the mitral apparatus and consequent obstruction of the left ventricular outflow tract is a known complication of mitral valve repair (MVREP). The edge-to-edge technique has been advocated for the repair of myxomatous mitral valves to avoid SAM. We present a new technique to prevent SAM in patients with a redundant lateral segment of the anterior leaflet by folding its elongated portion underneath the body of the anterior leaflet.

Case report: osteonecrosis of the mandible after laryngoscopy and endotracheal tube placement.

Four patients underwent laryngoscopy and general anesthesia surgery without apparent perioperative complications. Within days of their procedure, throat and mouth pain were reported and intraoral examination in all cases revealed exposed bone in the posterior mandible. The sequestra were easily removed and healing was uneventful. These lesions are likely associated with localized oral trauma during intubation causing periosteal damage, compromised blood supply, and subsequent bone necrosis. Because trauma to the mylohyoid ridge during intubation is likely more common than previously appreciated, anesthesiologists should be aware of this potential complication and refer patients to a specialist for management.

Defective DNA replication impairs mitochondrial biogenesis in human failing hearts.

RATIONALE: Mitochondrial dysfunction plays a pivotal role in the development of heart failure. Animal studies suggest that impaired mitochondrial biogenesis attributable to downregulation of the peroxisome proliferator-activated receptor gamma coactivator (PGC)-1 transcriptional pathway is integral of mitochondrial dysfunction in heart failure. OBJECTIVE: The study sought to define mechanisms underlying the impaired mitochondrial biogenesis and function in human heart failure. METHODS AND RESULTS: We collected left ventricular tissue from end-stage heart failure patients and from nonfailing hearts (n=23, and 19, respectively). The mitochondrial DNA (mtDNA) content was decreased by >40% in the failing hearts, after normalization for a moderate decrease in citrate synthase activity (P<0.05). This was accompanied by reductions in mtDNA-encoded proteins (by 25% to 80%) at both mRNA and protein level (P<0.05). The mRNA levels of PGC-1alpha/beta and PRC (PGC-1-related coactivator) were unchanged, whereas PGC-1alpha protein increased by 58% in the failing hearts. Among the PGC-1 coactivating targets, the expression of estrogen-related receptor alpha and its downstream genes decreased by up to 50% (P<0.05), whereas peroxisome proliferator-activated receptor alpha and its downstream gene expression were unchanged in the failing hearts. The formation of D-loop in the mtDNA was normal but D-loop extension, which dictates the replication process of mtDNA, was decreased by 75% in the failing hearts. Furthermore, DNA oxidative damage was increased by 50% in the failing hearts. CONCLUSIONS: Mitochondrial biogenesis is severely impaired as evidenced by reduced mtDNA replication and depletion of mtDNA in the human failing heart. These defects are independent of the downregulation of the PGC-1 expression suggesting novel mechanisms for mitochondrial dysfunction in heart failure.

Troponin is superior to electrocardiogram and creatinine kinase MB for predicting clinically significant myocardial injury after coronary artery bypass grafting.

AIMS: Cardiac biomarkers are routinely elevated after uncomplicated cardiac surgery to levels considered diagnostic of myocardial infarction in ambulatory populations. We investigated the diagnostic power of electrocardiogram (ECG) and cardiac biomarker criteria to predict clinically relevant myocardial injury using benchmarks of mortality and increased hospital length of stay (HLOS) in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS AND RESULTS: Perioperative ECGs, creatinine kinase MB fraction, and cardiac troponin I (cTnI) were assessed in 545 primary CABG patients. None of the ECG criteria for myocardial injury predicted mortality or HLOS. However, post-operative day (POD) 1 cTnI levels independently predicted 5-year mortality (hazard ratio = 1.42; 95% CI 1.14-1.76 for each 10 microg/L increase; P = 0.009), while adjusting for baseline demographic characteristics and perioperative risk factors. Moreover, cTnI was the only biomarker that significantly improved the prediction of 5-year mortality estimated by the logistic Euroscore (P = 0.02). Furthermore, the predictive value of cTnI for 5-year mortality was replicated in a separately collected cohort of 1031 CABG patients using cardiac troponin T. CONCLUSION: Electrocardiogram diagnosis of post-operative myocardial injury after CABG does not independently predict an increased risk of 5-year mortality or HLOS. Conversely, cTnI is independently associated with an increased risk of mortality and prolonged HLOS.

Idiopathic inflammatory aneurysm of the ascending aorta.

Inflammatory aneurysms of the ascending aorta are exceedingly rare. The principal cause of ascending aortic aneurysms remains arteriosclerosis. We present a patient with an ascending aortic aneurysm caused by active inflammatory disease superimposed on complex atherosclerotic disease of the aorta.

Mechanisms for increased glycolysis in the hypertrophied rat heart.

Glycolysis increases in hypertrophied hearts but the mechanisms are unknown. We studied the regulation of glycolysis in hearts with pressure-overload LV hypertrophy (LVH), a model that showed marked increases in the rates of glycolysis (by 2-fold) and insulin-independent glucose uptake (by 3-fold). Although the V(max) of the key glycolytic enzymes was unchanged in this model, concentrations of free ADP, free AMP, inorganic phosphate (P(i)), and fructose-2,6-bisphosphate (F-2,6-P2), all activators of the rate-limiting enzyme phosphofructokinase (PFK), were increased (up to 10-fold). Concentrations of the inhibitors of PFK, ATP, citrate, and H+ were unaltered in LVH. Thus, our findings show that increased glucose entry and activation of the rate-limiting enzyme PFK both contribute to increased flux through the glycolytic pathway in hypertrophied hearts. Moreover, our results also suggest that these changes can be explained by increased intracellular free [ADP] and [AMP], due to decreased energy reserve in LVH, activating the AMP-activated protein kinase cascade. This, in turn, results in enhanced synthesis of F-2,6-P2 and increased sarcolemma localization of glucose transporters, leading to coordinated increases in glucose transport and activation of PFK.