Gender Differences in Compensation in Anesthesiology in the United States: Results of a National Survey of Anesthesiologists.

BACKGROUND: A gender-based compensation gap among physicians is well documented. Even after adjusting for age, experience, work hours, productivity, and academic rank, the gender gap remained and widened over the course of a physician's career. This study aimed to examine if a significant gender pay gap still existed for anesthesiologists in the United States. METHODS: In 2018, we surveyed 28,812 physician members of the American Society of Anesthesiologists to assess the association of compensation with gender and to identify possible causes of wage disparities. Gender was the primary variable examined in the model, and compensation by gender was the primary outcome. Compensation was defined as the amount reported as direct compensation on a W-2, 1099, or K-1, plus all voluntary salary reductions (eg, 401[k], health insurance). The survey directed respondents to include salary, bonuses, incentive payments, research stipends, honoraria, and distribution of profits to employees. Respondents had the option of providing a point estimate of their compensation or selecting a range in $50,000 increments. Potential confounding variables that could affect compensation were identified based on a scoping literature review and the consensus expertise of the authors. We fitted a generalized ordinal logistic regression with 7 ranges of compensation. For the sensitivity analyses, we used linear regressions of log-transformed compensation based on respondent point estimates and imputed values. RESULTS: The final analytic sample consisted of 2081 observations (response rate, 7.2%). This sample represented a higher percentage of women and younger physicians compared to the demographic makeup of anesthesiologists in the United States. The adjusted odds ratio associated with gender equal to woman was an estimated 0.44 (95% confidence interval, 0.37-0.53), indicating that for a given compensation range, women had a 56% lower odds than men of being in a higher compensation range. Sensitivity analyses found the relative percentage difference in compensation for women compared to men ranged from -8.3 to -8.9. In the sensitivity analysis based on the subset of respondents (n = 1036) who provided a point estimate of compensation, the relative percentage difference (-8.3%; 95% confidence interval, -4.7 to -11.7) reflected a $32,617 lower compensation for women than men, holding other covariates at their means. CONCLUSIONS: Compensation for anesthesiologists showed a significant pay gap that was associated with gender even after adjusting for potential confounding factors, including age, hours worked, geographic practice region, practice type, position, and job selection criteria.

Time-Driven Activity-Based Costing to Model Cost Utility of Enhanced Recovery after Surgery Pathways in Microvascular Breast Reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are being used increasingly in microvascular breast reconstruction. However, it is unclear as to what extent the benefits outweigh the costs. We hypothesized that an ERAS pathway for microvascular breast reconstruction would be cost-effective relative to the standard of care. STUDY DESIGN: A decision-analytic model was made incorporating clinically relevant health states after microvascular breast reconstruction with ERAS vs standard of care. Probabilities and utility scores were abstracted from published sources, and a third-party payer perspective was adopted. Time-driven activity-based costing was used to map and estimate costs attributed to ERAS. Sensitivity analyses were performed to examine the robustness of the results. RESULTS: The results of 5 studies, totaling 986 patients, were pooled to generate health state probabilities. ERAS was found to be dominant, being both less expensive and more effective than standard of care. On sensitivity analysis, ERAS becomes cost-ineffective (incremental cost-utility ratio > $50,000/quality-adjusted life year) at an amount > $19,336.75. Length of stay would have to be reduced from 5.96 days to 3.36 days for standard of care to become cost-effective. Monte-Carlo analysis demonstrated ERAS to be the more cost-effective option across a range of willingness-to-pay values. CONCLUSIONS: Despite the increased medication and personnel costs attributed to ERAS, it is less costly overall and associated with superior outcomes compared with standard of care. These findings lend additional support to the value of ERAS implementation in microvascular breast reconstruction. Time-driven activity-based costing provides granular estimates and are useful in quality-improvement initiatives.

Distinguished Service Awards in Anesthesiology Specialty Societies: Analysis of Gender Differences.

The authors queried 9 anesthesiology societies to examine Distinguished Service Award recipients over time by gender. Of the 211 total Distinguished Service Awards given by all 9 societies, women received 25 (11.8%). Comparing pre-2008 data to the most recent decade, there was no statistical difference in the number of women Distinguished Service Award recipients with 8.9% and 17.1% women Distinguished Service Award recipients, respectively (P = .076). Societies varied greatly in their women awardees, from 40% to 0% in the last decade. Low levels of awardees stand in contrast to the increasing number of women in the academic pipeline. The authors recommend that societies collect gender membership data and study their award processes from nomination to selection.

Continuous Quality Improvement Measured With Time-Driven Activity-Based Costing in an Outpatient Cancer Surgery Center.

PURPOSE: As health care costs rise, continuous quality improvement and increased efficiency are crucial to reduce costs while providing high-quality care. Time-driven activity-based costing (TDABC) can help identify inefficiencies in processes of cancer care delivery. This study measured the process performance of Port-a-Cath placement in an outpatient cancer surgery center by using TDABC to evaluate patient care process. METHODS: Data were collected from the Anesthesia Information Management System database and OneConnect electronic health record (EHR) for Port-a-Cath cases performed throughout four phases: preintervention (phase I), postintervention, stabilization, and pre-new EHR (phases II and III), and post-new EHR (phase IV). TDABC methods were used to map and calculate process times and costs. RESULTS: Comparing all phases, as measured with TDABC methodology, a decrease in post-anesthesia care unit (PACU) length of stay (LOS) was identified (83 minutes v 67 minutes; P < .05). The decrease in PACU LOS correlated with increased efficiency and decreasing process costs and PACU nurse resource use by fast tracking patients for Port-a-Cath placement. Port-a-Cath placement success and the functionality of ports remained the same as patient experience improved. CONCLUSION: TDABC can be used to evaluate processes of care delivery to patients with cancer and to quantify changes made to those processes. Patients' PACU LOS decreased on the basis of the 2013 Port-a-Cath process improvement initiative and after implementation of a new EHR, over the course of 3 years, as quantified by TDABC. TDABC use can lead to improved efficiencies in patient care delivery that are quantifiable and measurable.

Perioperative factors associated with persistent opioid use after extensive abdominal surgery in children and adolescents: A retrospective cohort study.

BACKGROUND: In adults, preoperative opioid use and higher perioperative opioid consumption have been associated with higher odds of persistent opioid use after surgery. There are limited data on the prevalence and factors associated with persistent opioid use after major oncologic surgery in children. AIMS: In this study, we sought to determine the prevalence and factors associated with the development of persistent opioid use in a group of children and adolescents who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. METHODS: A retrospective study of patients ≤19 years of age was performed. Univariable logistic regression was used to assess factors associated with a postdischarge persistent opioid use of up to 6 months. RESULTS: Eighty-six children were identified. The median age was 12 years, and 43% were female. The proportion of patients with persistent opioid use over the immediate 3, 6, 12 and 24 postdischarge months was 54/77 (70%), 18/51 (35%), 13/45 (29%), and 3/24 (13%), respectively. The daily average in-patient pain scores were higher in the group of children who subsequently developed persistent opioid use of up to 6 months (estimated difference 0.5, 95% confidence interval [CI]: 0.3, 0.8, P < .01). Furthermore, higher postoperative opioid consumption was associated with greater odds of a subsequent persistent opioid use of up to 6 months (odds ratio 1.03, 95% CI: 1.00, 1.07, P = .05). CONCLUSION: In this retrospective study of children and adolescents who had undergone a major oncologic surgery, higher in-patient pain scores and higher postoperative opioid consumption were associated with a persistent opioid use of up to 6 months.

Assessing the survival impact of perioperative opioid consumption in children and adolescents undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Several studies in adult patients have suggested an unfavorable association between opioid consumption and cancer progression. AIMS: This study investigated the impact of opioid consumption on the survival of children and adolescents undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. METHODS: A retrospective study of patients <19 years who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was performed. Univariate and multivariate Cox proportional hazard analyses were used to identify factors associated with recurrence-free survival and overall survival. RESULTS: Seventy-five patients were identified. Median age was 11.6 years (range, 1.8-18.9), and 43% was female. Median perioperative opioid consumption was 18.9 morphine dose equivalents per kilogram (range, 0.6-339.6). There was no statistically significant association between opioid consumption and recurrence-free survival [hazard ratio, 1.00; 95% confidence interval, (0.99-1.02), P = 0.55] or overall survival [hazard ratio 1.01; 95% confidence interval (0.99-1.03), P = 0.22]. Independent prognostic factors associated with poor survival included incomplete cytoreduction and extra-abdominal disease. CONCLUSION: In this retrospective study of children and adolescents who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, there was no statistically significant association between opioid consumption and recurrence-free survival or overall survival.

Beat to Beat: A Measured Look at the History of Pulse Oximetry.

It can be argued that pulse oximetry is the most important technological advancement ever made in monitoring the well-being and safety of patients undergoing anesthesia. Before its development, the physical appearance of the patient and blood gas analysis were the only methods of assessing hypoxemia in patients. The disadvantages of blood gas analysis are that it is not without pain, complications, and most importantly does not provide continuous, real-time data. Although it has become de rigueur to use pulse oximetry for every anesthetic, the road leading to pulse oximetry began long ago.

Unanticipated Compression of the Trachea in a 5-Month-Old Undergoing an MRI for Evaluation of Neurofibromatosis.

Neurofibromatosis type 1 is an autosomal-dominant disorder with the tendency toward the formation of tumors. Plexiform neurofibromas are the most common type of tumors seen in neurofibromatosis type 1. Approximately 50% occur in the head and neck region with a 5% incidence of airway involvement. We describe the case of a 5 month old with a plexiform neurofibroma of the neck who developed complete airway obstruction on induction of anesthesia. Magnetic resonance imaging revealed a skull base neurofibroma extending to the hypopharynx and resulting in deviation of the airway. Because of the possibility of airway involvement, a careful preanesthetic evaluation as well as a slow induction with the maintenance of spontaneous ventilation should be considered in patients presenting with facial neurofibromas.

Effect of adjunctive dexmedetomidine on postoperative intravenous opioid administration in patients undergoing thyroidectomy in an ambulatory setting.

STUDY OBJECTIVE: Two of the most feared complications for patients undergoing thyroid surgery are pain and postoperative nausea and vomiting. Thyroidectomy is considered high risk for postoperative nausea and vomiting, and recent studies have looked at adjuncts to treat pain, limit narcotic use, "fast-track" the surgical process, and enhance recovery without compromising the patient's safety. One such perioperative medication of interest is dexmedetomidine (Dex), a centrally acting α-2 agonist that has been associated with reducing pain and postoperative opioid consumption. Our aim was to examine the effectiveness of Dex as an adjunctive intraoperative medication to reduce postoperative narcotic requirements in patients undergoing outpatient thyroid surgery. DESIGN, SETTING, PATIENTS AND INTERVENTION: After obtaining approval from the Institutional Review Board at The University of Texas MD Anderson Cancer Center, we searched the electronic medical record for the period October 2013 to March 2015 to identify patients who had undergone thyroid surgery in the ambulatory setting under general anesthesia. MEASUREMENTS AND MAIN RESULTS: A total of 71 patients underwent thyroidectomy or thyroid lobectomy in the outpatient setting. Of the patients receiving adjunctive Dex, a lower proportion (50%, n=9) received postoperative intravenous opioids when compared with control patients (79%, n=42) (P=.017). One patient (5%) in the Dex group required rescue postoperative antiemetics as compared to 11 (21%) patients in the control group (P=.273). CONCLUSIONS: Our data suggest that intraoperative use of Dex reduced narcotic administration in the postoperative period among study population patients undergoing thyroidectomy.

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire.

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m(2) (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

A multi-institutional pilot survey of anesthesia practices during proton radiation therapy.

BACKGROUND AND PURPOSE: Physicians responsible for anesthesia and/or sedation (A/S) at emerging proton radiation therapy centers (PTCs) seek information about practices at established centers. We conducted a survey of A/S practices at established PTCs to provide this information for physicians at new PTCs. METHODS AND MATERIALS: A web-based survey was sent to physicians responsible for A/S at 37 established PTCs. Questions were based on practice patterns and the preferred method of A/S delivery during proton-radiation therapy. One representative per institution was surveyed. RESULTS: A response rate of 38%, with a combined case load of more than 15,000 anesthetics per year was obtained. Children younger than 4 years old often (72%) required A/S. The most favored A/S techniques involved total intravenous anesthesia with propofol and an unprotected airway (57%) or general anesthesia with sevoflurane and a laryngeal mask airway (36%). It was notable that 21% of facilities did not have dedicated recovery rooms. Also, anesthesia gas evacuation outlets were absent at 43% of treatment rooms. CONCLUSIONS: A/S is commonly delivered to patients undergoing proton radiation therapy, most often with total intravenous anesthesia. To avert potential obstacles to the safe delivery of care, anesthesiologists at emerging centers are encouraged to participate throughout the design and planning phases of new PTCs.

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.

Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined (p < 0.0001) and at the off-site locations (p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.

Non-invasive anesthesia for children undergoing proton radiation therapy.

BACKGROUND: Proton therapy is a newer modality of radiotherapy during which anesthesiologists face specific challenges related to the setup and duration of treatment sessions. PURPOSE: Describe our anesthesia practice for children treated in a standalone proton therapy center, and report on complications encountered during anesthesia. MATERIALS AND METHODS: A retrospective review of anesthetic records for patients ⩽18years of age treated with proton therapy at our institution between January 2006 and April 2013 was performed. RESULTS: A total of 9328 anesthetics were administered to 340 children with a median age of 3.6years (range, 0.4-14.2). The median daily anesthesia time was 47min (range, 15-79). The average time between start of anesthesia to the start of radiotherapy was 7.2min (range, 1-83min). All patients received Total Intravenous Anesthesia (TIVA) with spontaneous ventilation, with 96.7% receiving supplemental oxygen by non-invasive methods. None required daily endotracheal intubation. Two episodes of bradycardia, and one episode each of; seizure, laryngospasm and bronchospasm were identified for a cumulative incidence of 0.05%. CONCLUSIONS: In this large series of children undergoing proton therapy at a freestanding center, TIVA without daily endotracheal intubation provided a safe, efficient, and less invasive option of anesthetic care.

Anaesthetic techniques for unique cancer surgery procedures.

Recent advances in cancer therapy have seen increased combinations of different treatment modalities as well as novel approaches that affect anaesthetic care. Increasingly, surgery is being combined with chemotherapy and radiation therapy. Moreover, minimally invasive procedures are gaining popularity and more targeted therapies are being used. These events have created a demand for new anaesthetic techniques from anaesthesiologists in order to provide safe patient care. This article will discuss anaesthetic considerations for proton therapy, hyperthermic intracavitary chemotherapy, limb perfusion, radiosurgery, robotic surgery and intra-operative radiation therapy and high-dose brachytherapy.