Japanese surgical resource utilization in 2016.

PURPOSE: The purpose of this paper is to examine from the viewpoint of resource utilization the Japanese surgical payment system which was revised in April 2016. DESIGN/METHODOLOGY/APPROACH: The authors collected data from surgical records in the Teikyo University electronic medical record system from April 1 till September 30, 2016. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated each surgeon's efficiency score using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. The authors compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and the Steel method. FINDINGS: The authors analyzed 2,558 surgical procedures performed by 109 surgeons. The difference in efficiency scores was significant (p = 0.000). The efficiency score of neurosurgery was significantly greater than obstetrics and gynecology, general surgery, orthopedics, emergency surgery, urology, otolaryngology and plastic surgery (p<0.05). ORIGINALITY/VALUE: The authors demonstrated that the surgeons' efficiency was significantly different among their specialties. This suggests that the Japanese surgical reimbursement scales fail to reflect resource utilization despite the revision in 2016.

Time to recovery after general anesthesia at hospitals with and without a phase I post-anesthesia care unit: a historical cohort study.

PURPOSE: There is little knowledge about how hospitals can best handle disruptions that reduce post-anesthesia care unit (PACU) capacity. Few hospitals in Japan have any PACU beds and instead have the anesthesiologists recover their patients in the operating room. We compared postoperative recovery times between a hospital with (University of Iowa) and without (Shin-yurigaoka General Hospital) a PACU. METHODS: This historical cohort study included 16 successive patients undergoing laparoscopic gynecologic surgery with endotracheal intubation for general anesthesia, at each of the hospitals, and with the hours from OR entrance until the last surgical dressing applied ≥ two hours. Postoperative recovery times, defined as the end of surgery until leaving for the surgical ward, were compared between the hospitals. RESULTS: The median [interquartile range] of recovery times was 112 [94-140] min at the University of Iowa and 22 [18-29] min at the Shin-yurigaoka General Hospital. Every studied patient at the University of Iowa had a longer recovery time than every such patient at Shin-yurigaoka General Hospital (Wilcoxon-Mann-Whitney, P < 0.001). The ratio of the mean recovery times was 4.90 (95% confidence interval [CI], 4.05 to 5.91; P < 0.001) and remained comparable after controlling for surgical duration (5.33; 95% CI, 3.66 to 7.76; P < 0.001). The anesthetics used in the Iowa hospital were a volatile agent, hydromorphone, ketorolac, and neostigmine compared with the Japanese hospital where bispectral index monitoring and target-controlled infusions of propofol, remifentanil, acetaminophen, and sugammadex were used. CONCLUSIONS: This knowledge can be generally applied in situations at hospitals with regular PACU use when there are such large disruptions to PACU capacity that it is known before a case begins that the anesthesiologist likely will need to recover the patient (i.e., when there will not be an available PACU bed and/or nurse). The Japanese anesthesiologists have no PACU labour costs but likely greater anesthesia drug/monitor costs.

Influence of the revision of surgical fee schedule on surgeons' productivity in Japan: A cohort analysis of 7602 surgical procedures in 2013-2016.

The goal of this study is to evaluate the pure impact of the revision of surgical fee schedule on surgeons' productivity. We collected data from the surgical procedures performed by the surgeons working in Teikyo University Hospital from 1 April through 30 September in 2013-2016. We employed non-radial and non-oriented Malmquist model. We defined the decision-making unit as a surgeon with the highest academic rank in surgery. Inputs were defined as (1) the number of doctors who assisted surgery and (2) the time of surgical operation. The output was defined as the surgical fee for each surgery. We focused on the revisions in 2014 and 2016. We first calculated each surgeon's natural logarithms of the changes in productivity, technique and efficiency in 2013-2014, in 2014-2015 and in 2015-2016. Then, we subtracted the changes in 2014-2015 from the changes in 2013-2014 and in 2015-2016. We analyzed 62 surgeons who performed 7602 surgical procedures. The productivity changes were not significantly different from 0. Their efficiency change was significantly greater than 0, while their technical change was smaller than 0 in revision 2014. Their efficiency change was significantly smaller than 0, while their technical change was greater than 0 in revision 2016 (p < 0.05). This finding suggests that we could increase overall productivity through revision if we could increase both efficiency and technique.

Efficiency of inpatient orthopedic surgery in Japan: a medical claims database analysis.

Purpose The purpose of this paper is to determine the characteristics of healthcare facilities that produce the most efficient inpatient orthopedic surgery using a large-scale medical claims database in Japan. Design/methodology/approach Reimbursement claims data were obtained from April 1 through September 30, 2014. Input-oriented Banker-Charnes-Cooper model of data envelopment analysis (DEA) was employed. The decision-making unit was defined as a healthcare facility where orthopedic surgery was performed. Inputs were defined as the length of stay, the number of beds, and the total costs of expensive surgical devices. Output was defined as total surgical fees for each surgery. Efficiency scores of healthcare facilities were compared among different categories of healthcare facilities. Findings The efficiency scores of healthcare facilities with a diagnosis-procedure combination (DPC) reimbursement were significantly lower than those without DPC ( p=0.0000). All the efficiency scores of clinics with beds were 1. Their efficiency scores were significantly higher than those of university hospitals, public hospitals, and other hospitals ( p=0.0000). Originality/value This is the first research that applied DEA for orthopedic surgery in Japan. The healthcare facilities with DPC reimbursement were less efficient than those without DPC. The clinics with beds were the most efficient among all types of management bodies of healthcare facilities.

Predictors of surgeons' efficiency in the operating rooms.

The sustainability of the Japanese healthcare system is questionable because of a huge fiscal debt. One of the solutions is to improve the efficiency of healthcare. The purpose of this study is to determine what factors are predictive of surgeons' efficiency scores. The authors collected data from all the surgical procedures performed at Teikyo University Hospital from April 1 through September 30 in 2013-2015. Output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis was employed to calculate each surgeon's efficiency score. Seven independent variables that may predict their efficiency scores were selected: experience, medical school, surgical volume, gender, academic rank, surgical specialty, and the surgical fee schedule. Multiple regression analysis using random-effects Tobit model was used for our panel data. The data from total 8722 surgical cases were obtained in 18-month study period. The authors analyzed 134 surgeons. The only statistically significant coefficients were surgical specialty and surgical fee schedule (p = 0.000 and p = 0.016, respectively). Experience had some positive association with efficiency scores but did not reach statistical significance (p = 0.062). The other coefficients were not statistically significant. These results demonstrated that the surgical reimbursement system, not surgeons' personal characteristics, is a significant predictor of surgeons' efficiency.

Surgeons' efficiency change is a major determinant of their productivity change.

Purpose - The sustainability of the Japanese healthcare system is in question because the government has had a huge fiscal debt. Despite an enormous effort to cut the deficit, our healthcare expenditure is increasing every year because of the rapidly aging population. One of the solutions for this problem is to improve the productivity of healthcare. The purpose of this paper is to determine the factors that change surgeons' productivity in one year. Design/methodology/approach - The authors collected data of all surgical procedures performed at Teikyo University Hospital from April 1 through September 30 in 2014 and 2015, and computed the surgeons' Malmquist index (MI), efficiency change (EC) and technical change (TC) using non-radial and non-oriented Malmquist model under the constant returns-to-scale assumptions. The authors then divided the surgeons into two groups; one whose productivity progressed and the other whose productivity regressed. These two groups were compared to identify factors that may influence their MI. Findings - The only significant difference between the two groups was ECs (p < 0.0001). The other factors, such as TC, experience, surgical volume, emergency cases, surgical specialty, academic ranks, medical schools and gender, were not significantly different between the two groups. Originality/value - EC is a major determinant of surgeons' productivity change. The best way to improve surgeons' productivity may be to enhance their efficiency regardless of their surgical volume and personal backgrounds.

Resource utilization in surgery after the revision of surgical fee schedule in Japan.

PURPOSE: The purpose of this paper is to examine whether the current surgical reimbursement system in Japan reflects resource utilization after the revision of fee schedule in 2014. DESIGN/METHODOLOGY/APPROACH: The authors collected data from all the surgical procedures performed at Teikyo University Hospital from April 1 through September 30, 2014. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated surgeons' efficiency scores using data envelopment analysis. FINDINGS: The efficiency scores of each surgical specialty were significantly different (p=0.000). ORIGINALITY/VALUE: This result demonstrates that the Japanese surgical reimbursement scales still fail to reflect resource utilization despite the revision of surgical fee schedule.

Combined use of two membrane-potential-sensitive dyes for determination of the Galvani potential difference across a biomimetic oil/water interface.

The fluorescence behavior of anionic membrane-potential-sensitive dyes, bis-(1,3-dibutylbarbituric acid) trimethine oxonol (DiBAC4(3)) and bis-(1,3-diethylthiobarbituric acid)trimethine oxonol (DiSBAC2(3)), at a biomimetic 1,2-dichloroethane (DCE)/water (W) interface was studied by the mean of potential-modulated fluorescence (PMF) spectroscopy. The respective dyes gave a well-defined PMF signal due to the adsorption/desorption at the DCE/W interface. It was also found that the potentials where the two dyes gave the PMF signals were different by about 100 mV. We then attempted a combined use of the two dyes for determination of the Galvani potential difference across the DCE/W interface. When 40 µM DiBAC4(3) and 15 µM DiSBAC2(3) were initially added to the W phase, distinctly different spectra were obtained for different interfacial potentials. The ratio of the PMF signal intensities at 530 and 575 nm (the fluorescence maximum wavelengths for the respective dyes) showed a clear dependence on the interfacial potential. These results suggested the potential utility of the combined use of two dyes for the determination of membrane potentials in vivo.

Bronchial blocker lung collapse technique: nitrous oxide for facilitating lung collapse during one-lung ventilation with a bronchial blocker.

BACKGROUND: Effective lung collapse of the nonventilated lung can facilitate thoracic surgery. Previous studies showed that using a bronchial blocker could delay the time of lung collapse compared with using a double-lumen endotracheal tube. We hypothesized that the use of nitrous oxide (N2O) in the inspired gas mixture during 2-lung ventilation would lead to clinically relevant improvement of lung collapse during subsequent 1-lung ventilation with a bronchial blocker. METHODS: Fifty patients were randomized into 2 groups: N2O (n =26) or O2 (n = 24). The N2O group received a gas mixture of oxygen and N2O (FIO2 = 0.5), and the O2 group received 100% oxygen until the start of 1-lung ventilation. Lung isolation was achieved with an Arndt® wire-guided bronchial blocker (Cook® Critical Care, Bloomington, IN. After turning patients to the lateral decubitus position, the cuff of the bronchial blocker was inflated under fiberoptic bronchoscopy surveillance, and thereafter, the dependent lung was ventilated with 100% oxygen during 1-lung ventilation in both groups. Surgeons blinded to the randomization evaluated the degree of lung collapse by using a verbal rating scale (lung collapse scale, 0 = no collapse to 10 = complete collapse) at 5 minutes after opening the pleura. Also, as secondary outcomes, lung collapse at 1 and 10 minutes were evaluated. RESULTS: The score on the lung collapse scale in the N2O group was significantly higher compared with the O2 group at 5 minutes after opening the pleura (7 vs 5, P < 0.001, WMWodds = 7.3, 95% confidence interval (CI), 6.0 to 9.0). It was also higher in the N2O group at 10 minutes (10 vs 7, P < 0.001, WMWodds = 10.1, 95% CI, 1.9-13.3). The lung collapse scale between groups was not significant at 1 minute after opening the pleura (2 vs 2, P = 0.76, WMWodds = 1.1, 95% CI, 0.96-1.2). None of the patients developed hypoxia (SpO2 <92%) during 1-lung ventilation. CONCLUSIONS: Filling the lung with 50% N2O before 1-lung ventilation facilitated lung collapse 5 minutes after opening the chest compared with 100% oxygen when a bronchial blocker was used. The N2O/O2 mixture (FIO2 = 0.5) did not have a harmful effect on subsequent arterial oxygenation during 1-lung ventilation.

Difficulty in placement of a left-sided double-lumen tube due to aberrant tracheobronchial anatomy.

A rare case of a tracheal bronchus coexisting with a left-shifted carina and an acute angle of left main bronchus is presented. A 66 year old man with a history of colon cancer was scheduled for right thoracoscopic pericardial window due to recurrent pericardial effusion. After induction of anesthesia, the trachea was intubated using a 39-French, left-sided double lumen tube (DLT); the DLT was positioned with fiberoptic bronchoscopic guidance. Significantly high airway pressure was noticed as we initiated one-lung ventilation after the patient was positioned in the left lateral decubitus position. While repositioning the DLT, we found an aberrant tracheal bronchus. Although multiple attempts were made to adjust the DLT so as to achieve lung isolation, we could not place the DLT in the appropriate position due to abnormal and distorted anatomy. Lung isolation was unsuccessful; both lungs were carefully ventilated with small tidal volumes.

Potential-modulated fluorescence spectroscopy of zwitterionic and dicationic membrane-potential-sensitive dyes at the 1,2-dichloroethane/water interface.

The previously introduced technique of potential-modulated fluorescence (PMF) spectroscopy was used to study the potential-induced fluorescence change of some different dyes at the polarized 1,2-dichloroethane (DCE)/water (W) interface. A zwitterionic dye (POLARIC 488PPS) showed a PMF response similar to that for the previously studied dye (di-4-ANEPPS) with the same ionic state, and the PMF response was likewise explained by the potential-dependent reorientation of the dye at the DCE/W interface. Though a monocationic dye (POLARIC 488PM) showed no distinct PMF signal, a dicationic dye (di-2-ANEPEQ) showed two relatively weak but detectable PMF signals at lower and higher potential. It has thus been found that the ionic state of a potential-sensitive dye strongly influences the potential-induced reorientation of the dye at the interface and consequently its PMF response. These results support the reorientation/solvatochromic mechanism proposed for "slow" dyes but do not necessarily exclude the electrochromic mechanism proposed for "fast" dyes. PMF spectroscopy would provide useful information on the design of slow dyes for the measurement of the resting potential of cell membranes.

[Femoral and sciatic nerve blocks for open reduction and internal fixation of a femoral condylar fracture in a patient with post-polio syndrome].

The post polio symdrome (PPS) refers to the development of delayed neuromuscular symptoms among survivors, years after the initial presentation of acute poliomyelitis. The symptoms of PPS vary widely and include flaccid palsy, muscle weakness, scoliosis, osteoarthritis, gait disturbance, sleep apnea syndrome (SAS), dysphagia, chronic lung dysfunction, and others. We report the successful combination of peripheral nerve blocks, femoral and sciatic nerve blocks, for surgery on the lower extremity in a patient with PPS. A 51-year-old man with continuous positive airway pressure therapy for restrictive ventilatory impairment due to scoliosis and SAS as part of the PPS was scheduled for open reduction and internal fixation (OR-IF) for a right femoral condylar fracture. Respiratory function tests demonstrated a vital capacity (VC) 1.41l (41% predicted). Arterial blood gas analysis on room air was; pH 7.376, PaCO2 55.0 mmHg, and PaO2 77.9 mmHg. With the patient in the supine position, ultrasound-guided right femoral nerve block in the infra-inguinal region was performed using 1.5% mepivacaine 10 ml and 0.75% ropivacaine 5 ml, followed by sciatic nerve block in the popliteal fossa using 1.5% mepivacaine 8 ml and 0.75% ropivacaine 4 ml in the prone position. OR-IF of the fractured femoral condyle was then successfully performed with propofol under spontaneous ventilation. Postoperatively, there were no adverse events; respiratory function was adequate, and his pain was within manageable bounds. Femoral and sciatic nerve blocks are safe and effective anesthetic methods for lower extremity surgery in patients with restrictive ventilatory impairment and hypercapnia due to scoliosis and SAS as PPS.

Efficacy of amiodarone on refractory ventricular fibrillation resistant to lidocaine and cardioversion during weaning from cardiopulmonary bypass in aortic valve replacement for severe aortic stenosis with left ventricular hypertrophy.

Intravenous injection of amiodarone, a class III anti-arrhythmic is widely used for persistent refractory arrhythmias. We present a case report suggesting the efficacy of amiodarone in refractory ventricular fibrillation (Vf) during weaning from cardiopulmonary bypass (CPB). A 66-year-old woman with hypertension had a medical examination as a result of an episode of palpitations and syncope. Echocardiography and an invasive hemodynamic study revealed severe aortic stenosis (AS) with left ventricular (LV) hypertrophy because of calcified degeneration in a congenital bicuspid aortic valve (AV). Aortic valve replacement (AVR) was scheduled under general anesthesia and CPB. Intraoperative diagnosis was AS with calcified AV, LV hypertrophy, and aneurysm of ascending aorta (Ao). AVR with a biological valve, artificial vessel replacement of ascending Ao, and excision of the outflow myocardial septum were performed under CPB with intermittent antegrade blood cardioplegia at a body temperature (BT) of 24°C. The patient suffered from Vf at a BT of 35.3°C. Vf was not responsive to lidocaine 100 mg and 10 direct current (DC) shocks. After continuous intravenous infusion of amiodarone 225 mg/h for 10 min and a single intravenous injection of amiodarone 150 mg followed by a single DC shock, she returned to normal sinus rhythm. Sinus rhythm was maintained by continuous intravenous infusion of amiodarone 60 mg/h. Total CPB time was 5 h 43 min. Aortic cross-clamping time was 3 h 50 min. Administration of amiodarone is effective for refractory Vf resistant to lidocaine and cardioversion during weaning from CPB in cardiac surgery for heart diseases with LV hypertrophy.

[Clinical anesthetic training at St. Vincent's Hospital, Melbourne Australia].

Anesthesia training system and operation theater management at St Vincent's hospital Melbourne in Australia, are very well organized, including tutorials, invitation lecture, transesophageal echocardiography conference as well as working hour, operation room, organization of comedical staffs such as nursing and technician staff, and day surgery and anesthesia. Good anesthesia training system and efficient operation theater management are necessary to establish better quality of medical services.

[Intermittent bradycardia-dependent bundle branch block during sevoflurane and remifentanil anesthesia].

Cardiac arrhythmia and bradycardia occasionally occur from the effect of inhaled anesthetic agent and opioid on cardiac conduction. We experienced a case of intermittent bradycardia-dependent bundle branch block (IBDBBB) during sevoflurane and remifentanil anesthesia. A 17-year-old woman suffering from recurrent left ottitis media was scheduled for tympanoplasty under general anesthesia. Her preoperative electrocardiogram (ECG) revealed normal sinus rhythm at heart rate (HR) of 48 beats x min(-1). Her tracheal was intubated following anesthesia induction with propofol and vecuronium, and anesthesia was maintained using inhalation of 40% oxygen with air and 1.5-2.0% sevoflurane, and continuous venous infusion of remifentanil at a rate of 0.15 microg x kg(-1) min(-1). Two hours 20 minutes after starting operation, the P-P interval was constant but the waveforms of low and broad QRS complexes appeared intermittently on the ECG monitor. The blood pressure remained stable at 95/55 mmHg and the HR decreased to 46 beats x min(-1). The waveform of pulse oxymetric oxygen saturation (Spo2) did not change. We diagnosed the ECG pattern as IBDBBB. After intravenous injection of atropine 0.5 mg, the waveforms of QRS complexes recovered to normal sinus rhythm at HR 90 beats x min(-1). Sevoflurane and remifentanil in adolescence could induce ventricular conduction disturbance and result in IBDBBB. Atropine could be effective for IBDBBB induced by sevoflurane and remifentanil.

[Anaesthesia training program in Australia].

We reviewed anaesthesia training program in Australia. Anaesthetists in Australia and New Zealand need to obtain the Diploma of Fellowship of the Australian and New Zealand College of Anaesthetists (FANZCA) to be recognised as specialists. The training sequence approved by ANZCA encompasses an initial two-year Prevocational Medical Education, Training (PMET) period, and the five-year period of ANZCA Approved Training, which included two-year Basic Training and three-year Advanced Training. On completion of all Training Program requirements the Trainee is awarded the Diploma of Fellowship and is entitled to use the qualification of FANZCA. The assessment of trainees in anaesthesia is principally by examination and the staff of the hospitals in which trainees work. There are a number of specific goals to be achieved during training. ANZCA accredits Hospital Departments of Anaesthesia and other training institutions across Australia, New Zealand, and South-East Asia, to provide approved training in anaesthesia for ANZCA trainees. Accreditation requires an onsite review by the College in order to assess a hospital's ability to provide training and supervision of the required standard, and its degree of compliance with ANZCA Professional Documents.