March 4, 2019
SUMMARY: We review additional e-posters from PRACTICE MANAGEMENT™ 2019, including a survey by one institution to assess the need and desire for a central resource for information on anesthesia drug costs, and the effectiveness of a screening questionnaire to identify patients who do and do not require an in-person preoperative evaluation.
As a follow up to last week’s eAlert, we review additional e-posters presented at the ASA’s PRACTICE MANAGEMENT™ 2019. As mentioned last week, please bear in mind that each of these studies represent the experience of a single institution, and the same study at your own institution might well produce a different result. These summaries are offered to serve as a catalyst for discussion and planning.
Anesthesia drug costs. How well do you and your anesthesia colleagues know the costs of the various anesthesia drugs used in the OR and other anesthetizing locations at your facilities, so that you can make the most cost-effective choices?
To evaluate provider awareness at their institution and assess the need and desire for a single, central source of drug information for all anesthesia clinicians, researchers led by Nasir Khatri, MD, at the University of North Carolina Hospitals surveyed anesthesia department members regarding their knowledge of the intravenous drug costs associated with three specific procedures: laparoscopic cholecystectomy, pulmonary wedge resection and craniotomy for stereotactic posterior fossa mass removal.
Participants then viewed a four-minute educational video about the actual drug costs associated with these and other procedures, followed by a post-survey to re-evaluate self-perceived knowledge of drug costs and to assess desire among department members for development of a central anesthesia drug cost resource.
Most study participants revealed little awareness of anesthesia IV drug costs. Eight percent, 6 percent and 0 percent of anesthesia providers correctly estimated the IV drug costs associated with lap chole, wedge resection and craniotomy, respectively. This widespread lack of knowledge at least partly explains the significant variation in utilization costs at UNC, the authors reported.
The survey also revealed substantial interest among participants for a central resource for IV drug cost information, preferably through a website (47 percent) or mobile app (38 percent). The vast majority of providers (97 percent) expressed support for such a resource, with 98 percent indicating a belief that the resource would facilitate cost-effective care. The study was limited by the fact that it looked only at IV drugs and did not evaluate inhaled anesthetics or local anesthetics used in peripheral nerve blocks.
Preoperative evaluation. As abundant research has shown, preoperative evaluations can improve anesthesia care safety, efficiency and quality and the patient’s perioperative experience. But is an in-person preoperative evaluation for every patient the most efficient use of resources?
Jagan Devarajan, MD, and colleagues at Cleveland Clinic wanted to know whether a screening tool developed at their institution could be used to identify low risk patients who would not need to be seen in-person before the day of surgery. Such a tool could free up time and resources for patients with multiple comorbidities who need extensive preoperative work and care coordination.
A valid screening test should have high negative predictive value and also accurately identify high risk patients to create “a window of opportunity for medical optimization” that could help reduce morbidity and mortality, they said, citing research showing that 11 percent of intraoperative events are due to poor preoperative preparation and that half of them are avoidable.
Two independent anesthesia researchers applied the 13-item questionnaire (see below) to a retrospective review of 70 charts to see whether responses to the questions would have identified high risk patients, and whether any patients who responded no to all of the questions were referred for optimization or specialty care.
1. Do you have heart problems (heart attack, heart (coronary) stents, congestive heart failure, valve problems, bypass surgery, aneurysm, irregular heart beat)?
2. Do you have a pacemaker or defibrillator?
3. Do you have chest pain or chest tightness on walking or exercising?
4. Do you have breathing problems (COPD, emphysema, chronic bronchitis) or use oxygen at home?
5. Have you had any recent asthma attack which required hospitalization within one month?
6. Do you have kidney failure requiring any type of dialysis?
7. Do you take blood thinners other than Aspirin (i.e., Coumadin, Pradaxa, Plavix, Effient)?
8. Have you ever had a stroke or seizure?
9. Have you or your blood relative had a major reaction to anesthesia? (becoming sick or developing nausea and vomiting is not included)
10. Do you get short of breath walking on flat ground?
11. Do you use insulin for diabetes?
12. Do you have sleep apnea?
13. Do you find it difficult to climb a full flight of stairs without stopping to rest?
Patients answering ‘YES’ to any of questions 1-10 require a PAT Clinic appointment. Patients answering ‘YES” to two or more of questions 11-13 require a PAT Clinic appointment.
All 13 patients who were referred for further consultations would have been accurately identified by the questionnaire, and none of the 21 patients who answered no to all of the questions (all ASA physical status I-II patients) required referral for optimization, had their procedures cancelled on the day of surgery or experienced any perioperative complications.
All of the e-posters from PRACTICE MANAGEMENT™ 2019 can be seen here.