Anaesthesia clinicians' perception of safety, workload, anxiety, and stress in a remote hybrid suite compared with the operating room.

BACKGROUND: Anaesthesia care outside of the standard operating room (OR) can be challenging. This prospective matched case-pair study describes the difference in anaesthesia clinicians' perception of safety, workload, anxiety, and stress in two settings by comparing similar neurosurgical procedures performed in either the OR or a remote hybrid room with intraoperative MRI (MRI-OR). METHODS: A visual numeric scale for safety perception and validated instruments for workload, anxiety, and stress were administered to enrolled anaesthesia clinicians after induction of anaesthesia and at the end of eligible cases. The difference in outcomes reported by the same clinician for unique pairs of similar operations performed in both settings (OR vs MRI-OR) was compared using the Student t-test with the general bootstrap algorithm to address the presence of clusters. RESULTS: Over 15 months, 37 clinicians provided data for 53 case pairs. Working in the remote MRI-OR vs OR was associated with lower perceived safety (7.3 [2.0] vs 8.8 [0.9]; P<0.001), higher scores in the workload subdomains effort and frustration (41.6 [24.1] vs 31.3 [21.6]; P=0.006 and 32.4 [22.9] vs 20.7 [17.2]; P=0.002, respectively), and higher anxiety (33.6 [10.1] vs 28.4 [9.2]; P=0.003) at the end of the case. Stress was rated higher in the MRI-OR after induction of anaesthesia (26.5 [15.5] vs 20.9 [13.4]; P=0.006). Effect sizes (Cohen's D) were moderate to good. CONCLUSIONS: Anaesthesia clinicians reported lower perceived safety and higher workload, anxiety, and stress in a remote MRI-OR compared with a standard OR. Improving non-standard work settings should benefit clinician well-being and patient safety. CLINICAL TRIAL REGISTRATION: .

Medicare reimbursement of lower extremity bypass does not cover cost of care for most patients with critical limb ischemia.

OBJECTIVE: Lower extremity bypass surgery remains an important treatment option for patients with critical limb ischemia (CLI), but is resource intensive. We sought to evaluate the cost and Medicare reimbursement for lower extremity bypass surgery in patients with CLI. METHODS: Hospital cost accounting systems were queried for total technical and professional costs incurred and reimbursement received for patients with CLI undergoing lower extremity bypass at our center between 2011 and 2017. Patients were identified by assignment to Diagnosis-Related Group (DRG) 252, 253, or 254 (other vascular procedure with major complication/comorbidity, with complication/comorbidity, and without complication/comorbidity, respectively). Additional clinical data were incorporated from the Vascular Quality Initiative clinical registry. For non-Medicare patients, reimbursement was indexed to Medicare rates. Contribution margins (reimbursement minus cost) from technical and professional services were analyzed for each patient and summarized by DRG. We compared technical, professional, and total costs; reimbursement; and contribution margins across DRGs using univariate statistics and evaluated factors associated with total contribution margin using median quantile regression. RESULTS: We analyzed 68 patients with hemodynamically confirmed CLI (46% rest pain, 54% tissue loss), of whom 25% received a prosthetic graft. Mean age was 66.1 ± 11.6 years, 69% were male, 49% diabetic, 44% current smokers, and 4% on dialysis. In general, total infrainguinal bypass cost was adequately compensated for patients assigned only the most complex DRG 252 (median, $2490; interquartile range [IQR], -$1,621 to $10,080). In the majority of patients with less complex DRG 253 (median, -$3,100; IQR, -$8499 to $109) and DRG 254 (median, -$4902; IQR, -$9259 to $1059), reimbursement did not cover the cost of care. Both technical costs and professional costs varied significantly with the complexity of DRG. Although reimbursement from technical services increased alongside increasing complexity of DRG, there was insignificant variation in professional reimbursement as DRG complexity increased. On multivariable modeling, longer length of stay (-$2547 per additional day) and preoperative dialysis (-$5555) were significantly associated with negative margins. CONCLUSIONS: For the majority of patients with CLI, current Medicare reimbursement does not adequately cover the cost of providing care after open bypass surgery. As commercial insurers move toward Medicare reimbursement rates, more granular risk stratification profiles are needed to ensure open surgical care for patients with CLI remains financially sustainable.

Differential Reliance on Lipid Metabolism as a Salvage Pathway Underlies Functional Differences of T Cell Subsets in Poor Nutrient Environments.

T cells compete with malignant cells for limited nutrients within the solid tumor microenvironment. We found that effector memory CD4 T cells respond distinctly from other T cell subsets to limiting glucose and can maintain high levels of interferon-γ (IFN-γ) production in a nutrient-poor environment. Unlike naive (TN) or central memory T (TCM) cells, effector memory T (TEM) cells fail to upregulate fatty acid synthesis, oxidative phosphorylation, and reductive glutaminolysis in limiting glucose. Interference of fatty acid synthesis in naive T cells dramatically upregulates IFN-γ, while increasing exogenous lipids in media inhibits production of IFN-γ by all subsets, suggesting that relative ratio of fatty acid metabolism to glycolysis is a direct predictor of T cell effector activity. Together, these data suggest that effector memory T cells are programmed to have limited ability to synthesize and metabolize fatty acids, which allows them to maintain T cell function in nutrient-depleted microenvironments.