Setting performance standards for an anesthesia department.

The Stanford University Department of Anesthesia established performance standards by identifying aspects of their service that were related to an important "customer's" perception of quality. A "quality grid" targeted service attributes that surgeons scored high for importance and low for performance. Control charts and flow charts helped establish reasonable performance levels for "timely first case starts" and "turnaround time." Control charts indicated that a reasonable performance standard for timely first case starts was "less than 20% of first case delays will be related to anesthesia activities." For turnaround time, the standard was set at "less than 10% of all turnaround times will be greater than 15 minutes, because of anesthesia-related activities." After instituting performance standards, the performance for first case start times improved from a 36% defective rate to a 9% defective rate. Anesthesia-related delays in turnaround times stabilized at a 16% defective rate. Using appropriate service standards can improve performance.

Hospital costs and severity of illness in three types of elective surgery.

BACKGROUND: If patients who are more severely ill have greater hospital costs for surgery, then health-care reimbursements need to be adjusted appropriately so that providers caring for more seriously ill patients are not penalized for incurring higher costs. The authors' goal for this study was to determine if severity of illness, as measured by either the American Society of Anesthesiologists Physical Status (ASA PS) or the comorbidity index developed by Charlson, can predict anesthesia costs, operating room costs, total hospital costs, or length of stay for elective surgery. METHODS: The authors randomly selected 224 inpatients (60% sampling fraction) having either colectomy (n = 30), total knee replacement (n = 100), or laparoscopic cholecystectomy (n = 94) from September 1993 to September 1994. For each surgical procedure, backward-elimination multiple regression was used to build models to predict (1) total hospital costs, (2) operating room costs, (3) anesthesia costs, and (4) length of stay. Explanatory candidate variables included patient age (years), sex, ASA PS, Charlson comorbidity index (which weighs the number and seriousness of coexisting diseases), and type of insurance (Medicare/Medicaid, managed care, or indemnity). These analyses were repeated for the pooled data of all 224 patients. Costs (not patient charges) were obtained from the hospital cost accounting software. RESULTS: Mean total hospital costs were $3,778 (95% confidence interval +/- 299) for laparoscopic cholecystectomy, $13,614 (95% CI +/- 3,019) for colectomy, and $18,788 (95% CI +/- 573) for knee replacement. The correlation (r) between ASA PS and Charlson comorbidity scores equaled 0.34 (P < .001). No consistent relation was found between hospital costs and either of the two severity-of-illness indices. The Charlson comorbidity index (but not the ASA PS) predicted hospital costs only for knee replacement (P = .003). The ASA PS, but not the Charlson index, predicted operating room and anesthesia costs only for colectomy (P < .03). CONCLUSIONS: Severity of illness, as categorized by ASA PS categories 1-3 or by the Charlson comorbidity index, was not a consistent predictor of hospital costs and lengths of stay for three types of elective surgery. Hospital resources for these lower-risk elective procedures may be expended primarily to manage the consequences of the surgical disease, rather than to manage the patient's coexisting diseases.

Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care.

BACKGROUND: Many health-care institutions are emphasizing cost reduction programs as a primary tool for managing profitability. The goal of this study was to elucidate the proportion of anesthesia costs relative to perioperative costs as determined by charges and actual costs. METHODS: Costs and charges for 715 inpatients undergoing either discectomy (n = 234), prostatectomy (n = 152), appendectomy (n = 122) or laparoscopic cholecystectomy (n = 207) were retrospectively analyzed at Stanford University Medical Center from September 1993 to September 1994. Total hospital costs were separated into 11 hospital departments. Cost-to-charge ratios were calculated for each surgical procedure and hospital department. Hospitalization costs were also divided into variable and fixed costs (costs that do and do not change with patient volume). Costs were further partitioned into direct and indirect costs (costs that can and cannot be linked directly to a patient). RESULTS: Forty-nine (49%) percent of total hospital costs were variable costs. Fifty-seven (57%) percent were direct costs. The largest hospital cost category was the operating room (33%) followed by the patient ward (31%). Intraoperative anesthesia costs were 5.6% of the total hospital cost. The overall cost-to-charge ratio (0.42) was constant between operations. Cost-to-charge ratios varied threefold among hospital departments. Patient charges overestimated resource consumption in some hospital departments (anesthesia) and underestimated resource consumption in others (ward). CONCLUSIONS: Anesthesia comprises 5.6% of perioperative costs. The influence of anesthesia practice patterns on "downstream" events that influence costs of hospitalization requires further study.

Principles of cost analysis.

In medicine, reimbursement changes that block cost shifting are rendering revenue-based strategies less productive. Under these conditions, cost-benefit and cost-effective analyses are being touted as more effective financial tools. The anesthesia literature reflects misunderstanding and misapplication of the terminology, and principles of cost analysis are reviewed in this essay. Current evidence suggests that anesthesia costs are a minor part of the problem of controlling health care expenditures. However, the ability to perform cost analysis is essential for anesthesia groups to secure their position in health care.

Chronic hypokalemia and intraoperative dysrhythmias.

To investigate whether chronic hypokalemia increases the occurrence of dysrhythmias during anesthesia, the authors recorded the intraoperative electrocardiograms of normokalemic (K+ = 5.0 -3.5 mEq/l; N = 88) and chronically hypokalemic patients (K+ = 3.4 - 2.6 mEq/l; N = 62). In each patient, serum potassium was measured and a 12-lead ECG was analyzed prior to surgery. No patient received potassium perioperatively. Lead II was monitored continuously during anesthesia, either by a Holter monitor (N = 81) or by a trained observer (N = 69). A variety of general anesthetic techniques were utilized, without consideration for the potassium level. The hypokalemic population had a higher incidence of hypertensive and ASA Class III patients (P = 0.03). Analysis of variance revealed no significant difference in the incidence of other characteristics between the hypokalemic and normokalemic groups: age, hypoxemia, cardiac disease, preoperative dysrhythmias, digitalis therapy, surgical site, anesthetic agent, and intubation. The method of ECG monitoring did not affect the incidence of dysrhythmias recorded. Multivariate analysis revealed that the occurrence of intraoperative dysrhythmias correlated with the presence of preoperative dysrhythmias only. The authors conclude that chronic hypokalemia per se is not associated with a higher incidence of intraoperative dysrhythmias.

Thermoregulatory responses to desert heat: age, race and sex.

Sixty-nine whites (38 men and 31 women) aged 17 to 88 years and 48 blacks (19 men and 29 women) aged 17 to 61 years were studied. Each person walked in desert heat for 1 hour at a rate requiring 40% of aerobic capacity. Observations were recorded on their rectal temperature (Tre), skin temperature (Tsk), heart rate (HR), blood pressure, and sweat rate (SR). Older men and women of both races were able to complete their walks without any ill effects. Age, per se, did not significantly reduce elderly individuals' ability to tolerate the combined stress of dry heat and exercise. Men of both races had higher sweat rate and lower heart rate and rectal and skin temperature than women working at the same percentage of aerobic capacity. Success of thermoregulation at 40% of aerobic capacity of blacks and whites was equal, but in both races men thermoregulated more successful than women. Our data suggest that thermoregulatory capacity of humans under desert conditions differs between sexes and is not influenced significantly by age or race except for differences in aerobic capacity.

Reversal of combination nondepolarized neuromuscular block.

The antagonism of a pancuronium-curare (P + C) neuromuscular block was assessed and compared to the antagonism of a pancuronium (P) block. One group of seven patients received P + C (0.024 mg/kg + 0.144 mg/kg); another similar group of seven patients received P (0.07 mg/kg). Both groups were anesthetized with nitrous oxide/oxygen/narcotic anesthesia. Each patient received 0.025 mg/kg of neostigmine when a train-of-four revealed only one twitch (90% block). The resultant antagonism of the pancuronium-curare blocks was the same as the antagonism of the pancuronium blocks (train-of-four ratio, 0.38 vs 0.32; P = 0.5). The authors conclude that neostigmine requirements for combination blocks are the same as those for single agent blocks.

Metabolic observations on Caucasian men and women aged 17 to 88 years.

Aerobic capacity (VO2 max) and body fat were measured indoors and VO2 was measured at about 36 to 42 degrees C in desert walks or runs in 69 adults aged 17 to 88 years. Eleven were athletic youths, and many of the older adults had participated in jogging programs. Body fat increased and VO2 max decreased with age, although there were notable exceptions. Rates of walking and running were planned to require about 40% of VO2 max. Midway in each walk VO2 (ml O2/horizontal m . kg) served as a measure of skill; skill was high in 10 of 11 youths who did many walks or runs. Each older adult did three walks; skill improved. In four groups with some persons aged 50 and older with body fat up to 40%, skill in their third walk matched that of youths. The least fit women and the least fit men did not attain that level of skill.