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Four key considerations can affect the size of an anesthesia subsidy: Staffing models. The fair market value compensation for clinicians. The type of provider the organization needs. The payment approach for management of anesthesia services.

Background and Objectives: Preanesthesia evaluation (PAE) is fundamental in the preparation of a surgical patient. Among its advantages is the reduction of preoperative care costs. Although prior studies had observed this benefit, it is not clear whether it can be taken into consideration among us. The objective of the present study was to compare the costs of preoperative care performed by the surgeon with estimated costs based on PAE. In parallel, we compared the American Society of Anesthesiologists (ASA) physical status classification determined by the anesthesiologist with that estimated by other specialists., Methods: Two hundred patients scheduled for elective surgery or diagnostic procedures whose preoperative care was made by the surgeon underwent PAE after hospital admission. The anesthesiologist determined which ancillary exams or referrals necessary for each patient. The number and cost of ancillary exams or referrals requested by the anesthesiologist were compared with those of the preoperative preparation. The ASA classification according to the anesthesiologist was also compared to that of the physician in charge of the consultation., Results: Out of 1,075 ancillary exams performed, 55.8% were not indicated, which corresponded to 50.8% of the total cost of exams. The anesthesiologist considered that 37 patients (18.5%) did not require exams. The cost of surgeon-oriented preoperative care was higher than that based on the preanesthesia evaluation and this difference in costs was statistically significant (p < 0.01). In 9.3% of the patients discordance in ASA classification according to the specialist was observed., Conclusions: Preoperative care based on judicious preanesthesia evaluation can result in significant reduction in costs when compared to that oriented by the surgeon. Good concordance in ASA classification was observed., (Copyright © 2011 Elsevier Editora Ltda. All rights reserved.)

Purpose of Review: To review the current state of anesthesiology for operative and invasive procedures, with an eye toward possible future states., Recent Findings: Anesthesiology is at once a mature specialty and in a crisis--requiring breakthrough to move forward. The cost of care now approaches reimbursement, and outcomes as commonly measured approach perfection. Thus, the cost of further improvements seems ready to topple the field, just as the specialty is realizing that seemingly innocuous anesthetic choices have long-term consequences, and better practice is required., Summary: Anesthesiologists must create more headroom between costs and revenues in order to sustain the academic vigor and creativity required to create better clinical practice. We outline three areas in which technological and organizational innovation in anesthesiology can improve competitiveness and become a driving force in collaborative efforts to develop the operating rooms and perioperative systems of the future: increasing the profitability of operating rooms; increasing the efficiency of anesthesia; and technological and organizational innovation to foster improved patient flow, communication, coordination, and organizational learning.

Introduction: In anaesthesiology, economic aspects have been insufficiently studied., Objective: The aim of this paper was the assessment of rational choice of the anaesthesiological services based on the analysis of the scope, distribution, trend and cost., Methods: The costs of anaesthesiological services were counted based on "unit" prices from the Republic Health Insurance Fund. Data were analysed by methods of descriptive statistics and statistical significance was tested by Student's t-test and chi2-test., Results: The number of general anaesthesia was higher and average time of general anaesthesia was shorter, without statistical significance (t-test, p = 0.436) during 2006 compared to the previous year. Local anaesthesia was significantly higher (chi2-test, p = 0.001) in relation to planned operation in emergency surgery. The analysis of total anaesthesiological procedures revealed that a number of procedures significantly increased in ENT and MFH surgery, and ophthalmology, while some reduction was observed in general surgery, orthopaedics and trauma surgery and cardiovascular surgery (chi2-test, p = 0.000). The number of analgesia was higher than other procedures (chi2-test, p = 0.000). The structure of the cost was 24% in neurosurgery, 16% in digestive (general) surgery,14% in gynaecology and obstetrics, 13% in cardiovascular surgery and 9% in emergency room. Anaesthesiological services costs were the highest in neurosurgery, due to the length anaesthesia, and digestive surgery due to the total number of general anaesthesia performed., Conclusion: It is important to implement pharmacoeconomic studies in all departments, and to separate the anaesthesia services for emergency and planned operations. Disproportions between the number of anaesthesia, surgery interventions and the number of patients in surgical departments gives reason to design relation database.

Purpose: To determine the effect of sedative and anesthetic administration on the duration and costs of pediatric magnetic resonance (MR) imaging., Materials and Methods: This prospective study was approved by the institutional research ethics board; informed consent and/or assent was obtained from all participants or their parents. A patient flow study was conducted in a pediatric MR imaging clinic in which research assistants tracked participants' progress through the clinic. Demographic, visit process, and medication information was collected for 237 participants, categorized as awake, sedated, or anesthetized. The data were analyzed to (a) determine total visit duration differences, (b) investigate variations in visit stage durations according to patient type, and (c) estimate visit costs on the basis of human resource and medication use. Linear regression, the Shapiro-Wilk test, the two-tailed t test, and the nonparametric Mann-Whitney test were used., Results: Complete data sets were obtained for 148 awake, 28 sedated, and 27 anesthetized participants. Data revealed 12 stage sequences among patient visits; dominant sequences differed according to patient category. An awake patient's average visit duration (2 hours 21 minutes) differed significantly from that of sedated (3 hours 38 minutes, P < .001) and anesthetized (4 hours 7 minutes, P < .001) patients; sedated and anesthetized visit durations did not differ significantly (P < .073), although this finding may be attributable to the small sample sizes. Variation in stage durations was also evident within and among patient types. Visit costs for sedated and anesthetized patients were 3.24 and 9.56 times higher, respectively, than those for awake patients. Costs for anesthetized patients were 2.95 times higher than those for sedated patients., Conclusion: Visit durations were significantly longer for anesthetized and sedated patients. Anesthetized patients incurred the highest costs, followed by sedated patients.

Fast-tracking in cardiac surgery refers to the concept of early extubation, mobilization and hospital discharge in an effort to reduce costs and perioperative morbidity. With careful patient selection, fast-tracking can be performed in many patients undergoing surgery for congenital heart disease (CHD). In order to accomplish this safely, a multidisciplinary coordinated approach is necessary. This manuscript reviews currently used anesthetic techniques, patient selection, and available information about the safety and patient outcome associated with this approach.

The advantages of ambulatory surgery and anaesthesia are widely recognised. Apart from their interest in terms of reducing hospital costs, they are overwhelmingly preferred by patients. Of all patients, it is children who can benefit the most.

Study Objective: To characterize the accuracy of clinician knowledge of anesthesia drug and equipment costs at one institution., Design: Anonymous survey instrument., Setting: Large academic medical center., Measurements: 130 questionnaires were sent to departmental practitioners, including residents, CRNAs, and attendings. An updated list of acquisition costs for commonly used drugs and equipment is posted on our departmental website and is sent to all clinical staff by electronic mail annually. For each item, the respondent was given a choice of price ranges and indicated the range in which they believed the actual cost of the item to be. Accuracy was calculated as the difference between the identifier of the correct and chosen ranges. The mean and variance of these differences were then calculated for each item within each practitioner group and tested to identify statistically significant differences among practitioner groups., Main Results: A total of 103 (79%) completed questionnaires were received. Many practitioners overestimated or underestimated the actual costs of most of the items. There was no significant difference between the groups for the mean accuracy across the entire set of items. For variance in price estimation, there was a statistically significant greater variance only for CA1 residents compared with attendings, CRNAs, and CA3 residents., Conclusions: Many experienced practitioners in an academic setting lack accurate knowledge of the acquisition costs of common drugs and supplies.

Background & Aims: Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation., Methods: We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death., Results: A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million., Conclusions: EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Objective: To compare efficacy, required resources, and perioperative complications between laser lithotripsy and cystotomy for urolith (ie, urocystoliths and urethroliths) removal in dogs., Design: Retrospective case-control study., Animals: 66 dogs with urolithiasis treated by laser lithotripsy (case dogs) and 66 dogs with urolithiasis treated by cystotomy (control dogs)., Procedures: Medical records were reviewed. Complete urolith removal rate, resources (ie, duration of hospitalization, procedure time, anesthesia time, procedure cost, and anesthesia cost), and complications (ie, hypotension, hypothermia, incomplete urolith removal, and requirement of an ancillary procedure) were compared between cystotomy group dogs and lithotripsy group dogs., Results: Duration of hospitalization was significantly shorter for lithotripsy group dogs, compared with cystotomy group dogs. Procedure time was significantly shorter for cystotomy group dogs, compared with lithotripsy group dogs. Cost of anesthesia was significantly less for cystotomy group dogs, compared with lithotripsy group dogs. No significant differences were found between cystotomy group dogs and lithotripsy group dogs with regard to urolith removal rate, procedure cost, anesthesia time, or any of the evaluated complications., Conclusions and Clinical Relevance: Laser lithotripsy is a minimally invasive procedure that has been shown to be safe and effective in the removal of urocystoliths and urethroliths in dogs. No significant differences were found in the required resources or complications associated with laser lithotripsy, compared with cystotomy, for removal of uroliths from the lower portions of the urinary tract of dogs. Laser lithotripsy is a suitable, minimally invasive alternative to surgical removal of urethroliths and urocystoliths in dogs.

Healthcare financial executives should employ a systematic approach to anesthesia contract negotiations that: Establishes costs and considers alternative options to reduce anesthesia expense. Defines expected value. Aligns compensation Defines performance parameters. Establishes tracking metrics.

Background: Many studies have attempted to determine the "best" anaesthetic technique for neurosurgical procedures in patients without intracranial hypertension. So far, no study comparing intravenous (IA) with volatile-based neuroanaesthesia (VA) has been able to demonstrate major outcome differences nor a superiority of one of the two strategies in patients undergoing elective supratentorial neurosurgery. Therefore, current practice varies and includes the use of either volatile or intravenous anaesthetics in addition to narcotics. Actually the choice of the anaesthesiological strategy depends only on the anaesthetists' preferences or institutional policies. This trial, named NeuroMorfeo, aims to assess the equivalence between volatile and intravenous anaesthetics for neurosurgical procedures., Methods/design: NeuroMorfeo is a multicenter, randomized, open label, controlled trial, based on an equivalence design. Patients aged between 18 and 75 years, scheduled for elective craniotomy for supratentorial lesion without signs of intracranial hypertension, in good physical state (ASA I-III) and Glasgow Coma Scale (GCS) equal to 15, are randomly assigned to one of three anaesthesiological strategies (two VA arms, sevoflurane + fentanyl or sevoflurane + remifentanil, and one IA, propofol + remifentanil). The equivalence between intravenous and volatile-based neuroanaesthesia will be evaluated by comparing the intervals required to reach, after anaesthesia discontinuation, a modified Aldrete score > or = 9 (primary end-point). Two statistical comparisons have been planned: 1) sevoflurane + fentanyl vs. propofol + remifentanil; 2) sevoflurane + remifentanil vs. propofol + remifentanil. Secondary end-points include: an assessment of neurovegetative stress based on (a) measurement of urinary catecholamines and plasma and urinary cortisol and (b) estimate of sympathetic/parasympathetic balance by power spectrum analyses of electrocardiographic tracings recorded during anaesthesia; intraoperative adverse events; evaluation of surgical field; postoperative adverse events; patient's satisfaction and analysis of costs. 411 patients will be recruited in 14 Italian centers during an 18-month period., Discussion: We presented the development phase of this anaesthesiological on-going trial. The recruitment started December 4th, 2007 and up to 4th, December 2008, 314 patients have been enrolled.

Objectives: In the German diagnosis-related group (G-DRG) system, hospital reimbursement for anesthesia is linked to specific surgical procedures, irrespective of case duration. Accordingly, costs of innovative procedures, such as endoscopic cardiac surgery, may be underreimbursed. The authors assessed to what extent anesthesia costs for endoscopic cardiac surgery are reimbursed with the G-DRG system., Design: Retrospective analysis., Setting: University hospital., Participants: Eighty-four patients were studied undergoing general anesthesia for minimally invasive endoscopic port-access intracardiac surgery (n = 42) or conventional "open" surgery (n = 42) for similar indications., Interventions: None., Measurements and Main Results: The authors measured anesthesia staffing time, costs, and reimbursement for endoscopic cardiac surgery and compared results with data from a matched group undergoing conventional surgery. Endoscopic surgery increased anesthesia staffing time per case by 521 minutes (977 minutes +/- 177 v 456 +/- 92, mean +/- standard deviation, p = 0.0001) and costs by approximately 200%. Anesthesia duration increased by 152 minutes (503 minutes +/- 89 v 351 +/- 69, p = 0.0001). In contrast, staffing reimbursement did not increase at the time of the patient's surgery (euro500/case [446-569] v 492 [452-508], p = 0.75, median [interquartile range]) or with the 2007 G-DRG matrix (euro548/case [463-559] v 503 [503-568], p = 0.48). Cost recovery was only 66% +/- 17.4% and 72.7 +/- 38.9 in the 2007 G-DRG matrix, respectively., Conclusions: It was shown that (1) endoscopic cardiac surgery consumed more anesthesia resources and was underreimbursed both relative to actual costs and to conventional surgery, (2) costs for such anesthesia services were inappropriately reflected in the G-DRG system, and (3) a DRG system's inability to adapt timely to innovative procedures may adversely affect anesthesia departments and medical progress.

Purpose of Review: Anesthesia is a three-step process: preoperative evaluation, the intervention itself and postanesthetic care. In France, this scheme has been legally regulated since 1994. Since then, significant progress has been made in terms of safety. Nevertheless, challenges in the delivery and financing of anesthesia services persist; in particular, demographic (patients and medical staff, as in other western countries), budgetary and organizational restrictions., Recent Findings: The poor efficiency (i.e. low utilization rate) of operating sites remains problematic. Results of published surveys yield the same observations: low productivity (anesthesia personnel present and paid but insufficiently occupied with mean occupied-time rate of approximately 60%), absence or poor planning and inadequate risk management. The failure to define policies to obtain better distribution of anesthesiologists throughout the country and to optimize operating-suite use are major barriers. In addition, the appropriate composition of anesthesia teams, for example nurses and physicians, for specific procedures remains undefined. Moreover, the number of anesthesia cases has grown constantly over the past 20 years, and in some situations they are not medically justified. Finally, pressure to increase productivity is becoming a potential threat to safety and deserves more discussion., Summary: Paths to improvement of delivery of anesthesia in France may include: more optimal sharing of medical resources; better utilization of operating sites, perhaps by consolidating and reducing locations; applying improved organizational skills; and improved risk management.

Achieving fundamental reform of the health care system to improve patient outcomes will take decades of effort and a major shift in financial, medical, and political behaviors that have built up since the beginning of health insurance in the United States. To the extent that the present payment systems contribute to the high cost, poor quality, and lack of accountability that characterizes today's health care delivery system, there is hope that reforms are within reach.

Most financial analysis regarding the cost of non-operating room anesthesia in hospitals is incorrect. This article indicates why this situation exists and suggests how to perform the cost analysis in the right way. It also reviews financial and operational strategies that can result in more efficient scheduling of anesthesia, thereby freeing up anesthesiologist time in the main operating room for non-operating room needs.

Background: The introduction of innovative drugs in anesthesiological treatment has the potential to improve perioperative efficiency. This article examines the impact of the new muscle relaxant encapsulator Bridion on emergence from anesthesia and on the efficiency of the perioperative organization., Methods: To analyze the effects of medical innovations, computer simulation was used as an experimental frame. The simulation was based on a realistic model of an operating room setting and used historical data to study the effect of innovation on the operational performance and the economic outcomes., Results: The use of medical innovations in anesthesiological emergence yields new potentials for a hospital under certain conditions. Due to shorter block times and anesthesia-controlled times, additional benefits for the operating room could be realized. This results in an increase of up to 2.4% additional cases during similar working hours and planning periods., Conclusion: The introduction of innovative medicines may reveal more efficient and economical conditions in operating rooms. The overall result depends, for example, on the rate of application of the patient's portfolio or the organization and access rules of the surgical suite. Based on the anesthesia-controlled time no general a priori statement about the economic potentials can be confirmed. Future empirical studies should investigate the impact on quality and economic benefits for the entire patient pathway.

Anesthesia information management systems add value to the anesthesiologist and the hospital above that which is provided by manual anesthesia records. The more complete documentation and less biased recording of vital signs in this system, relative to manual records, provide data needed for quality initiatives and operating room management and for clinical research. The system can improve the ability to increase anesthesia charge capture, meet the requirements of pay-for-performance programs, and assist in the defense of malpractice allegations. Realization of value from the anesthesia information management systems requires additional expenditures of resources to adapt the systems to meet specific institutional requirements.

Levels of public and private funding for anesthesia services and health research reflect their value to the patient, the payor, and society. Improvements in anesthesia depend heavily on technologic advances. This article presents practical realistic assessment of medical innovation and barriers to its commercialization. Innovation by either academia or industry working in isolation is not possible. Innovation, education, and commercialization are interdependent and contribute to medical progress only when applied as a whole. Subordinating productive relationships between anesthesiologists and industry representatives to concerns of conflict of interest potentially puts diminishes the value of medical services, including anesthesia.

Part-time clinical practice in anesthesia is increasing due to the feminization and the aging of the medical workforce, as well as the arrival of generations X and Y to the health care workforce. Recruiting the best and brightest physicians requires accommodating their needs and interests, as well as retaining older workers who wish to reduce their hours as they approach retirement. This article discusses steps to help departments or groups optimally manage the part-time anesthesia workforce.

Background: Dexmedetomidine is an alpha(2) agonist that is currently being investigated for its suitability to provide anesthesia for children. We compared the pharmacodynamic responses to dexmedetomidine-midazolam and propofol in children anesthetized with sevoflurane undergoing magnetic resonance imaging (MRI)., Methods: Forty ASA 1 or 2 children, 1-10 yr of age, were randomized to receive either dexmedetomidine-midazolam or propofol for maintenance of anesthesia for MRI after a sevoflurane induction. Dexmedetomidine was administered as an initial loading dose (1 microg/kg) followed by a continuous infusion (0.5 microg x kg(-1) x h(-1)). Midazolam (0.1 mg/kg) was administered i.v. when the infusion commenced. Propofol was administered as a continuous infusion (250-300 microg x kg(-1) x min(-1)). Recovery times and hemodynamic responses were recorded by one nurse who was blinded to the treatments., Results: We found that the times to fully recover and to discharge from the ambulatory unit after dexmedetomidine administration were significantly greater (by 15 min) than those after propofol. Analysis of variance demonstrated that heart rate was slower and systolic blood pressure was greater with dexmedetomidine than propofol. Respiratory indices for the two treatments were similar. During recovery, hemodynamic responses were similar. Cardiorespiratory indices during anesthesia and recovery remained within normal limits for the children's ages. No adverse events were recorded., Conclusion: Dexmedetomidine-midazolam provides adequate anesthesia for MRI although recovery is prolonged when compared with propofol. Heart rate was slower and systolic blood pressure was greater with dexmedetomidine when compared with propofol. Respiratory indices were similar for the two treatments.

Purpose: Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicoureteral reflux with success rates of 94% to 99% and up to 89%, respectively. It was reported that unilateral extravesical reimplantation may be performed safely in an outpatient setting. Given that, we analyzed total system reimbursement to compare planned outpatient unilateral extravesical reimplantation to subureteral Deflux injection in patients with unilateral vesicoureteral reflux., Materials and Methods: Data were collected on consecutive patients undergoing outpatient procedures for unilateral vesicoureteral reflux. Assessment of total system reimbursement was made using a payer mix adjusted calculation of surgery plus anesthesia plus hospital reimbursement. This was compared per procedure and in terms of total system reimbursement for each approach to obtain a similar resolution rate., Results: A total of 209 consecutive patients were identified, of whom 26 underwent subureteral Deflux injection and 183 underwent unilateral extravesical reimplantation. Mean operative time was 93 minutes for reimplantation and 45 minutes for injection. The mean volume of dextranomer-hyaluronic acid was 1.2 ml. Total initial system reimbursement per patient was $3,813 for reimplantation and $4,259 for injection. A 3% hospital admission rate for reimplantation increased the total to $3,945. Higher reimbursement for injection depended largely on the material expense for dextranomer-hyaluronic acid., Conclusions: In terms of total system reimbursement it is less expensive in our system to treat unilateral vesicoureteral reflux with unilateral extravesical reimplantation than with subureteral Deflux injection using dextranomer-hyaluronic acid. The ability to perform unilateral reimplantation as an outpatient procedure has shifted this relationship.

Background: Recent publications have focused on increased operating room (OR) throughput without increasing total OR time. The authors hypothesized that a system of parallel processing for lower extremity joint arthroplasties sustainably reduces nonoperative time and increases throughput., Methods: The high-throughput parallel processing strategy included neuraxial anesthesia performed in an "induction room" adjacent to the OR, patient selection, an additional circulating nurse, and end-of-case transfer of care to a recovery room nurse who transported the patient from the OR to recovery. Instruments and supplies were prepared in a dedicated sterile setup area. Data were extracted from administrative databases. Group comparisons used standard statistical methods; statistical process control was used to evaluate performance over time., Results: There were 688 historic control cases from 299 days over 16 months, and 905 high-throughput cases from 304 days spanning 24 consecutive months starting September 1, 2004. Throughput increased from 2.6 +/- 0.7 (mean +/- SD) to 3.4 +/- 0.8 arthroplasties per day per room. Nonoperative time decreased by 36 min (or 50%) per case. Operative time also decreased by 14 min (12%) per case. The end time for the high-throughput OR day was only 16 min later than control. Nonoperative time, operative time, and throughput remained significantly improved after 2 yr of operation. Contribution margin increased 19.6%., Conclusion: Reorganizing the perioperative work process for total joint replacements sustainably increased OR throughput. Because joint arthroplasties generated a positive margin greater than the incremental cost, the high-throughput system improved financial performance.

Background: The cost of wasted anesthetic related agents has not been clear in Japanese hospitals. We investigated whether the trainees in anesthesiology influence the cost of wasted anesthetic related agents., Methods: Investigation was carried out at the University of Tokyo Hospital. We interviewed each trainee in anesthesiology about all prepared anesthetic drugs and wasted ones at the end of each anesthetic management., Results: The percentage of wasted ampoules of anesthetic related agents was 15.85%, but the percentage of wasted cost was 5.15%. A large difference was not observed in transition of training period, and this percentage was not improved by training. We considered that this wasted cost is within permissible ranges in comparison with other reports., Conclusions: During the training it is also important to develop a sense of medical economics.

Background: Many surgical interventions worldwide are performed in developing countries. To improve survival of acutely and critically ill patients in these countries, basic problems and demands of anesthesia care need to be identified. Using this survey, we evaluated the current status of anesthesia and its allied disciplines (intensive care medicine, emergency medicine, and pain therapy) in the Republic of Zambia., Methods: Questionnaires were sent to 87 hospitals registered at the Zambian Ministry of Health as performing minor or major surgery. The questionnaire consisted of 111 questions grouped into five sections: general hospital information, anesthesia, intensive care, emergency medicine, and pain therapy., Results: Sixty-eight questionnaires could be statistically evaluated (78%). The most common operations were obstetric/gynecological and abdominal surgical procedures. Dissociative ketamine anesthesia was the technique most often used for general anesthesia (50%). Endotracheal intubation was performed in 10% of patients undergoing general anesthesia. In most hospitals (78%), anesthesia was administered by nonphysicians. Only 5 of 68 hospitals (7%) reported having an intensive care unit, with 29 beds to serve the entire country. Anesthesiologists play almost no role in emergency medicine and pain therapy., Conclusions: Anesthesia in the Republic of Zambia is a highly under-developed and under-resourced medical specialty.

Institutional support to anesthesia groups for clinical care is very common, particularly when compensation for certified registered nurse anesthetists and anesthesiology residents is considered. Poor contracts can reduce incentives for good operating room (OR) management. We show that two types of agreements for institutional support are rational, and that alternatives to those models increase profit for either the hospital or anesthesia group at the expense of the other. For both agreements, costs are based on survey data, not actual costs. Terms in equations are not recalculated regularly, thereby preventing undesirable incentives such as the anesthesia group profiting from reduced OR workload. Support is not based on hours worked late, because such an agreement would ignore the underutilized OR time sustained by the group. The support would create a disincentive to decision-making that would reduce overutilized OR time such as decreasing turnovers and starting add-on cases expeditiously. For groups with uncommonly low net collections, group profit is higher if the hospital provides support expected to assure a reasonable (fair) income for the group to recruit and retain members. For what is likely the majority of groups, with average net collections per anesthesia hour exceeding the hospital's compensation per scheduled hour, expected profit is higher if institutional support is payment at a reasonable rate (fair market value) for the expected incremental hours of underutilized OR time (i.e., nonbillable idle time) caused by the specialty-specific staffing (i.e., OR allocations). Such an agreement creates incentives whereby the hospital and anesthesia group both profit from increased OR workload and from more accurate specialty-specific staffing.

Historically, calculation of staffing requirements for anesthesia has developed from index numbers derived from the workplace method to the service performance method (XX time). The DRG revenues result from an average calculation of costs that results from an assumed calculation of staffing requirements based on the service performance method. In contrast to the principle of full cost coverage, a much stronger process orientation is needed under the conditions of the DRG system. When calculating personnel needs this process orientation also requires that it be oriented to the organization by differentiating between theater-related and non-theater-related anesthesiological services. In a second step the services rendered in a specified organization are then assessed for efficiency and if necessary optimized. Just as it applies to the whole clinical center, in departments of anesthesiology DRG revenues should be brought in line with the actual costs.

The objective of this survey was to describe the current state of dehorning practices by dairy producers and veterinarians in Ontario and to identify opportunities to improve on existing practices. Two hundred and seven producers and 65 veterinarians completed a survey on dehorning practices during the summer of 2004. Seventy-eight percent of dairy producers dehorn their own calves; 22% use local anesthetics. Veterinarians dehorn calves for 31% of dairy clients; 92% use local anesthetics. Pain management was the most common reason for use of local anesthetics for both groups, while time (veterinarians) and time and cost (producers) were the most common reasons for lack of use. Producers who used local anesthetics were 6.5 times more likely to have veterinary involvement in their dehorning decisions. Thirteen percent of producers were unaware of the options for pain management. These results suggest that veterinarians should take the initiative to educate their clients about the options for pain management.

In Germany the economical framework of the health system in general and the hospitals in particular has changed dramatically over the last years. The conversion of funding to DRGs has implicated a reduction of budgets. The apportioning of budgets by keys of officially calculating hospitals forces single departments and disciplines to choose financial goals of a hospital as their particular interest and not the financial goals of a department. The calculation of a budget for a department of anaesthesia and/or intensive care medicine is possible from fractions of all DRGs, that have been generated inside a hospital within a period of one year. However, this calculation comprises some problems, because anaesthesia and intensive care medicine are interdisciplinary disciplines, which cannot influence its achievements and its processes solely by its own, but are dependent on efficiency and quality of its partners. Internal cost allocation for improving processes seems not to be sensible in the system of DRGs as long as it is used not only as an instrument of controlling, but also as an instrument of benchmarking.

Introduction: Cancellous bone grafting is currently the most frequent method for replacement of bone material. In recent years, several alternative methods came into practice. However, up to now it remains unclear whether cancellous bone grafting is cheaper as compared to these new methods. Therefore, the aim of this study was to calculate the direct costs of cancellous bone grafting., Materials and Methods: For calculation of the direct costs operation time needed in addition to the main surgical intervention was measured and the material used recorded in a consecutive series of 50 interventions including bone grafting at the Department of Trauma Surgery at the University Hospital of Bonn Medical School. Surgical staff costs were calculated on the basis of a standard team consisting of one surgical attendant, surgical resident, surgical nurse, and nurse's service. Cost of anaesthesia was calculated on a per minute base., Results: Mean additional operation time was 26.3 min (range 17-35 min). Surgical staff costs per operation minute were 2.70 Euro, costs for anaesthesiological service were 4.18 Euro/min. Material additional used consisted of sutures and sterilization costs. Material costs summed up to 32.01 Euro. The total direct costs of bone grafting were 212.95 Euro., Conclusion: The direct costs of harvesting cancellous bone graft and the use of bone replacement material are comparable. Due to the high complication rate at the donor site the total-cost-of-illness might be higher when using autologous bone graft.

Background and Goal: For reimbursement via diagnosis-related groups (DRG), lump compensation-based payment of medical cases in German hospitals requires a case-related measuring and billing of resources that has to be consistent with DRG guidelines. Only through this, can the real costs be compared with the standard costs as calculated by the hospital reimbursment system (InEK) on a case-related basis and the DRG-specific break-even level be identified., Methods: In the present paper the authors introduce and validate two newly created alternative methods for case-related allocation of material costs in the field of anaesthesia. Method 1 allows online documentation of material costs via pre-defined anaesthesia standards. This full cost method is suitable for hospitals that have implemented an electronic hospital information system in their daily clinical documentation routine. For other hospitals method 2 could be applicable as the case-related allocation of material costs is done retrospectively based on the data collected in an electronic anaesthesia protocol record system (andoc, medlinq)., Results: Method 1 makes it possible to allocate 90.3% of anaesthesia-related material costs to a specific case corresponding to a Pearsson coefficient of 0.77. After iterative improvement through optimisation of modules the documentation quality could be raised to >98% and a Pearsson coefficient of 0.96. Although the expense for implementation and maintenance is considerable, the necessary documentation work for the clinician is low. Method 2 demands no further clinical effort in documentation and implementation and 49.1% of all material costs can be assigned on a case-related basis., Conclusions: The online documentation of material costs via predefined anaesthesia standards accounts for nearly all material costs in anaesthesia and only a negligible documentation effort is necessary for the clinician. Nevertheless, a complex and time-consuming configuration of standards and a continuous iterative alignment of the modules with the actual processes are required. Due to its process-orientated character, method 1 can also be used for workflow optimisation in terms of standard operating procedures (SOPs). Allocation of material costs with data from the electronic anaesthesia record system is a method that can be easily implemented but only a partial case relation is rendered possible.

The increasing mechanisation, specialisation and sub-specialisation in medicine have enduringly supported the delegation of originally medical activities to non-medical personnel and sometimes also made it necessary. Economical considerations have recently given additional impulse to these developments. It is indisputable that medical activities can be delegated to assistant personnel, however, it is equally indisputable that within the scope of the total spectrum of medical activities, there are limits to the extent of delegation, i.e. activities reserved exclusively for medical doctors. These include, by consensus of opinion, the physical examination, diagnosis, assessment of indication, determination of the therapy plan and informing the patient. The following article justifies from professional and legal viewpoints why anaesthesia also belongs to the genuine medical duties and is reserved exclusively for medical personnel. Therefore, the correct performance of parallel narcosis is coupled with far-reaching liability risks for all participants involved in this form of organisation or those responsible for them.

Background: Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting., Methods: We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders., Results: A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement., Conclusions: The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.

Background: Injection laryngoplasty (IL) continues to evolve as new indications, techniques, approaches, and injection materials are developed. Although historically performed under local or general anesthesia in the operating room suite, IL is now increasingly being performed in an office-based setting. This report presents the results of a reimbursement analysis comparing office-based versus operative IL., Objective: The objective of this study was to compare the reimbursement of office-based injection laryngoplasty with the reimbursement of performing the same procedure in the operating room., Design: The authors conducted reimbursement and outcome analysis through retrospective office chart and hospital record review., Methods: A retrospective review was performed of the hospital records of patients having undergone injection laryngoplasty at the University of Pittsburgh Voice Center from July 1998 through March 2005. Group I included patients who underwent IL in the operating room, whereas group II included those who had office-based IL. A reimbursement analysis for both groups was then performed comparing surgeon fees, anesthesia, and hospital charges and reimbursement. The clinical efficacy of IL performed in either office versus operating room settings was measured by comparing the pre- and postintervention Voice Handicap Index-10 scores for all patients. A predictive model of potential cost savings is developed based on the results of the analysis., Results: Average reimbursement was 2,505 dollars for group I (n = 108) and 496 dollars for group II (n = 50). This reimbursement differential was preserved across the various insurance types examined. There was no significant difference in Voice Handicap Index-10 change after surgery between group I and II., Conclusions: Office-based IL is both clinically and financially effective, providing patients with a convenient and flexible alternative to operating room-based intervention for glottal insufficiency.

A systematic and comprehensive review of the scientific literature revealed 4 evidence-based methods that contribute to a positive return on investment from anesthesia information management systems (AIMS): reducing anesthetic-related drug costs, improving staff scheduling and reducing staffing costs, increasing anesthesia billing and capture of anesthesia-related charges, and increased hospital reimbursement through improved hospital coding. There were common features to these interventions. Whereas an AIMS may be the ideal choice to achieve these cost reductions and revenue increases, alternative existing systems may be satisfactory for the studied applications (i.e., the incremental advantage to the AIMS may be less than predicted from applying each study to each facility). Savings are likely heterogeneous among institutions, making an internal survey using standard accounting methods necessary to perform a valid return on investment analysis. Financial advantages can be marked for the anesthesia providers, although hospitals are more likely to purchase the AIMS.

Background: Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors., Methods: Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and e-mail. The software's efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey., Results: After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0+/-0.1 days to 1.1+/-0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification., Conclusion: This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their department's revenue by approximately $400,000 per year.

The precise titration of anaesthetic agents is necessary to avoid the consequences of a too light depth of anaesthesia such as unexpected intraoperative awareness, as well as a too deep level of anaesthesia, which can be deleterious in terms of postoperative morbidity and mortality. The clinical evaluation of the depth of anaesthesia is poorly sensitive and specific. It does not permit to distinguish between pharmacodynamic components of anaesthesia. Several paraclinical depth of anaesthesia indices are currently available. Most of them are mainly designed to monitor the depth of the hypnotic component of anaesthesia. Their calculation is mostly based on the mathematical analysis of the electroencephalogram. They are efficient at reducing the incidence of unexpected intraoperative awareness, adjusting anaesthetic depth at an individual scale, predicting the time needed for recovery, allowing early extubation of patients, reducing their length of stay in the post anaesthesia care unit, and limiting the number of episodes of peroperative over and under dosage of anaesthetic agents. The knowledge of conditions that may impede the accurate interpretation of those indices is mandatory for an optimal use. Although undoubtedly beneficial for the patients, the use of those monitors is frequently responsible for supplementary' costs, particularly when the procedure is short.

Telephone enquiries about the cost of cleaning the teeth of cats or dogs cannot be answered without clinical investigation of the animal and oral examination under sedation or anaesthesia. This article describes the procedures used during the professional cleaning of the teeth of companion animals. An itemized list of procedures and their cost means that the era of "shopping around" for teeth cleaning is past.

Study Objective: To evaluate the potential differences in the type of anesthesia provided to patients of different race, gender, and source of payment undergoing inguinal hernia repair (IHR)., Design: Retrospective cohort study., Setting: Ambulatory surgical centers/National Survey of Ambulatory Surgery., Patients: 5810 patients older than 14 years who underwent IHR in an ambulatory surgical center., Interventions: Inguinal hernia repair under different types of anesthesia., Measurements: The association of race, gender, and source of payment with different types of anesthesia for IHR as determined by multivariate regression analysis., Results: Significant discrepancies in the use of various anesthetics between patients of different race, gender, and source of payment were found. Patients identified as black and those of other minority groups were significantly more likely to receive general anesthesia compared with those identified as white (odds ratio [OR] 2.76, confidence interval [CI] 1.96-3.88 and OR 1.66, CI 1.14-2.42, respectively). Those identified as black were less likely to receive epidural anesthesia compared with their white counterparts (OR 0.36, CI 0.14-0.95). Women were less likely than men to undergo IHR with epidural anesthesia (OR 0.5, 95% CI 0.3-0.85)., Conclusion: Significant discrepancies in the use of various anesthetics for IHR between patients of different race, gender, and insurance status were found. Despite limitations inherent to secondary data analysis, the findings raise the possibility that nonmedical factors may influence anesthetic management.