RESUMEN
BACKGROUND: Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice. We report changes in practice at 4 and 12-18 months after SAFE-OB courses in Madagascar and the Republic of Congo. METHODS: We used a concurrent embedded mixed-methods design based on the Kirkpatrick model for evaluating educational training courses. The primary outcome was qualitative determination of personal and organizational change at 4 months and 12-18 months. Secondary outcomes were quantitative evaluations of knowledge and skill retention over time. From 2014 to 2016, 213 participants participated in 5 SAFE-OB courses in 2 countries. Semistructured interviews were conducted at 4 and 12-18 months using purposive sampling and analyzed using thematic content analysis. Participants underwent baseline knowledge and skill assessment, with 1 cohort reevaluated using repeat knowledge and skills tests at 4 months and another at 12-18 months. RESULTS: At 4 months, 2 themes of practice change (Kirkpatrick level 3) emerged that were not present at 12-18 months: neonatal resuscitation and airway management. At 12-18 months, 4 themes emerged: management of obstetric hemorrhage, management of eclampsia, using a structured approach to assessing a pregnant woman, and management of spinal anesthesia. With respect to organizational culture change (Kirkpatrick level 4), the same 3 themes emerged at both 4 and 12-18 months: improved teamwork, communication, and preparation. Resistance from peers, lack of senior support, and lack of resources were cited as barriers to change at 4 months, but at 12-18 months, very few interviewees mentioned lack of resources. Identified catalysts for change were self-motivation, credibility, peer support, and senior support. Knowledge and skills tests both showed an immediate improvement after the course that was sustained. This supports the qualitative responses suggesting personal and organizational change. CONCLUSIONS: Participation at a SAFE-OB course in the Republic of Congo and in Madagascar was associated with personal and organizational changes in practice and sustained improvements in knowledge and skill at 12-18 months.
Asunto(s)
Anestesia Obstétrica/normas , Competencia Clínica/normas , Evaluación Educacional/normas , Personal de Salud/educación , Personal de Salud/normas , Anestesia Obstétrica/economía , Anestesia Obstétrica/métodos , Congo/epidemiología , Evaluación Educacional/métodos , Femenino , Humanos , Madagascar/epidemiología , Pobreza/economía , Embarazo , Factores de TiempoRESUMEN
STUDY OBJECTIVE: To provide a contemporary medicolegal analysis of claims brought against anesthesia providers in the United States related to neuraxial blocks for surgery and obstetrics. DESIGN: In this retrospective analysis, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2007 and 2016. SETTING: Closed claims from inpatient and outpatient settings related to neuraxial anesthesia for surgical procedures and obstetrics. PATIENTS: Forty-five claims were identified for analysis. These patients underwent a variety of surgical procedures, included both children and adults, and with ages ranging from 6 to 82. INTERVENTIONS: Patients receiving neuraxial anesthesia (spinals, epidurals) for surgery or obstetrics. MEASUREMENTS: Data collected includes patient demographics, alleged injury type/severity, surgical specialty, likely contributors to the alleged damaging event, and case outcome. Some of the data were drawn directly from coded variables in the CRICO database, and some were gathered from narrative case summaries. MAIN RESULTS: Settlement payments were made in 20% of claims. Reported adverse outcomes ranged from temporary minor to permanent major injuries. Most closed claims were classified as permanent minor injuries. The greatest number of claims involved residual weakness and radiculopathy resulting from epidurals. The largest contributing factor to these injuries was noted to be "Technical Knowledge/Performance" of the anesthesia provider followed by "Missing or Documentation Error." Over half of the claims arose from obstetric patients (31%) and patients undergoing orthopedic surgery (27%). CONCLUSIONS: Patients with pre-existing radiculopathy or comorbidities may warrant more thorough informed consent about the increased risk of injury. Additionally, prompt follow-up, monitoring, and documentation of post-operative symptoms, such as weakness or radiculopathy, are crucial for improving patient safety and satisfaction. More timely communication with the patient and the surgical team regarding residual neurologic symptoms is important for earlier diagnosis of injury.
Asunto(s)
Anestesia Epidural/efectos adversos , Anestesia Obstétrica/efectos adversos , Revisión de Utilización de Seguros/estadística & datos numéricos , Mala Praxis/estadística & datos numéricos , Complicaciones Posoperatorias/economía , Radiculopatía/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anestesia Epidural/economía , Anestesia Obstétrica/economía , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/economía , Benchmarking/economía , Benchmarking/legislación & jurisprudencia , Benchmarking/estadística & datos numéricos , Niño , Comunicación , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Humanos , Consentimiento Informado/legislación & jurisprudencia , Seguro de Responsabilidad Civil/estadística & datos numéricos , Masculino , Mala Praxis/economía , Mala Praxis/legislación & jurisprudencia , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Relaciones Médico-Paciente , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Embarazo , Radiculopatía/epidemiología , Radiculopatía/etiología , Radiculopatía/prevención & control , Estudios Retrospectivos , Procedimientos Quirúrgicos Operativos/efectos adversos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Socioeconomic deprivation is associated with reduced use of antenatal resources and poor maternal outcomes with pregnancy. Research examining the association between socioeconomic deprivation and use of obstetric anesthesia care in a country providing universal health coverage is scarce. We hypothesized that in a country providing universal health coverage, France, socioeconomic deprivation is not associated with reduced use of anesthetic care during pregnancy and delivery. This study aimed to examine the association between socioeconomic deprivation and (1) completion of a mandatory preanesthetic evaluation during pregnancy and (2) use of neuraxial analgesia during labor. METHODS: Data were from a cohort of 10,419 women who delivered between 2010 and 2011 in 4 public teaching hospitals in Paris. We used a deprivation index that included 4 criteria: social isolation, poor housing condition, no work-related household income, and state-funded health care insurance. Socioeconomic deprivation was defined as a deprivation index greater than 1. Preanesthetic evaluation was considered completed if performed more than 48 hours before delivery. The association between socioeconomic deprivation and completion of the preanesthetic evaluation and use of neuraxial labor analgesia was assessed by multivariable logistic regression adjusting for education level, country of birth, and maternal and pregnancy characteristics. RESULTS: Preanesthetic evaluation was completed for 8142 of the 8624 women (94.4%) analyzed and neuraxial labor analgesia was used by 6258 of the 6834 women analyzed (91.6%). After adjustment, socioeconomic deprivation was associated with reduced probability of completed preanesthetic evaluation (adjusted odds ratio 0.88 [95% confidence interval, 0.79-0.98]; P = .027) but not use of neuraxial labor analgesia (adjusted odds ratio 0.97 [95% confidence interval, 0.87-1.07]; P = .540). CONCLUSIONS: In a country providing universal health care coverage, women who were socioeconomically deprived showed reduced completion of preanesthetic evaluation during pregnancy but not reduced use of neuraxial labor analgesia. Interventions should be targeted to socioeconomically deprived women to increase the completion of the preanesthetic evaluation.
Asunto(s)
Anestesia Obstétrica/economía , Anestesia Obstétrica/estadística & datos numéricos , Parto Obstétrico/economía , Manejo del Dolor/economía , Manejo del Dolor/estadística & datos numéricos , Clase Social , Analgesia Obstétrica/economía , Analgesia Obstétrica/estadística & datos numéricos , Estudios de Cohortes , Femenino , Francia/epidemiología , Humanos , Embarazo , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND: The United Nations 2015 Millennium Development Goals targeted a 75% reduction in maternal mortality. However, in spite of this goal, the number of maternal deaths per 100,000 live births remains unacceptably high across Sub-Saharan Africa. Because many of these deaths could likely be averted with access to safe surgery, including cesarean delivery, we set out to assess the capacity to provide safe anesthetic care for mothers in the main referral hospitals in East Africa. METHODS: A cross-sectional survey was conducted at 5 main referral hospitals in East Africa: Uganda, Kenya, Tanzania, Rwanda, and Burundi. Using a questionnaire based on the World Federation of the Societies of Anesthesiologists (WFSA) international guidelines for safe anesthesia, we interviewed anesthetists in these hospitals, key informants from the Ministry of Health and National Anesthesia Society of each country (Supplemental Digital Content, http://links.lww.com/AA/B561). RESULTS: Using the WFSA checklist as a guide, none of respondents had all the necessary requirements available to provide safe obstetric anesthesia, and only 7% reported adequate anesthesia staffing. Availability of monitors was limited, and those that were available were often nonfunctional. The paucity of local protocols, and lack of intensive care unit services, also contributed significantly to poor maternal outcomes. For a population of 142.9 million in the East African community, there were only 237 anesthesiologists, with a workforce density of 0.08 in Uganda, 0.39 in Kenya, 0.05 in Tanzania, 0.13 in Rwanda, and 0.02 anesthesiologists in Burundi per 100,000 population in each country. CONCLUSIONS: We identified significant shortages of both the personnel and equipment needed to provide safe anesthetic care for obstetric surgical cases across East Africa. There is a need to increase the number of physician anesthetists, to improve the training of nonphysician anesthesia providers, and to develop management protocols for obstetric patients requiring anesthesia. This will strengthen health systems and improve surgical outcomes in developing countries. More funding is required for training physician anesthetists if developing countries are to reach the targeted specialist workforce density of the Lancet Commission on Global Surgery of 20 surgical, anesthetic, and obstetric physicians per 100,000 population by 2030.
Asunto(s)
Anestesia Obstétrica/economía , Atención a la Salud/economía , Países en Desarrollo/economía , Costos de la Atención en Salud , Pautas de la Práctica en Medicina/economía , Adulto , África Oriental , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/mortalidad , Anestesia Obstétrica/normas , Anestesiólogos/economía , Anestesiólogos/educación , Anestésicos/economía , Anestésicos/provisión & distribución , Lista de Verificación , Estudios Transversales , Atención a la Salud/normas , Femenino , Encuestas de Atención de la Salud , Necesidades y Demandas de Servicios de Salud/economía , Disparidades en Atención de Salud/economía , Humanos , Mortalidad Materna , Persona de Mediana Edad , Evaluación de Necesidades/economía , Admisión y Programación de Personal/economía , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Embarazo , Respiración Artificial/economía , Medición de Riesgo , Factores de Riesgo , Ventiladores Mecánicos/economía , Ventiladores Mecánicos/provisión & distribuciónRESUMEN
BACKGROUND: The safety of anesthetic care provided during childbirth has improved during the past 2 decades in the United States, with a marked decrease in the rate of anesthesia-related adverse events (ARAEs). To date, there is little research on the costs of ARAEs in obstetrics. This study aims to assess the excess cost and cost per admission associated with ARAEs during labor and delivery. METHODS: Data came from the New York State Inpatient Database 2010. Discharge records indicating labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. ARAEs were defined as minor if not associated with maternal death, cardiac arrest, or severe morbidity. Costs were calculated as the product of hospital charges and the group average all-payer inpatient charge-to-cost conversion ratio. Excess cost was calculated as the difference between the mean cost of discharges with and without ARAEs. The cost per admission was calculated as the product of the excess cost and ARAE incidence. Excess costs and cost per admission were also calculated for 2 pregnancy-related complications: postpartum hemorrhage and preeclampsia/eclampsia. RESULTS: There were 228,104 delivery-related discharges in the study; of these, 1053 recorded at least 1 ARAE (4.6 per 1000), with 1034 (98.2%) of the ARAEs being minor. The adjusted excess cost associated with ARAEs was $1189 (95% confidence interval [CI], 1033-1350) and the cost per admission $5.49 (95% CI, 4.77-6.23). The incidence of postpartum hemorrhage and preeclamspia/eclampsia was 25.1 and 43.8 per 1000, respectively. The adjusted excess cost was $679 (95% CI, 608-748) and $1328 (95% CI, 1272-1378), respectively; the cost per admission was $17.07 (95% CI, 15.27-18.81) and $58.16 (95% CI, 55.72-60.34), respectively. CONCLUSIONS: ARAEs during labor and delivery are associated with significant excess cost. However, the excess cost per admission for ARAEs is significantly less compared with the excess cost per admission for preeclampsia/eclampsia and postpartum hemorrhage.
Asunto(s)
Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/economía , Parto Obstétrico/efectos adversos , Parto Obstétrico/economía , Costos de Hospital , Parto , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Complicaciones del Embarazo/economía , Complicaciones del Embarazo/epidemiología , Adulto , Anestesia Obstétrica/mortalidad , Cesárea/efectos adversos , Cesárea/economía , Bases de Datos Factuales , Parto Obstétrico/mortalidad , Femenino , Precios de Hospital , Humanos , Incidencia , Trabajo de Parto Inducido/efectos adversos , Trabajo de Parto Inducido/economía , Modelos Económicos , New York/epidemiología , Admisión del Paciente/economía , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Embarazo , Complicaciones del Embarazo/mortalidad , Complicaciones del Embarazo/terapia , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
AIM: Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates. METHODS: A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness. RESULTS: Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted. CONCLUSIONS: Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.
Asunto(s)
Analgesia Obstétrica/efectos adversos , Presentación de Nalgas/cirugía , Sistemas de Apoyo a Decisiones Clínicas , Bloqueo Nervioso/efectos adversos , Versión Fetal/efectos adversos , Adulto , Analgesia Epidural/efectos adversos , Analgesia Epidural/economía , Analgesia Obstétrica/economía , Anestesia Epidural/efectos adversos , Anestesia Epidural/economía , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/economía , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/economía , Presentación de Nalgas/economía , Cesárea/efectos adversos , Cesárea/economía , Ahorro de Costo , Costos y Análisis de Costo , Árboles de Decisión , Femenino , Costos de Hospital , Humanos , Reembolso de Seguro de Salud , Bloqueo Nervioso/economía , Embarazo , Estados Unidos , Versión Fetal/economíaRESUMEN
The proportion of laboring women utilizing neuraxial techniques for labor analgesia has steadily increased over the past decades in North America, the UK and parts of Europe. Anesthesiologists in many other countries may want to introduce an obstetric neuraxial service but may lack the knowledge and experience necessary to ensure its safety. The focus of this article is to address the necessity, benefit and challenges of establishing such a service in a resource-limited environment. Even successful financial institutions may be considered resource-limited if critical components necessary for an obstetric neuraxial service are missing due to either perceived unimportance or non-availability. There is a need to deploy a culture of safety by ensuring the availability of resuscitation equipment, developing protocols and training, fostering communication among members of the care team and initiating quality-control measures. Patient education and satisfaction are additional key components of a successful service. Even in financially low-resource settings, proper safety measures must be adopted so that the neuraxial procedure itself does not contribute to morbidity and mortality. A viable and safe neuraxial service can be developed using innovative strategies based on local constraints.
Asunto(s)
Anestesia Epidural , Anestesia Obstétrica , Área sin Atención Médica , Adulto , Anestesia Epidural/efectos adversos , Anestesia Epidural/economía , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/economía , Femenino , Humanos , Monitoreo Fisiológico , Educación del Paciente como Asunto , Embarazo , Garantía de la Calidad de Atención de Salud , ResucitaciónAsunto(s)
Anestésicos Intravenosos/economía , Seguridad del Paciente/economía , Jeringas/economía , Tiopental/economía , Anestesia Obstétrica/economía , Anestesia Obstétrica/métodos , Anestésicos Intravenosos/administración & dosificación , Costos y Análisis de Costo/economía , Equipos Desechables/economía , Servicios Médicos de Urgencia/economía , Servicios Médicos de Urgencia/métodos , Humanos , Inyecciones Intravenosas/economía , Inyecciones Intravenosas/instrumentación , Tiopental/administración & dosificación , Reino UnidoRESUMEN
STUDY OBJECTIVE: To examine the relationship between body mass index (BMI), perioperative times, and anesthetic interventions in patients undergoing elective cesarean delivery. DESIGN: Retrospective chart review. SETTING: University-affiliated hospital. MEASUREMENTS: All patients were ranked according to BMI (kg/m(2)) at the time of delivery. The BMI groups were designated a priori: ≤ 29.9 kg/m(2) (Group C); 30-34.9 kg/m(2) (Group I); 35-39.9 kg/m(2) (Group II), and ≥ 40 kg/m(2) (Group III). One hundred patients (25 pts per group) underwent elective cesarean delivery. Data collected included anesthetic technique, perioperative times, anesthesia-related costs, and neonatal outcomes. MAIN RESULTS: A higher percentage of Group III patients (60%) received combined spinal-epidural (CSE) anesthesia than did Group C or Group I (18% and 16%, respectively; P < 0.05). The total intraoperative period was significantly longer in Group III (101 min) compared with Groups C, I, and II (81 min, 90 min, and 92 min, respectively; P < 0.05). Total intraoperative time increased significantly with BMI (R = 0.394 kg/m(2); P < 0.001). The highest anesthesia-related costs during the study were generated by patients with BMI ≥ 40 kg/m(2). CONCLUSION: Our single-center experience showed that choice of anesthetic technique (CSE vs. spinal anesthesia) varies according to obesity class. Longer intraoperative periods must be considered in deciding upon the mode of anesthesia for patients with BMI ≥ 40 kg/m(2) who undergo elective cesarean delivery.
Asunto(s)
Anestesia Epidural/métodos , Anestesia Obstétrica/métodos , Anestesia Raquidea/métodos , Obesidad/complicaciones , Adulto , Anestesia Epidural/economía , Anestesia Obstétrica/economía , Anestesia Raquidea/economía , Índice de Masa Corporal , Cesárea/métodos , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Hospitales Universitarios , Humanos , Recién Nacido , Embarazo , Resultado del Embarazo , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
Ultrasound equipment is increasingly used by non-radiologists to perform interventional techniques and for diagnostic evaluation. Equipment is becoming more portable and durable, with easier user-interface and software enhancement to improve image quality. While obstetric utilisation of ultrasound for fetal assessment has developed over more than 40years, the same technology has not found a widespread role in obstetric anaesthesia. Within the broader specialty of anaesthesia; vascular access, cardiac imaging and regional anaesthesia are the areas in which ultrasound is becoming increasingly established. In addition to ultrasound for neuraxial blocks, these other clinical applications may be of value in obstetric anaesthesia practice.
Asunto(s)
Anestesia General , Anestesia Obstétrica , Ultrasonografía , Adulto , Anestesia Obstétrica/economía , Catéteres de Permanencia , Ecocardiografía , Femenino , Humanos , Recién Nacido , Bloqueo Nervioso/métodos , Dolor Postoperatorio/diagnóstico por imagen , Dolor Postoperatorio/terapia , Embarazo , Ultrasonografía/economíaRESUMEN
We analysed 366 claims related to regional anaesthesia and analgesia from the 841 anaesthesia-related claims handled by the National Health Service Litigation Authority between 1995 and 2007. The majority of claims (281/366, 77%) were closed at the time of analysis. The total cost of closed claims was pound12,724,017 (34% of the cost of the anaesthesia dataset) with a median (IQR [range]) of pound4772 (pound0-28,907 [pound0-2,070,092]). Approximately half of the claims (186/366; 51%) were related to obstetric anaesthesia and analgesia and of the non-obstetric claims, the majority (148/180; 82%) were related to neuraxial block. The total cost for obstetric closed claims was pound5,433,920 (median (IQR [range]) pound5678 (pound0-27,690 [pound0-1,597,565]) while that for non-obstetric closed claims was pound7,290,097 (pound3337 (pound0-31,405 [pound0-2,070,062]). Non-obstetric claims were more likely to relate to severe outcomes than obstetric ones. The maximum values of claims were higher for claims related to neuraxial blocks and eye blocks than for peripheral nerve blocks. Despite many limitations, including lack of clinical detail for each case, the dataset provides a useful overview of the extent, patterns and cost associated with the claims.
Asunto(s)
Anestesia de Conducción/economía , Compensación y Reparación/legislación & jurisprudencia , Anestesia de Conducción/efectos adversos , Anestesia de Conducción/métodos , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/economía , Anestesia Obstétrica/métodos , Inglaterra , Femenino , Humanos , Mala Praxis/economía , Mala Praxis/legislación & jurisprudencia , Mala Praxis/estadística & datos numéricos , Embarazo , Medicina Estatal/economía , Medicina Estatal/legislación & jurisprudenciaRESUMEN
BACKGROUND: Modern medicine is becoming increasingly aware of economic-organizational aspects. In the field of anaesthesiology, the number of agents used markedly increases due to continuous pharmacological progress. A high proportion of them are expensive. The aim of the study was to compare hospital costs of general vs. subarachnoid anaesthesia for Caesarean section. METHODS: Costs were assessed from the perspective of a service provider. Direct costs were measured using the micro-cost method based on detailed data of the resources used during anaesthetic procedures. Non-medical costs were calculated by the direct allocation method (costs of auxiliary units). Unit costs of hospitalization were determined using the "top-to-bottom" assessment. Costs related to anaesthetic staff work were calculated by the micro-cost method based on duration of anaesthesia. Sensitivity analysis was performed. RESULTS: Mean direct cost of general anaesthesia for Caesarean section was lower than of subarachnoid anaesthesia. Mean personnel cost of subarachnoid anaesthesia was found to be higher compared to general anaesthesia. Costs of pharmaceuticals for general anaesthesia were lower than for subarachnoid one. Costs of medical materials related to the method used were significantly higher in subarachnoid anaesthesia. CONCLUSIONS: Subarachnoid anaesthesia takes more time than general one, which results in higher costs of medical staff work. Avoiding inhalation anaesthetics (sevoflurane) makes indirect costs of general anaesthesia lower compared to subarachnoid anaesthesia.
Asunto(s)
Anestesia Epidural/economía , Anestesia General/economía , Anestesia Obstétrica/economía , Cesárea/economía , Adulto , Costos y Análisis de Costo , Femenino , Humanos , Polonia , Embarazo , Estudios Prospectivos , Espacio SubaracnoideoRESUMEN
The position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged best by the care given her at the birth of her child. Obstetric anesthesia, by definition, is a subspecialty of anesthesia devoted to peripartum, perioperative, pain and anesthetic management of women during pregnancy and the puerperium. Today, obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps, no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. This article reviews the challenges associated with implementing safe obstetric anesthesia practice in Eastern Europe.
Asunto(s)
Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Anestesia Obstétrica/economía , Anestesiología/economía , Anestesiología/educación , Cesárea , Parto Obstétrico , Europa Oriental , Ayuno , Femenino , Humanos , Indonesia , Trabajo de Parto , Complicaciones del Trabajo de Parto/terapia , Obstetricia/educación , Guías de Práctica Clínica como Asunto , Embarazo , Factores de Riesgo , Estados UnidosRESUMEN
OBJECTIVE: The aim of the present study was to compare the consumption and cost of ephedrine in parturients with respect to two packagings: ampoules and prefilled syringes. STUDY DESIGN: Prospective observational study in a French university obstetrical unit. PATIENTS AND METHODS: Assessing the consumption and cost of ephedrine during two consecutive periods of 14 days: use of ampoules for period 1 (P1) versus use of prefilled syringes for period 2 (P2). Consumption was daily evaluated. The costs (ampoules and consumable supplies for P1 and prefilled syringes for P2) were calculated on the basis of the price list given by our institutional pharmacy. The number of parturients and the anaesthetic techniques which were performed were prospectively recorded. RESULTS: One hundred and thirteen parturients were managed for the present study. The number of parturients and the anaesthetic care were similar between the two periods. In contrast, 155 ampoules were used for P1 versus 45 prefilled syringes for P2 (p<0.0001). The cost per parturient was 3.1 euro for P1 versus 2.6 euro for P2, i.e. 0.5 euro was saved for each parturient. CONCLUSION: The results of the present study show that the use of prefilled syringes reduces significantly the wastage of ephedrine, allowing subsequent cost minimization in obstetrical anaesthesia.
Asunto(s)
Adrenérgicos/administración & dosificación , Anestesia Obstétrica/economía , Costos de los Medicamentos/estadística & datos numéricos , Efedrina/administración & dosificación , Hipotensión/tratamiento farmacológico , Complicaciones del Trabajo de Parto/tratamiento farmacológico , Servicio de Ginecología y Obstetricia en Hospital/economía , Jeringas , Adrenérgicos/economía , Adrenérgicos/uso terapéutico , Adulto , Analgesia Epidural/efectos adversos , Analgesia Epidural/economía , Analgesia Obstétrica/efectos adversos , Anestesia Epidural/efectos adversos , Anestesia Epidural/economía , Anestesia Obstétrica/efectos adversos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/economía , Anestésicos Locales/efectos adversos , Cesárea , Ahorro de Costo , Embalaje de Medicamentos , Efedrina/economía , Efedrina/uso terapéutico , Femenino , Francia , Hospitales Universitarios/economía , Hospitales Universitarios/estadística & datos numéricos , Humanos , Hipotensión/economía , Hipotensión/etiología , Complicaciones del Trabajo de Parto/economía , Complicaciones del Trabajo de Parto/etiología , Servicio de Ginecología y Obstetricia en Hospital/estadística & datos numéricos , Embarazo , Estudios Prospectivos , Jeringas/economíaAsunto(s)
Anestesia Obstétrica , Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Dolor de Parto/tratamiento farmacológico , Anestesia Obstétrica/economía , Bupivacaína/administración & dosificación , Bupivacaína/análogos & derivados , Bupivacaína/economía , Análisis Costo-Beneficio , Femenino , Humanos , Levobupivacaína , EmbarazoRESUMEN
BACKGROUND: Obstetrical anesthesia services may be provided by Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, or a combination of the two providers. Research is needed to assist hospitals and anesthesia groups in making cost-effective staffing choices. OBJECTIVES: To identify differences in the rates of anesthetic complications in hospitals whose obstetrical anesthesia is provided solely by CRNAs compared to hospitals with only anesthesiologists. METHODS: Washington State hospital discharge data were obtained from 1993 to 2004 for all cesarean sections, and were merged with a survey of hospital obstetrical anesthesia staffing. Anesthetic complications were identified via International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Resulting rates were risk-adjusted using regression analysis. RESULTS: Hospitals with CRNA-only staffing had a lower rate of anesthetic complications than those with anesthesiologist staffing (0.58% vs. 0.76%, p=.0006). However, after regression analysis, this difference was not significant (odds ratio for CRNA vs. anesthesiologist complications: 1.046 to 1, 95% confidence interval 0.649-1.658, p=.85). DISCUSSION: There is no difference in rates of complications between the two types of staffing models. As a result, hospitals and anesthesiology groups may safely examine other variables, such as provider availability and costs, when staffing for obstetrical anesthesia. Further study is needed to validate the use of ICD-9-CM codes for anesthesia complications as an indicator of quality.
Asunto(s)
Servicio de Anestesia en Hospital , Anestesia Obstétrica/economía , Anestesia Obstétrica/enfermería , Cesárea/economía , Costos de la Atención en Salud , Enfermeras Anestesistas , Evaluación de Resultado en la Atención de Salud , Adolescente , Adulto , Servicio de Anestesia en Hospital/economía , Anestesia Obstétrica/efectos adversos , Análisis Costo-Beneficio , Femenino , Humanos , Incidencia , Complicaciones Intraoperatorias , Enfermeras Anestesistas/economía , Admisión y Programación de Personal/economía , Embarazo , Análisis de Regresión , Estudios Retrospectivos , Ajuste de Riesgo , Seguridad , Washingtón , Recursos HumanosRESUMEN
OBJECTIVE: The purpose of this study was to estimate the cost differences between elective cesarean delivery and the alternative of attempted vaginal delivery and to assess the economic impact of cesarean delivery on demand. STUDY DESIGN: Cost data were obtained over a 12-month period from a not-for-profit community hospital to calculate a per-patient cost for clinical alternatives. RESULTS: The average cost of an attempted vaginal delivery without oxytocin (Pitocin) or epidural anesthesia was 15.1% lower in nulliparous women and 20% lower in multiparous women than with elective cesarean delivery. However, in nulliparous women, the addition of Pitocin nullified any cost differences; if epidural anesthesia was also used, total costs exceeded the cost of elective cesarean delivery by almost 10%. The cost of a failed attempt at vaginal delivery was much higher than elective cesarean delivery for both groups. The average cost for all women who attempted vaginal delivery was only 0.2% less than the per-patient cost of elective cesarean delivery. CONCLUSION: The adoption of a policy of cesarean delivery on demand should have little impact on the overall cost of obstetric care.
Asunto(s)
Cesárea/economía , Parto Obstétrico/economía , Procedimientos Quirúrgicos Electivos/economía , Costos de Hospital/estadística & datos numéricos , Anestesia Epidural/economía , Anestesia Obstétrica/economía , Parto Obstétrico/métodos , Femenino , Necesidades y Demandas de Servicios de Salud , Hospitales Comunitarios/economía , Hospitales Filantrópicos/economía , Humanos , Oxitocina/economía , Paridad , Embarazo , TexasRESUMEN
BACKGROUND AND OBJECTIVE: The study was designed to compare the costs of propofol versus sevoflurane for the maintenance of the hypnotic component of anaesthesia during general anaesthesia, guided by the bispectral index, for gynaecological laparoscopic surgery. METHODS: Forty ASA Grade I-II female patients scheduled for gynaecological laparoscopy were randomly allocated to two groups. All patients received a continuous infusion of remifentanil (0.25 microg kg(-1) min(-1)) for 2 min. Then anaesthesia was induced with propofol 1% at 300 mL h(-1) until loss of consciousness. To guide the bispectral index between 40 and 60, Group 1 patients received propofol 10 mg kg(-1) h(-1) initially, which was increased or decreased by 2 mg kg(-1) h(-1) steps; Group 2 patients received sevoflurane, initially set at 2 vol.% and adjusted with steps of 0.2-0.4%. The time and quality of anaesthesia and recovery were assessed in two postoperative standardized interviews. RESULTS: Patient characteristics, the propofol induction dose, the bispectral index and the haemodynamic profiles during induction of anaesthesia, and its duration, were similar between the groups. In Group 1, 7.55 +/- 1.75 mg kg(-1) h(-1) propofol and in Group 2, 0.20 +/- 0.09 mL kg(-1) h(-1) liquid sevoflurane were used for maintenance. The cost for maintenance, including wasted drugs, was higher when using propofol (Euro 25.14 +/- 10.69) than sevoflurane (Euro 12.80 +/- 2.67). Postoperatively, recovery profiles tended to be better with propofol; however, the day after discharge no differences were found. CONCLUSIONS: When applying the bispectral index to guide the administration of hypnotic anaesthetic drugs, propofol-based maintenance of anaesthesia was associated with the highest cost. A trend towards a better recovery profile was obtained with propofol. However, on the day after discharge, no differences in quality were observed.