Effects of anesthetic technique on myocardial wall motion abnormalities during abdominal aortic surgery.

OBJECTIVE: To assess the impact of regional supplemented general anesthesia (RSGEN) on regional myocardial function during abdominal aortic surgery (AAS). DESIGN: Prospective randomized study. SETTING: Single academic medical center. PARTICIPANTS: Seventy-three patients scheduled for infrarenal aortic aneursymectomy. INTERVENTIONS: Patients received standardized intraoperative anesthetic management consisting of either general anesthesia (GA; n = 37) or general anesthesia supplemented by epidural anesthesia (RSGEN; n = 36). MEASUREMENTS AND MAIN RESULTS: Hemodynamic measurements and transesophageal echocardiograms (TEE) were obtained at eight intraoperative times. The electrocardiogram (ECG) was continuously recorded using Holter monitoring. Of the 56 patients with interpretable TEE recordings, 8 of 30 (27%) GA patients and 7 of 26 (27%) RSGEN patients developed new segmental wall motion abnormalities (SWMAs). There was no treatment effect on either the incidence (p = 0.23) or the intensity (p = 0.34) of SWMAs. Cross-clamping of the aorta was associated with the onset of new SWMAs (odds ratio, 8.2; 95% CI, 1.1 to 64; p = 0.04). Among the 63 patients with interpretable Holter recordings, 9 of 34 (26%) GA patients and 9 of 29 (31%) RSGEN patients exhibited intraoperative ischemia. There was no treatment effect on the incidence (p = 0.22) or intensity (p = 0.67) of ECG ischemia. CONCLUSION: Despite providing modest hemodynamic depression, RSGEN did not reduce the incidence or intensity of either regional myocardial dysfunction or ECG ischemia. New SWMAs were temporally associated with cross-clamping of the aorta and tended to resolve with unclamping.

Medicare coverage, Medicare costs, and medical technology.

One possible approach to containing Medicare costs involves explicit changes in Medicare's coverage policy with respect to medical technology. This paper first describes the development and diffusion of medical technology in general and then describes how technologies are identified, assessed, and approved for payment by Medicare. Currently, cost is neither a criterion nor an explicit issue in coverage decisions, although coverage policy is an integral part of payment policy. A combination of policies to reduce the rates of adoption and use of certain technologies is needed--including cost considerations in technology assessments for coverage decisions, limiting diffusion of technology to certain providers and sites, limiting utilization to certain indications, and tightening administrative processes. Finally, the interaction between coverage policy and DRG payment needs to be explored more thoroughly.

Policy implications of the diffusion and control of medical technology.

Medical technology has become a controversial national policy issue, largely because of rapidly rising national health expenditures and their relation to medical technology. These costs are increasingly viewed in relation to benefits or effectiveness. Attempts to control medical technology, to consider benefits in relation to costs, have largely been regulatory, and have failed to ameliorate cost rises. This failure has stimulated consideration of the reimbursement system as a controlling device. The Medicare program already has developed a rather formal process for making reimbursement decisions based on technology assessments. However, fundamental reform of the reimbursement system seems necessary to counter perverse incentives built into payment. Recent proposals to shift to prospective payment is an example of such a change. However, the basically private nature of the health care system and the limited leverage of the Medicare program limits the power of the federal government to make change.