Implementation of a medical coding curriculum for surgery residents.

BACKGROUND: Medical coding knowledge is important for practice. We hypothesized that general surgery residents lack confidence in medical coding (MC) and that implementation of focused didactics would increase resident confidence and knowledge. METHODS: A MC curriculum was delivered to general surgery residents covering domains of the global procedural period (GPP), evaluation and management (E/M) coding, and hospital payment and quality metrics (HPQM). A 21-question survey was developed to assess resident comfort coding knowledge. Efficacy of the MC curriculum was measured by anonymous paper pre-test and post-test surveys. RESULTS: Pre-test (n = 50) findings revealed that residents were uncomfortable with MC. Following three MC lectures, the post-test (n = 24) demonstrated significant increases in resident comfort with MC (p < 0.001) and resident performance on domains of GPP (p = 0.014), E/M (p < 0.001), and HQPM (p = 0.025). CONCLUSIONS: Residents feel uncomfortable with MC without formal education. This study supports a focused curriculum to prepare residents for practice.

Process Improvement Initiative for the Perioperative Management of Patients With a Cardiovascular Implantable Electronic Device.

BACKGROUND: Economic, personnel, and procedural challenges often complicate and interfere with efficient and safe perioperative care of patients with cardiovascular implantable electronic devices (CIEDs). In the context of a process improvement initiative, we created and implemented a comprehensive anesthesiologist-run perioperative CIED service to respond to all routine requests for perioperative CIED consultations at a large academic medical center. This study was designed to determine whether this new care model was associated with improved operating room efficiency, reduced institutional cost, and adequate patient safety. METHODS: We included patients with a CIED and a concurrent cohort of patients with the same eligibility criteria but without a CIED who underwent first-case-of-the-day surgery during the periods between February 1, 2008, and August 17, 2010 (preintervention) and between March 4, 2012, and August 1, 2014 (postintervention). The primary end point was delay in first-case-of-the day start time. We used multiple linear regression to compare delays in start times during the preintervention and postintervention periods and to adjust for potential confounders. A patient safety database was queried for CIED-related complications. Cost analysis was based on labor minutes saved and was calculated using nationally published administrative estimates. RESULTS: A total of 18,148 first-case surgical procedures were performed in 15,100 patients (preintervention period-7293 patients and postintervention period-7807 patients). Of those, 151 (2.1%) patients had a CIED in the preintervention period, and 146 (1.9%) had a CIED in the postintervention period. After adjustment for imbalances in baseline characteristics (age, American Society of Anesthesiologists physical status, and surgical specialty), the difference in mean first-case start delay between the postintervention and preintervention periods in the cohort of patients with a CIED was -16.7 minutes (95% confidence interval [CI], -26.1 to -7.2). The difference in mean delay between the postintervention and preintervention periods in the cohort without a CIED was -4.7 minutes (95% CI, -5.4 to -3.9). There were 3 CIED-related adverse events during the preintervention period and none during the postintervention period. Based on reduction in first-case start delay, the intervention was associated with cost savings (estimated institutional savings $14,102 annually, or $94.06 per CIED patient), with a return on investment ratio of 2.18 over the course of the postintervention period. CONCLUSIONS: Based on our experience, specially trained anesthesiologists can provide efficient and safe perioperative care for patients with CIEDs. Other centers may consider implementing a similar strategy as our specialty adopts the perioperative surgical home model.

United States anesthesiologists over 50: retirement decision making and workforce implications.

BACKGROUND: Anesthesiology is among the medical specialties expected to have physician shortage. With little known about older anesthesiologists' work effort and retirement decision making, the American Society of Anesthesiologists participated in a 2006 national survey of physicians aged 50-79 yr. METHODS: Samples of anesthesiologists and other specialists completed a survey of work activities, professional satisfaction, self-defined health and financial status, retirement plans and perspectives, and demographics. A complex survey design enabled adjustments for sampling and response-rate biases so that respondents' characteristics resembled those in the American Medical Association Physician Masterfile. Retirement decision making was modeled with multivariable ordinal logistic regression. Life-table analysis provided a forecast of likely clinical workforce trends over an ensuing 30 yr. RESULTS: Anesthesiologists (N = 3,222; response rate = 37%) reported a mean work week of 49.4 h and a mean retirement age of 62.7 yr, both values similar to those of other older physicians. Work week decreased with age, and part-time work increased. Women worked a shorter work week (mean, 47.9 vs. 49.7 h, P = 0.024), partly due to greater part-time work (20.2 vs. 13.1%, P value less than 0.001). Relative importance of factors reported among those leaving patient care differed by age cohort, subspecialty, and work status. Poor health was cited by 64% of anesthesiologists retiring in their 50s as compared with 43% of those retiring later (P = 0.039). CONCLUSIONS: This survey lends support for greater attention to potentially modifiable factors, such as workplace wellness and professional satisfaction, to prevent premature retirement. The growing trend in part-time work deserves further study.

Moderate sedation for chest physicians.

Specialists in pulmonary and critical care medicine frequently perform invasive procedures that may require sedation or anesthesia for patient comfort. The number and complexities of interventional pulmonary procedures that can be performed in the bronchoscopy suite or critical care unit continues to expand. Procedures that formerly were done only in the operating room on inpatients are now done routinely in the office, ambulatory surgery center, or hospital outpatient department. No matter the setting, the key to successfully performing these procedures is a safe, pain-free environment for the patient. Anesthesia care and procedural sedation services share the goals of providing the patient comfort during a painful procedure and the operating physician an acceptable working environment. Historically, anesthesiologists have applied the expertise gained in managing anesthesia for major surgeries to sedation care for minor procedures. While the supply of anesthesiologists and anesthetists has shown only a modest increase, the growth in minimally invasive procedures has been explosive in recent years. To meet demand, a service, originally known as conscious sedation and now referred to as moderate sedation, has become common, in which the operating physician supervises a specially trained sedation nurse. This article will provide a clinical definition of moderate sedation and then focus on ways to properly code and bill for pulmonary procedures performed with moderate sedation.