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In the field of anaesthesia the demands on the quality and quantity of documentation are increasing constantly. Patient Data Management Systems (PDMS) have proved an effective means of handling the volume of data generated. The main reasons for introducing a PDMS vary greatly, nevertheless, it is possible to formulate general requirements such as those of the "Position Paper of the Study Group on Patient Data Management Systems (PDMS) of the University Departments of Anaesthesiology in Bavaria". Although these requirements are very broad, they provide a good basis for comparing different approaches to computer-assisted documentation in anaesthesiology. The stage currently reached at the Department of Anaesthesiology and Intensive Care Medicine (KAI) of the University of Leipzig is analysed in comparison with the position paper. The COPRA system was established at KAI Leipzig eight years ago. It was developed from an existing version for intensive care medicine. It meets the demands made on it when it was introduced and can be enlarged and adjusted to the special needs of anaesthesiology. One particular requirement was that it should be possible to handle computer-assisted documentation and conventional documentation on paper simultaneously. This requirement is met by making the printed forms and those shown on the VDU practically the same in appearance. The anaesthetist is able to recognize "his" record on the screen. This greatly reduces the time required for familiarization and training. If possible, the orientation and updating of the system should be in the hands of an anaesthetist, since this is the only way to ensure that it remains geared primarily to medical needs. Administrative aspects have to be taken into account, but they should not dominate the system. The anaesthetist managing the system should have some basic training in EDP, or at least take a special interest in it. This ensures that minor enlargements can be carried out easily, as soon as required. Proper, expert evaluation of the compiled data requires both a knowledge of medicine and anaesthesiology and an understanding of how information is presented in an EDP system. Enlargements of the system resulting from increasing documentation obligations and quality assurance can be integrated smoothly. In its current form the system is able to depict all parts of the specialist field with the same user interface. By systematically meeting general requirements and taking the special needs of a hospital into account, it has been possible to create a flexible electronic documentation system covering all areas of the anaesthetist's work.
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OBJECTIVE: To analyze the number of articles by Spanish authors in three international anesthesiology journals and assess the impact of Spanish anesthesiology literature during the same period by way of citations. MATERIAL AND METHODS: Articles published in Anesthesiology, British Journal of Anesthesiology (BJA) and Anesthesia & Analgesia (Anesth Analg) during 1997 were reviewed. We collected the following data: type of document, country of origin of the authors, total number of references, number of citations of Spanish articles and the journals from which they were cited. Later, the Spanish contribution was compared to that of other countries of the European Union, with data considered in function of Gross National Product per capita (GNPpc) of each country. RESULTS: The incidence of Spanish articles published in Anesthesiology, BJA and Anesth Analg was 0.37%, 0.71% and 0.9%, respectively. The production of Spanish documents in function of GNPpc ranked Spain in the tenth position in Anesthesiology, eleventh in BJA and sixth in Anesth Analg. Of the total number of citations, 143 (0.4%) were of Spanish publications. In Spanish articles in Anesthesiology the percentage of Spanish citations was 11%, in BJA the figure was 44% and in Anesth Analg it was 13%. Finally, over 90% of the Spanish articles cited in Anesthesiology and in Anesth Analg were published in English in foreign journals. CONCLUSIONS: The number of Spanish articles published in Anesthesiology, BJA, and Anesth Analg is low, although the comparison of our productivity with that of other EU countries in function of GNPpc places us in an intermediate position. The impact of Spanish literature on international studies is low, particularly research published in Spanish national journals, a circumstance that is reflected even in articles published by Spanish authors.
We examined the effects of Resource-based Relative Value Scale (RBRVS)- and physician diagnosis-related groups (MDDRG)-based payment for anesthesiology services related to surgery by simulating these physician payment reform options. We merged Medicare Part A (hospital) and Part B (anesthesiology) payment data for 7,770 patients for the MDDRG analysis and examined 10,431 surgical procedures for the RBRVS analysis within 27 diagnosis-related groups (DRGs) during the second half of 1986 in 16 hospitals representing different geographic regions, bed size, and teaching status. Assuming budget neutrality (i.e., constant total expenditure for anesthesiology services) and using the proposed methodologies, we simulated RBRVS and MDDRG payments and compared them to current payments for anesthesiology services. Individual surgical procedures demonstrated a two- to more than four-fold variation in duration, accompanied by a similar variation in anesthesiology payments. Within DRGs, there was a three- to ten-fold variation in duration, and a two- to seven-fold variation in anesthesiology payments. Anesthesiology time was highly correlated with surgical time (r = 0.86-0.96). Compared to the current system, RBRVS and MDDRG systems were associated with systematic variations in payments, such that on average, on each case, anesthesiologists practicing in rural and nonteaching hospitals would gain, whereas those in urban or suburban and teaching facilities would lose. After adjusting for complexity of procedure, the distribution of payment gains and losses was a function of duration of surgery, which is not influenced by the anethesiologist. Longer cases of a given surgical procedure result in payment decreases. The results document the importance of retaining a time factor in the payment methodology for anesthesiology services to maintain equitable payment across practice settings--an objective of physician payment reform.
UNLABELLED: We performed a financial analysis at a large university tertiary care hospital to determine the incremental cost of replacing its anesthesiology residents with alternative dependent providers (i.e., certified registered nurse anesthetists in the operating room, advanced practice nurses and physician assistants outside the operating room). The annual average net cost of an anesthesiology resident during a 3-yr residency is approximately $38,000, and residents performed an average of $89,000 of essential clinical work annually based on replacement costs. The incremental cost (replacement labor cost minus net resident cost) to replace all essential clinical duties performed by an anesthesiology resident at Duke University Medical Center and affiliated hospitals is approximately $153,000 throughout 3 yr of clinical anesthesiology training. If this approach were applied nationwide, incremental costs of substitution would range from $36,000,000 to $93,000,000 per year. We conclude that maintaining clinical service in the face of anesthesiology residency reductions can have a marked impact on the overall cost of providing anesthesiology services in teaching hospitals. Simply replacing residents with alternate nonphysician providers is a very expensive option. IMPLICATIONS: We sought to calculate the financial burden resulting from a decreased number of anesthesiology residents. Replacing each resident's essential clinical work with similarly skilled healthcare providers would cost hospitals approximately $153,000 over the course of a 3-yr residency. Varying projections yield future nationwide costs of $36,000,000 to $93,000,000 per year. Simply replacing residents with alternate nonphysician providers is a very expensive option.
UNLABELLED: Productivity measurements based on "per operating room (OR) site" and "per case" are not influenced by staffing ratios and have permitted meaningful comparisons among small samples of both academic and private-practice anesthesiology groups. These comparisons have suggested that a larger sample would allow for clinical groups to be compared using a number of different variables (including type of hospital, number of OR sites, type of surgical staff, or other organizational characteristics), which may permit more focused benchmarking. In this study, we used such grouping variables to compare clinical productivity in a broad survey of academic anesthesiology programs. Descriptive, billing, and staffing data were collected for 1 fiscal or calendar year from 37 academic anesthesiology departments representing 58 hospitals. Descriptive data included types of surgical staff (e.g., academic versus private practice) and hospital centers (e.g., academic medical centers and ambulatory surgical centers [ASCs]). Billing and staffing data included total number of cases performed, total American Society of Anesthesiologists units (tASA) billed, total time units billed (15-min units), and daily number of anesthetizing sites staffed (OR sites). Measurements of total productivity (tASA/OR site), billed hours per OR site per day (h/OR/d), surgical duration (h/case), hourly billing productivity (tASA/h), and base units/case were compared. These comparisons were made according to type of hospital, number of OR sites, and type of surgical staff. The ASCs had significantly less tASA/OR site, fewer h/OR/d, and less h/case than non-ASC hospitals. Community hospitals had significantly less h/OR/d and h/case than academic medical centers and indigent hospitals and a larger percentage of private-practice or mixed surgical staff. Academic staffs had significantly less tASA/h and significantly more h/case. tASA/h correlated highly with h/case (r = -0.68). This study showed that the hospitals at which academic anesthesiology groups provide care are not all the same from a clinical productivity perspective. By grouping based on type of hospital, number of OR sites, and type of surgical staff, academic anesthesiology departments (and hospitals) can be better compared by using clinical productivity measurements based on "per OR site" and "per case" measurements (tASA/OR, billed h/OR/d, h/case, tASA/h, and base/case). IMPLICATIONS: Organizational factors, including type of hospital, number of operating rooms, and type of surgical staff, influence the clinical productivity of academic anesthesiology departments. Reporting quartile data by focused grouping variables allows anesthesiology groups to compare their clinical productivity with groups practicing in similar clinical settings.
BACKGROUND: Anesthesiology is a vital specialty that permits the safe and humane performance of painful procedures. Most Israeli anesthesiologists are immigrants, while only a minimal number of Israeli medical school graduates enter the specialty. Unfortunately, the supply of immigrant physicians is declining due to falling immigration rates. OBJECTIVES: To examine the current Israeli anesthesiology workforce and project future needs. METHODS: Demographic and professional information about Israeli hospital anesthesiologists was solicited from anesthesiology department heads. Data were also gathered about the past, present and projected future growth, age distribution and birth rate of the Israeli population. Needs and demand-based analyses were used to project future anesthesiology workforce requirements. RESULTS: Data on 711 anesthesiologists were obtained from 30 hospital anesthesiology department heads. Eighty-seven anesthesiologists (12.2%) graduated from Israeli medical schools and 459 (64.6%) graduated from medical schools in the former Soviet Union. Among the 154 anesthesiology residents < or = 40 years old, only 13 (8.4%) graduated from Israeli medical schools. There are approximately 10.8 anesthesiologists per 100,000 population. Projections for 2005-2015 revealed a need for 250-300 new anesthesiologists. CONCLUSIONS: The anesthesiology workforce is predominantly composed of immigrants. This has vast implications for the future viability of the specialty because of the continuing reduction in immigration, the lack of interest in the specialty by Israeli medical school graduates, and the projected need for many new anesthesiologists to replace retirees and to provide care to a growing and aging population.
Each year, many anesthesiology housestaff positions remain vacant or are filled by foreign medical graduates. While possibly reflecting an overabundance of such housestaff positions, this situation also suggests a lack of U.S. student interest in anesthesiology. To investigate this phenomenon, the authors conducted a survey of American medical school graduates of 1976. The results reveal that 65% of students receive minimal or no systematic exposure to anesthesiology or anesthesiologists. When such exposure occurs, it comes after many students have developed strong specialty preferences. Many students saw anesthesiology as limited in scope and unchallenging and indicated that they did not select anesthesiology because it entails insufficient primary patient care. Contrasts between those entering and not entering anesthesiology suggest, however, that certain variables which are subject to manipulation--such as amount, timing, and content of exposure to anesthesiology--could alter student attitudes and potentially generate increased student interest in the specialty.
OBJECTIVE: Transesophageal echocardiographic examination tends to be somewhat observer and experience dependent, and observer bias can arise easily when data are calculated and interpreted by unskilled, nonblinded, or single observers. The study plan was to see whether authors have adequately described how observer bias is minimized in their studies. Thus, a study was conducted systematically reviewing methods reported in transesophageal echocardio graphy articles in peer-reviewed anesthesiology journals versus those reported in peer-reviewed cardiology journals. INTERVENTIONS: After MEDLINE searches of the literature published from 1997 through 1999, the authors investigated 56 anesthesiology reports and 56 randomly selected, year-matched cardiology reports. An 8-item questionnaire was developed that examined several factors: the number of observers and their experience levels, whether observers were blind to clinical data, whether low-quality images were excluded, the use of on-line or off-line analysis, and observer variability. MAIN RESULTS: The analysis revealed inadequacies in reporting of important information that relates to bias and quality in 91.1% of anesthesiology and 98.2% of cardiology articles. Observer variability was not reported in 50.0% of the anesthesiology reports and 67.9% of the cardiology reports; however, difference between the 2 bodies of literature was not significant. The journal impact factor was significantly higher for the cardiology literature than for the anesthesiology literature (2.42 [0.386-10.893] v 1.07 [0.664-3.439]; median [range], p < 0.001). CONCLUSION: Articles reviewed had at least some inadequacies in reporting the methods to minimize observer bias in both the anesthesiology and cardiology literature. Reporting methodology standards in TEE examinations remain to be established.
BACKGROUND: In 1992, Medicare changed its method for calculating physician payments. The resulting fee schedules have contained low payments for anesthesiologists. Now, other third-party (insurance) payers are using these schedules. The financial impact on anesthesiologists if all payers pay Medicare rates is unknown. METHODS: Payments from Medicare were compared with payments from other third parties in each clinical procedural terminology (CPT) grouping used by the West Virginia University Department of Anesthesiology during 1998. Changes in total Department of Anesthesiology receipts were determined if non-Medicare third-party payers paid Medicare rates. Then, the effect of adding payments at Medicare rates from patients without insurance was determined. Finally, potential changes in receipts of the Departments of Anesthesiology, Radiology, Surgery, and Medicine were compared by considering only patients with insurance and recalculating total payments to the departments using Medicare rates. RESULTS: Medicare paid less than other third-party payers in every clinical procedural terminology group. Total Department of Anesthesiology payments would decrease by 31% if all non-Medicare third-parties paid Medicare rates. Adding payments at Medicare rates from patients without insurance still leads to a 21% decrease in total Department of Anesthesiology receipts. Considering only patients with third-party coverage, Medicare-rate payments would decrease total Department of Anesthesiology payments by 37%, whereas radiology, surgery, and medicine payments would decrease by 26, 22, and 13% respectively. CONCLUSIONS: Universal payments at Medicare rates would substantially reduce revenue to anesthesiologists, proportionally more than to radiologists, surgeons, or internists.
UNLABELLED: We surveyed health care professionals about their preparations to manage the clinical problems associated with patients exposed to hazardous substances, including weapons of mass destruction (WMD). Training for WMD is considered a key part of public health policy and preparedness. Although such events are rare, when they do occur, they can cause mass casualties. In many models of mass casualty management, anesthesiology personnel are responsible for treating patients immediately on arrival at the hospital. We studied the extent of training offered to anesthesiology personnel in the use of WMD protective gear and patient management in United States (US) anesthesiology residency programs. Information was obtained via an online survey to all program directors and chair persons of anesthesiology programs. We polled all of the 135 US anesthesiology programs of which 90 (67%) responded. Only 37% had any form of training, and many of them did not repeat training after initial sessions. Twenty-eight percent of programs east of the Mississippi River reported some form of training whereas only 17% of programs west of it reported training available. The majority of anesthesia residency programs in the US that responded to our survey provided little or no training in the management of patients exposed to WMD. IMPLICATIONS: In an attack involving weapons of mass destruction or toxic chemicals, anesthesiologists will provide care. Our survey of United States anesthesiology residency programs demonstrated that there is limited training of residents regarding the anesthetic management of patients injured by weapons of mass destruction. This has serious public health implications.
To determine incidence and outcome of reentry into anesthesiology training programs by residents with histories of substance abuse, a survey was sent to the 159 US anesthesiology training programs. One hundred thirteen (71%) responded, with 82 (73%) submitting at least one case report of substance abuse. A total of 180 case reports were submitted, including 26 in which the resident died as a result of substance abuse. The prevalence of substance abuse among trainees was 2%. Sixty-one (74%) of the responding training programs submitted a total of 113 case reports of resident reentry into anesthesiology training. The success rate of reentry in the parenteral opioid abuser group was 34% (27/79). The success rate of reentry for the nonopioid abuser group was 70% (16/23). There were 14 cases of suicide or lethal overdose among trainees who were allowed to reenter anesthesiology training. Death as the initial relapse symptom occurred in 16% (13/79) of the parenteral opioid abusers who were allowed to reenter anesthesiology training. This study suggests that drug rehabilitation followed by redirection into another specialty may be the most prudent course for the anesthesiology trainee who abuses parenteral opioids.
OBJECTIVE: To determine nursing functions in anesthesiology, postoperative recovery care, and pain management in Catalan hospitals and to analyze the roles of nurses in this specialty. METHODS: Development of a mail questionnaire sent to 70 public and private hospitals in Catalonia, to be filled in and returned separately by the nursing supervisor and by the anesthesiology department of each hospital. The survey included questions on whether tasks were or were not carried out by nurses. RESULTS: Responses were received from 31% of nursing supervisors and 45% of anesthesiology departments. Only 22% of the hospitals employed nursing staff with duties exclusively in the anesthesiology department. Nurses took on more responsibilities in major outpatient surgery services and postanesthetic recovery care units than in other areas. Significant discrepancies were found between answers given by nursing supervisors and those returned by anesthesiology departments regarding tasks of nurses in this specialty. Items with the greatest agreement were those related to maintenance of material. Those with the lowest agreement were related to drug management. CONCLUSIONS: Although responses came from only a third of the target population, the information obtained suggests a lack of definition in Spain of nursing tasks in the field of anesthesiology. This situation is different from that of most European countries and of the United States of America.
STUDY OBJECTIVE: To determine the current status and future plans of residency programs to train residents in office-based anesthesiology (OBA), which is rapidly emerging as an important specialty within the field of anesthesiology. DESIGN: Survey questionnaire. SETTING: University hospital. MEASUREMENTS: A 14-question survey was sent to the 134 listed members of the Society of Academic Anesthesia Chairs/Association of Anesthesiology Program Directors to elicit the current status of educational endeavors and clinical exposure of anesthesiology residents to this type of practice. MAIN RESULTS: There were 95 respondents (72%). Fifteen (15.8%) academic anesthesiology programs provide OBA services in the community and two (2.1%) of the academic programs provide clinical exposure to their residents. CONCLUSIONS: Residents are receiving minimal, if any, exposure to OBA during their training.
UNLABELLED: This article examines recent trends in the management of academic physician practice groups, and in particular the allocation of revenues and expenses to anesthesiology departments. The history of academic group practice is traced, beginning with the "corporate model," in which each department functioned in financial independence from the others. This evolved gradually into the "feudal system," in which departments were ostensibly independent, but paid variable and often large "assessments" to the central group. The final stage in this evolution is the "big bag," in which all clinical revenue is pooled by the central practice group, and then distributed by the group to departments or individuals according to some compensation plan formula. The advantages and disadvantages of each of these systems are discussed as they apply to anesthesiology departments. A productivity-based compensation plan formula under the big bag system is calculated for a typical anesthesiology department. This calculation shows that if the compensation formula is truly based on measured clinical productivity, anesthesiology departments may actually fare better under the big bag than under the feudal system. Finally, options for survival in the academic practice groups of the future are discussed. IMPLICATIONS: The history, current status, and trends of finances in academic anesthesiology departments are reviewed. Knowledge of these issues will help departments develop funds allocation methods to ensure that they receive an appropriate share of their faculty practice group's clinical income.
Modern anesthesiology differs widely from what it was 40-50 years ago, not only because of what anesthesiology now involves in the operating room, but also because anesthesiology has expanded its horizons and activities above and beyond the provision of surgical anesthesia. These changes and the identity of modern anesthesiology are, however, but poorly understood, if understood at all, by the majority of laity and physicians alike. Such lack of identity, especially in the minds of those at the policy- and decision-making level, can only endanger the vitality and future of anesthesiology in an era of sweeping changes in health care-delivery systems. The problem of public identity of our specialty includes the historically correct, but, contemporaneously, all too often misleading name of our specialty. It is suggested that it is appropriate, at this time, to at least consider the potential advantages of changing the name of our specialty to, say, metesthesiology and metesthesiologist, to indicate that while, today, our specialty continues to involve operative anesthesia, it extends above and beyond to include a wide variety of professional activities outside the operating room richly rewarding to patient and practitioner alike.