"The proper study of mankind is man"--rather, men and women undergoing anesthesia and surgery.
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Anesthetics↗
Biomedical subjects
Donald S Prough
Publications and source records attributed to Donald S Prough.
The prevalence and characteristics of incentive plans for clinical productivity among academic anesthesiology programs.
Performance-based compensation is encouraged in medical schools to improve faculty productivity. Medical specialties other than anesthesiology have used financial incentives for clinical work. The goal of this study was to determine the prevalence and the types of clinical incentive plans among academic anesthesiology departments. We performed an electronic survey of the members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors in the spring of 2003. The survey included questions about departmental size, presence of a clinical incentive plan, characteristics of existing incentive plans, primary quantifiers of productivity, and factors used to modify productivity measurements. An incentive plan was considered to be present if the department measured clinical productivity and varied compensation according to the measurements. The plans were grouped by the primary measure used into the following categories: None, Charges, Time, Shift, Late/Call (only late rooms and call), and Other. Eighty-eight (64%) of 138 programs responded to the survey, and 5 were excluded for incomplete data. Of the responding programs, 29% had no system, 30% used a Late/Call system, 20% used a Shift system, 11% used a Charges system, 6% used a Time system, and 3% fit in the Other category. Larger groups (>40 faculty members) had a significantly more frequent prevalence of incentive plans compared with smaller groups (<20 faculty members). Incentives were paid monthly or quarterly in 85% of the groups. In 90% of groups, incentive payments accounted for <25% of total compensation. Adjustments for operating room schedule supervisors, personally performed cases, day surgery preoperative clinics, pain-management services, and critical care services were included in less than half of the programs that reported incentive plans. Call and late room compensation was based on varied formulas. Sixty-nine percent of academic anesthesiology departments did not vary compensation according to clinical activity during regular hours. Most did vary payments on the basis of call and/or late rooms worked. Larger departments were more likely to use clinical incentive plans.
Academic Medical Centers↗
Sepsis produced by Pseudomonas bacteremia does not alter plasma volume expansion after 0.9% saline infusion in sheep.
Clinicians generally consider sepsis to be a state in which fluid is poorly retained within the vasculature and accumulates within the interstitium. We hypothesized that infusion of 0.9% saline in conscious, chronically instrumented sheep with hyperdynamic bacteremic sepsis would be associated with less plasma volume expansion (PVE) and greater interstitial fluid volume expansion than in conscious, nonseptic sheep. Six conscious adult sheep received an IV infusion of 25 mL/kg of 0.9% saline over 20 min (1.25 mL.kg(-1).min(-1)) in a control nonseptic state and during early and late sepsis (4 and 24 h, respectively, after initiation of a standard infusion of live Pseudomonas aeruginosa). The distribution and elimination of infused fluid were studied by mass balance (after measurement of plasma volume using Evans blue dye) and volume kinetic analysis. Mass balance demonstrated no significant differences in the time-course of PVE between control, early sepsis, and late sepsis. At the end of the infusions, which averaged 1050 +/- 125 mL in sheep weighing an average of 42 +/- 5 kg, calculated PVE was 312 +/- 50 mL, 386 +/- 34 mL, and 400 +/- 51, respectively. Volume kinetic analysis was similar in all three protocols. In both nonseptic and septic sheep, infusion of 0.9% saline resulted in similar peak PVE and resolution of PVE over a 3-h interval and similar kinetic parameters. Contrary to clinical impressions and to our hypothesis, the distribution of 0.9% saline in this animal model was not changed by bacteremia produced by infusion of Pseudomonas aeruginosa.
Algorithms↗
Method for identifying neuronal cells suffering zinc toxicity by use of a novel fluorescent sensor.
During excitotoxic brain damage, injured neurons accumulate an anomalous, pathological burden of weakly bound, rapidly exchangeable Zn(2+) that diffusely fills the soma, nucleus and proximal dendrites. Mounting evidence indicates that this Zn(2+) is a major contributing factor in the subsequent demise of the damaged neurons. Thus, identifying, imaging, and characterizing zinc-filled cells have become essential steps in understanding excitotoxicity. Here we demonstrate that a new fluorescent stain for zinc can rather selectively and quite vividly label zinc-filled neurons in frozen histologic sections. The method is more sensitive and selective than the existing stain TSQ, and simpler than the Timm-Danscher silver staining techniques. A previously unobserved population of apparently injured cells in the dentate gyrus has been discovered with the new reagent. Whereas cells viewed in situ in normal, healthy tissue virtually never display any perikaryal staining by histochemical methods for zinc, injured cells stain intensely for zinc in culture, acute slice preparations and in tissue harvested in vivo. Thus, the presence of rapidly-exchangeable, "stainable" perikaryal zinc may be taken as an indicator of cell injury.
Animals↗
Continuous, noninvasive monitoring of total hemoglobin concentration by an optoacoustic technique.
Measurement of total hemoglobin concentration [Hgb] is a blood test that is widely used to evaluate outpatients, hospital inpatients, and surgical patients, especially those undergoing surgery associated with extensive blood loss, rapid fluid administration, and transfusion of packed red blood cells. Current techniques for measurement of [Hgb] are invasive (requiring blood sampling) and cannot provide real-time, continuous monitoring. We propose to use an optoacoustic technique for noninvasive and continuous monitoring of [Hgb]. The high resolution of the optoacoustic technique may provide accurate measurement of [Hgb] by detection and analysis of optoacoustic signals induced by short optical pulses in blood circulating in arteries or veins. We designed, built, and tested in vitro (in both tissue phantoms and in preliminary in vivo experiments) a portable optoacoustic system for the monitoring of [Hgb] in the radial artery. The system includes a nanosecond laser operating in the near-infrared spectral range and a sensitive optoacoustic probe designed to irradiate the radial artery through the skin and detect optoacoustic signals induced in blood. Results of our studies demonstrated that (1) the slope of optoacoustic waves induced in blood in the transmission mode is linearly dependent on [Hgb] in the range from 6.2 to 12.4 g/dl, (2) optoacoustic signals can be detected despite optical attenuation in turbid tissue phantoms with a thickness of 1 cm, and (3) the optoacoustic system detects signals induced in blood circulating in the radial artery. These data suggest that the optoacoustic system can be used for accurate, noninvasive, real-time, and continuous monitoring of [Hgb].
Acoustics↗
Laser capture microdissection and analysis of amplified antisense RNA from distinct cell populations of the young and aged rat brain: effect of traumatic brain injury on hippocampal gene expression.
To explore the molecular mechanisms underlying the increased vulnerability of the aged brain to traumatic brain injury (TBI), we compared the expression of several age-related genes in the CA1, CA3 and dentate gyrus subfields of the young and aged rat hippocampus before and after lateral fluid percussion TBI. Using laser capture microdissection (LCM), we obtained hippocampal neurons and glia from the neuropil adjacent to the pyramidal and granule cell layers. Subsequently, we linearly amplified and analyzed the antisense mRNA using Northern blot and ribonuclease protection assays (RPA). Our procedures, which have not been previously applied to quantitative analysis of LCM mRNA from neural tissue, included a modified reverse transcription step to enhance full-length cDNA synthesis, thus enhancing the yield of larger components of in vitro-transcribed mRNA for downstream analysis. Northern analysis showed greater expression of two aging-associated genes, p21 and brain-derived neurotrophic factor (BDNF) in the aged hippocampus. The age-related differences in p21 and BDNF expression were particularly prominent after TBI. By quantitative RPA analysis, we found that the expression of p21, known to be induced in senescent cells, was significantly greater in the CA3 region of aged rats, an area that is selectively vulnerable to TBI. However, expression of genes associated with regenerative and repair functions was significantly decreased in aged hippocampus. Our RPA results indicate that substantial age-dependent differences in the transcriptional profile of distinct regions of the hippocampal formation may account, in part, for their differential susceptibility to brain injury.
Age Factors↗
Protective effects of zinc chelation in traumatic brain injury correlate with upregulation of neuroprotective genes in rat brain.
Chelation of excessive neuronal zinc ameliorates zinc neurotoxicity and reduces subsequent neuronal injury. To clarify the molecular mechanisms of this neuroprotective effect, we used a focused cDNA array of stress-response genes with zinc chelation (calcium EDTA) in our rat model of fluid percussion brain injury at 2 h, 24 h, and 7 days after injury. In parallel experiments, we compared neuronal cell death in TUNEL-stained brain sections in traumatized rats with and without calcium EDTA treatment. Zinc chelation induced the expression of several neuroprotective genes; neuroprotective gene expression correlated with substantially decreased numbers of TUNEL-positive cells.
Animals↗
Cerebral pressure autoregulation is intact and is not influenced by hypothermia after traumatic brain injury in rats.
In head-injured patients and experimental traumatic brain injury (TBI), important cerebrovascular abnormalities include decreases in cerebral blood flow (CBF) and impairment of cerebral pressure autoregulation. We evaluated CBF and pressure autoregulation after fluid percussion injury (FPI) and hypothermia in rats with the hypothesis that hypothermia would ameliorate changes in posttraumatic CBF. Male Sprague-Dawley rats, intubated and mechanically ventilated, were prepared for parasagittal FPI (1.8 atm) and laser Doppler CBF flow (LDF) measurement. The abdominal aorta was cannulated for rapid removal and reinfusion of blood. Baseline autoregulatory testing in all groups consisted of LDF measurements at normothermia and a mean arterial pressure (MAP) of 100 mm Hg, followed by randomly ordered changes of MAP to 80, 60, and 40 mm Hg. Animals were then randomized to one of five groups: normothermic control without FPI; normothermia with FPI; hypothermic control (32 degrees C) without FPI; hypothermia initiated before FPI; and hypothermia initiated immediately after FPI injury. For each group, a complete, randomly ordered autoregulatory sequence was performed at 30 and 60 min after FPI or sham TBI. In a second study, rats were prepared identically, maintained at normothermic temperatures and autoregulation was tested before and after TBI using a set of randomly ordered levels of hypotension or using progressive reductions in MAP (i.e., 80, 60, 40 mm Hg) with the hypothesis that the technical manner and timing of decreasing of the blood pressure would effect CBF after TBI. Due to high acute mortality, the group in which hypothermia was induced before FPI was excluded from the analysis. At baseline, autoregulation was similar in all groups. There was no change in CBF or autoregulation in the normothermic control group at 30 and 60 min. In the other groups at 30 and 60 min, there was a similar, statistically significant decrease in absolute CBF (i.e., a decrease of 27-57% of baseline values), but pressure autoregulation was intact except at the lowest blood pressure tested at 60 min, where there was a slight improvement in the hypothermic group. Thus, in these experiments, absolute CBF decreased with hypothermia and FPI, while neither hypothermia nor FPI significantly altered autoregulation. In the second study, autoregulatory function was not different before TBI when comparing random and sequential blood pressure changes, but, when comparing the groups after TBI at the 60 mm Hg blood pressure level, CBF was significantly lower in the sequential group than in the random order group. This suggests that the mechanism of creating hypotension, whether random or sequential, significantly affects the measurement of CBF and autoregulation after TBI in rats.
Animals↗
The effects of traumatic brain injury on cerebral blood flow and brain tissue nitric oxide levels and cytokine expression.
Adult, male, Sprague-Dawley rats were anesthetized, intubated, and mechanically ventilated with 1.5-2.0% isoflurane in oxygen (30%) and air. Rats were prepared for fluid percussion traumatic brain injury (TBI), laser Doppler flowmetry, and measurement of brain tissue nitric oxide (NO) levels using an ISO-NO electrode system. After preparation, isoflurane was reduced to 1.5%, and the rats were randomly assigned to receive sham (n = 6), moderate (1.9 atm, n = 6), or severe (2.8 atm, n = 6) parasagittal fluid percussion TBI. CBF and brain tissue NO levels were measured for 4 h, and then isoflurane levels were increased to 4.0% and the rats were decapitated and the brains were removed. Total RNA was isolated from rat brains and cytokine expression was determined. Laser Doppler flow velocity remained constant in the sham-injured rats but decreased significantly in rats subjected to moderate (p < 0.05) or severe (p < 0.05) TBI. Brain tissue NO levels remained constant in the sham-injured rats but decreased significantly (p < 0.01) after moderate TBI. Severe TBI produced slight, insignificant reductions in NO levels. Cytokine expression was very low in the shaminjured rats. TBI-induced expression of mRNAs for interleukin-1 alpha (IL-1alpha), IL-1beta, IL-6, and tumor necrosis factor-alpha (TNFa). IL-1alpha and IL-1beta mRNA expression increased significantly (p < 0.05 vs. sham-injury) after severe TBI and IL-6 and TNFa mRNA expression increased significant (p < 0.05 vs. sham-injury) after both moderate and severe TBI. Other cytokine mRNA expression was unchanged after TBI.
Animals↗
Quantifying net staffing costs due to longer-than-average surgical case durations.
BACKGROUND: Anesthesiology departments incur staffing costs that are not covered by revenue because the operating room (OR) time allocation and case scheduling are not done to maximize OR efficiency and because surgical durations are longer than average. The purpose of this article is to demonstrate a method to quantify net anesthesia staffing costs due to longer-than-average surgical durations and evaluate the factors that influence staffing costs. METHODS: Data collected from two anesthesiology departments in academic hospitals for 1 yr included date of surgery, time that patients entered the OR, time that patients exited the OR, surgical service, and the Current Procedural Terminology code for the primary surgical procedure. Anesthesia care performed outside the main surgical suite and services not billed with American Society of Anesthesiologists units were excluded. National average surgical durations were determined from the Current Procedural Terminology code from the Centers for Medicare and Medicaid Services' database. Actual surgical durations were then used to determine staffing solutions to maximize OR efficiency; national average surgical durations were then used to determine a second solution. The difference in staffing costs between these two staffing solutions represented the staffing costs attributable to longer surgical durations. Costs were converted to dollar amounts using compensation values reported in a national compensation survey. The differences in revenue were determined by applying conversion factors to the differences in surgical durations. The annual net cost attributable to longer surgical durations equaled the staffing costs minus the revenue produced by longer durations. Net staffing costs were estimated for two hospitals using median staffing compensation and median payer mix. Net staffing costs were then recalculated by varying the parameters (conversion factors, limits on differences between actual and average surgical duration, levels of compensation, surgical service size of OR allocation). RESULTS: Using the median compensation of staff and an average conversion factor, the net annual staffing costs attributable to longer surgical durations were $672,100 for the first hospital. However, if staff members were highly compensated and the payer mix was unfavorable, the net staffing costs were $1,688,000. Reducing the difference between actual and average duration resulted in lower staffing costs. Net staffing costs were less in a second hospital studied that had many low-volume surgical services. CONCLUSIONS: Longer-than-average surgical durations can increase net staffing costs for anesthesiology groups. The increase is dependent on factors such as staffing compensation and payer mix.
Anesthesia Department, Hospital↗
Revenue gain for academic anesthesiology departments if the Centers for Medicare and Medicaid Services provide full reimbursement to teaching physicians.
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Anesthesia Department, Hospital↗
Two reports of propofol anesthesia associated with metabolic acidosis in adults.
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Acidosis↗
Elimination rate constant describing clearance of infused fluid from plasma is independent of large infusion volumes of 0.9% saline in sheep.
BACKGROUND: The purpose of this study was to determine the influence of varying large crystalloid infusion volumes, ranging from a volume that has been safely administered to volunteers to a volume that greatly exceeds a practical volume for studies in normovolemic humans, of rapidly infused 0.9% saline on the elimination rate constant in sheep. METHODS: Six sheep underwent three randomly ordered, 20 min, intravenous infusions of 0.9% saline in volumes of 25 ml/kg, 50 ml/kg and 100 ml/kg. Repeated measurements of arterial plasma dilution were analyzed using the volume kinetic approach to determine the apparent volumes of the central (V1) and peripheral (V2) body fluid spaces, the elimination rate constant (kr) describing clearance from the central fluid space and the rate constant (kt) for the diffusion of fluid between the central and the peripheral fluid spaces. The latter constant was split in to two constants, one describing flow out from the central fluid space and one describing flow into the central fluid space. Urinary output was measured in all sheep. RESULTS: kr was comparable at each infused volume (38.3 +/- 4.5, 32.2 +/- 4.2, and 36.7 +/- 7.0 ml/min, respectively, in the 25 ml/kg, 50 ml/kg, and 100 ml/kg protocols). However, for the largest infusion, other kinetic parameters were influenced by the magnitude of the infusion. V2 was significantly increased (P < 0.05) and the area under the dilution-time curve divided by the infused volume was 20% lower for the largest infusion (P < 0.03). Although urinary output increased as the infusion volume increased, only 59% of the administered volume had been excreted at 180 min after the 100 ml/kg infusion as compared with approximately 90% after the other two infusions (P < 0.01). CONCLUSIONS: Elimination from the central fluid space of large, rapidly infused volumes of saline solution is independent of infused volume. Larger volumes are apparently cleared from the central fluid space (V1) by expansion of a peripheral volume (V2) as renal excretion fails to increase in proportion to the volume of infused fluid.
Anesthetics, Inhalation↗
Influence of the type of anesthesia provider on costs of labor analgesia to the Texas Medicaid program.
BACKGROUND: The Texas Medicaid Program (Medicaid) defines billable time for labor analgesia as face-to-face time; therefore, anesthesia providers determine billed time. The authors' goal was to determine the influence of anesthesia providers on labor analgesia costs billed to Medicaid. METHODS: Under the Freedom of Information Act, Medicaid provided data on claims paid for 6 months in 2001 for labor analgesia administered during the course of a vaginal delivery. Claims were either time based (codes 00946 or 00955) or a flat fee (codes 26311 or 26319). Using modifiers, the authors grouped time-based claims as either anesthesiologist group or certified registered nurse anesthetist (CRNA) group. The cost to Medicaid was based on the 2001 fee schedule. The conversion factor was 18.21 USD per American Society of Anesthesiologists unit. The flat-fee reimbursement was 152.50 USD. CRNA services were paid at 85% of the fee schedule. Average time per time claim, percent of providers with more than 4 h of billed time, and cost per claim were determined for each group. Providers with more than 120 claims (> 20 claims/month) were considered high-volume. RESULTS: The database included 21,378 claims (anesthesiologist group: 12,698 claims from 219 providers; CRNA group: 8,680 claims from 117 providers). For time-based claims, the average time per case was significantly higher in the CRNA group (146 min) than in the anesthesiologist group (105 min). The CRNA group cost to Medicaid (225.11 USD) was 19% more per claim than the anesthesiologist group (189.26 USD). The difference in cost per claim was greater among high-volume providers--213.10 USD for the CRNA group versus 168.76 USD for the anesthesiologist group. If a flat-fee program were instituted using the average cost per claim for all groups (203.81 USD), the Texas Medicaid program would save more than 500,000 USD annually. CONCLUSIONS: The costs of labor analgesia billed to Texas Medicaid were 19% to 26% less per patient when provided by anesthesiologists than by CRNAs, despite lower per-unit reimbursement of CRNAs.
Analgesia, Obstetrical↗
Effects of different catecholamines on the dynamics of volume expansion of crystalloid infusion.
BACKGROUND: The authors studied the influence of alpha, beta, and dopaminergic catecholamines on blood volume expansion in conscious normovolemic sheep before, during, and after a bolus infusion of a crystalloid. METHODS: A 0.9% NaCl bolus (24 ml/kg in 20 min) was infused in four paired experiments each: no drug, dopamine infusion (50 microg . kg . min), isoproterenol infusion (0.1 microg . kg . min), and phenylephrine infusion (3 microg . kg . min). Blood volume expansion was calculated by the dilution of blood hemoglobin concentration. RESULTS: Dopamine had little effect on peak blood volume expansion (12.7 +/- 0.9 ml/kg) compared with 0.9% NaCl (13.0 +/- 2.7 ml/kg); in contrast, isoproterenol augmented blood volume expansion (18.5 +/- 1.8 ml/kg), and phenylephrine reduced blood volume expansion (8.9 +/- 1.4 ml/kg). Two hours after the 0.9% NaCl bolus, sustained blood volume expansion was greatest in the isoproterenol protocol (12.2 ml/kg), whereas the dopamine protocol (6.8 ml/kg) remained similar to the control protocol (4.1 ml/kg), and the phenylephrine protocol had a net volume loss (-1.9 ml/kg). Some blood volume expansion differences were attributed to changes in renal function as phenylephrine infusion increased urinary output, whereas isoproterenol was associated with antidiuresis. However, dopamine caused diuresis and sustained augmentation of blood volume. CONCLUSION: Catecholamines can alter the intravascular volume expansion of fluid therapy. beta-Receptor (isoproterenol) stimulation augmented blood volume expansion, whereas alpha (phenylephrine) stimulation reduced blood volume expansion. Combined dopaminergic, beta, and possibly alpha stimulation with dopamine augmented blood volume expansion and cardiac output while inducing diuresis.
Adrenergic alpha-Agonists↗
Impact of intensivists on outcome of critically ill neurologic and neurosurgical patients.
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APACHE↗
Hypotensive resuscitation of multiple hemorrhages using crystalloid and colloids.
Hypotensive resuscitation has been advocated as a better means to perform field resuscitation of penetrating trauma. Our hypothesis is that hypotensive resuscitation using either crystalloid or colloid provides equivalent or improved metabolic function while reducing the overall fluid requirement for resuscitation of hemorrhage. We compared hypotensive and normotensive resuscitation of hemorrhage using lactated Ringer's (LR) with hypotensive resuscitation using Hextend (Hex), 6% hetastarch in isotonic buffered saline. Instrumented conscious sheep were hemorrhaged in three separate bleeds, 25 mL/kg at T0 and 5 mL/kg at both T50 and T70. Resuscitation was started at T30 and continued until T180. Hypotensive resuscitation to a mean arterial pressure (MAP) of 65 mmHg was performed with LR or Hex using a closed-loop resuscitation (CLR) system for a LR-65 and Hex-65 treatment protocol. A control treatment protocol was resuscitation with LR to a MAP target of 90 mmHg, LR-90. All treatment protocols were successfully resuscitated to near target levels. Two animals in the hypotensive treatment protocols died during the second and third bleedings, one in the LR-65 and one in the Hex-65 treatment protocol. Mean infused volumes were 61.4 +/- 11.3, 18.0 +/- 5.9, and 11.6 +/- 1.9 mL/kg in the LR-90, LR-65, and Hex-65 treatments, respectively (*P < 0.05 versus LR-90). Mean minimum base excess (BE) values were +1.9 +/- 1.4, -5.8 +/- 4.3, and -5.9 +/- 4.0 mEq/L in the LR-90, LR-65, and Hex-65 treatments, respectively. Hypotensive resuscitation with LR greatly reduced volume requirements as compared with normotensive resuscitation, and Hex achieved additional volume sparing. However, trends toward lower BE values and the occurrence of deaths only in the hypotensive treatment protocols suggest that resuscitation to a target MAP of 65 mmHg may be too low for optimal outcomes.
Animals↗
Increasing the value of time reduces the lost economic opportunity of caring for surgeries of longer-than-average times.
UNLABELLED: Anesthesiology groups that provide care for surgical procedures of longer-than-average duration are economically disadvantaged by both increased staffing costs and reduced revenue. Under the current billing system, anesthesia time is valued the same regardless of the total case duration. In this study, we evaluated the effect on four academic anesthesiology departments of two hypothetical scenarios by changing the anesthesia care billing system to make more valuable either 1) all time units or 2) just second-hour and subsequent time units. From the four departments, case-specific data (anesthesia Current Procedural Terminology code and minutes of care) were collected for all anesthesia cases billed for 1 yr. Basic units were determined from the American Society of Anesthesiologists (ASA) relative value guide. The average time for each case was defined as the average anesthesia time for that specific Current Procedural Terminology code, as published by the Center for Medicare and Medicaid Services (CMS). The actual total ASA units per hour (tASA/h) was determined by adding all the basic units and time units and dividing by hours of anesthesia care (minutes of anesthesia care divided by 60). We then calculated a hypothetical CMS tASA/h for each group by substituting the CMS average time for each anesthesia procedure time for the actual time reported by each group and using 15-min time units. For each group, the Actual (Act) tASA/h and CMS tASA/h were calculated for both options-changing the interval for all time units or only for second and subsequent hours. Intervals were 15, 12, 10, 7, 6, or 5 min. When changing all time units, Act tASA/h and CMS tASA/h were never equal for all groups. The two productivity measures became approximately equal if only time units after the first hour were changed to 6- to 7-min intervals. When changes were applied only to the Act tASA/h (with CMS tASA/h remaining at 15-min intervals), at the 12-min interval either option resulted in a similar or higher Act tASA/h than CMS tASA/h. Both options increase the value of time and help compensate for the lost economic opportunity of longer-than-average surgical durations. IMPLICATIONS: Longer-than-average surgical durations result in less potential revenue per hour under current billing methodology. This study quantifies the increase in billing productivity when the value of time is increased, when evaluating the billing productivity of four academic anesthesiology groups.
Academic Medical Centers↗