Comparing clinical productivity of anesthesiology groups

Larger anesthesia practitioner per operating room ratios are needed to prevent unnecessary non-operative time than to mitigate patient risk: A narrative review

When choosing the anesthesia practitioner to operating room (OR) ratio for a hospital, objectives are applied to mitigate patient risk: 1) ensuring sufficient anesthesiologists to meet requirements for presence during critical intraoperative events (e.g., anesthesia induction) and 2) ensuring sufficient numbers to cover emergencies outside the ORs (e.g., emergent reintubation in the post-anesthesia care unit). At a 24-OR suite with each anesthesiologist supervising residents in 2 ORs, because critical events overlapped among ORs, ≥14 anesthesiologists were needed to be present for all critical events on >90% of days. The suitable anesthesia practitioner to OR ratio would be 1.58, where 1.58 = (24 + 14)/24. Our narrative review of 22 studies from 17 distinct hospitals shows that the practitioner to OR ratio needed to reduce non-operative time is reliably even larger. Activities to reduce non-operative times include performing preoperative evaluations, making prompt evidence-based decisions at the OR control desk, giving breaks during cases (e.g., lunch or lactation sessions), and using induction and block rooms in parallel to OR cases. The reviewed articles counted the frequency of these activities, finding them much more common than urgent patient-care events. Our review shows, also, that 1 anesthesiologist per OR, working without assistants, is often more expensive, from a societal perspective, than having a few more anesthesia practitioners (i.e., ratio > 1.00). These results are generalizable among hundreds of hospitals, based on managerial epidemiology studies. The implication of our narrative review is that existing studies have already shown, functionally, that artificial intelligence and monitoring technologies based on increasing the safety of intraoperative care have little to no potential to influence anesthesia or OR productivity. There are, in contrast, opportunities to use sensor data and decision-support to facilitate communication among anesthesiologists outside of ORs to choose optimal task sequences that reduce non-operative times, thereby increasing production and OR efficiency.

Association of surgeons' gender with elective surgical lists in the State of Florida is explained by differences in mean operative caseloads

BACKGROUND

A recent publication reported that at three hospitals within one academic health system, female surgeons received less surgical block time than male surgeons, suggesting potential gender-based bias in operating room scheduling. We examined this observation's generalizability.

METHODS

Our cross-sectional retrospective cohort study of State of Florida administrative data included all 4,176,551 ambulatory procedural encounters and inpatient elective surgical cases performed January 2017 through December 2019 by 8875 surgeons (1830 female) at all 609 non-federal hospitals and ambulatory surgery centers. There were 1,509,190 lists of cases (i.e., combinations of the same surgeon, facility, and date). Logistic regression adjusted for covariables of decile of surgeon's quarterly cases, surgeon's specialty, quarter, and facility.

RESULTS

Selecting randomly a male and a female surgeons' quarter, for 66% of selections, the male surgeon performed more cases (P < .0001). Without adjustment for quarterly caseloads, lists comprised one case for 44.2% of male and 54.6% of female surgeons (difference 10.4%, P < .0001). A similar result held for lists with one or two cases (difference 9.1%, P < .0001). However, incorporating quarterly operative caseloads, the direction of the observed difference between male and female surgeons was reversed both for case lists with one (-2.1%, P = .03) or one or two cases (-1.8%, P = .05).

CONCLUSIONS

Our results confirm the aforementioned single university health system results but show that the differences between male and female surgeons in their lists were not due to systematic bias in operating room scheduling (e.g., completing three brief elective cases in a week on three different workdays) but in their total case numbers. The finding that surgeons performing lists comprising a single case were more often female than male provides a previously unrecognized reason why operating room managers should help facilitate the workload of surgeons performing only one case on operative (anesthesia) workdays.

Benchmarking Surgeons’ Gender and Year of Medical School Graduation Associated With Monthly Operative Workdays for Multispecialty Groups

Background

Female surgeons reportedly receive less surgical block time and fewer procedural referrals than male surgeons. In this study, we compared operative days between female and male surgeons throughout Florida. Our objective was to facilitate benchmarking by multispecialty groups, both the endpoint to use for statistically reliable results and expected differences.

Methodology

The historical cohort study included all 4,060,070 ambulatory procedural encounters and inpatient elective surgical states performed between January 2017 and December 2019 by 8,472 surgeons at 609 facilities. Surgeons’ gender, year of medical school graduation, and surgical specialty were obtained from their National Provider Identifiers.

Results

Female surgeons operated an average of 1.0 fewer days per month than matched male surgeons (99% confidence interval 0.8 to 1.2 fewer days, P < 0.0001). The mean differences were 0.8 to 1.4 fewer days per month among each of the five quintiles of years of graduation from medical school (all P ≤ 0.0050). Results were comparable when repeated using the number of monthly cases the surgeons performed.

Conclusions

An average difference of ≤1.4 days per month is a conservative estimate for the current status quo of the workload difference in Florida. Suppose that a group’s female surgeons average more than two fewer operative days per month than the group’s male surgeons of the same specialty. Such a large average difference would call for investigation of what might reflect systematic bias. While such a difference may reflect good flexibility of the organization, it may show a lack of responsiveness (e.g., fewer referrals of procedural patients to female surgeons or bias when apportioning allocated operating room time).

Transition from Private to Academic Anesthesia Provision Changes Process and Patient Centered Outcomes in an Ambulatory Surgery Center

A recurring concern in the discussion of performance of anesthesia practices is that academic practitioners are slower, less efficient, or produce poorer operational outcomes than their private practice counterparts. A simple overnight 'swap' of a private anesthesia practice with an academic anesthesia practice took place in an outpatient surgery center where the case volume, case mix, surgeons, and staff remained the same. Operational and quality measures were analyzed for comparison between the practices over the span of two years. All patients who had a procedure at the outpatient surgery center in the year prior to the takeover and the year after were studied. Post-anesthesia care unit times, hospital transfer data, pain scores at discharge, opioids dispensed, and anesthesia control times were compared over two years. Charts were manually abstracted by non-clinical administrative staff who were unaware of the study hypothesis. Procedure data and clinical outcomes were compared between the two years using standard statistical techniques. After exchange to the academic group, the median (mean) pain score at post-anesthesia care unit (PACU) discharge was reduced from 2 (2.0) to 0 (1.7) (Wilcoxon rank sum test p < 0.001), and the odds of having moderate or severe pain was reduced by 32% (95% CI, 25, 39, p < 0.001) after adjusting for surgery type. The year-on-year average recovery room time was reduced by 13.9 min (95% CI, 12.5, 15.4, p < 0.001) after adjusting for surgery type. There was a significant reduction in hospital transfer rate after changing groups (0.45% vs. 0.07%, Pearson chi square test p = 0.005). Hospital transfer rates, dispensed opioids in PACU, pain scores at discharge, and PACU times were all improved after the conversion from a private practice to an academic one, without a compromise in efficiency or throughput.

Trends in Direct Hospital Payments to Anesthesia Groups: A Retrospective Cohort Study of Nonacademic Hospitals in California

BACKGROUND

In addition to payments for services, anesthesia groups in the United States often receive revenue from direct hospital payments. Understanding the magnitude of these payments and their association with the hospitals' payer mixes has important policy implications.

METHODS

Using a dataset of financial reports from 240 nonacademic California hospitals between 2002 and 2014, the authors characterized the prevalence and magnitude of direct hospital payments to anesthesia groups, and analyzed the association between these payments and the fraction of anesthesia revenue derived from public payers (e.g., Medicaid).

RESULTS

Of hospitals analyzed, 69% (124 of 180) made direct payments to an anesthesia group in 2014, compared to 52% (76 of 147) in 2002; the median payment increased from $242,351 (mean, $578,322; interquartile range, $72,753 to $523,861; all dollar values in 2018 U.S. dollars) to $765,128 (mean, $1,295,369; interquartile range, $267,006 to $1,503,163) during this time period. After adjusting for relevant covariates, hospitals where public insurers accounted for a larger fraction of anesthesia revenues were more likely to make direct payments to anesthesia groups (β = 0.45; 95% CI, 0.10 to 0.81; P = 0.013), so that a 10-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 4.5-percentage point increase in the probability of receiving any payment. Among hospitals making payments, our results (β = 2.10; 95% CI, 0.74 to 3.45; P = 0.003) suggest that a 1-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 2% relative increase in the amount paid.

CONCLUSIONS

Direct payments from hospitals are becoming a larger financial consideration for anesthesia groups in California serving nonacademic hospitals, and are larger for groups working at hospitals serving publicly insured patients.

Measuring Clinical Productivity of Anesthesiology Groups

Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent.

Anesthesia Workload Nationally During Regular Workdays and Weekends

BACKGROUND

We analyze data from the American Society of Anesthesiologist's (ASA) Anesthesia Quality Institute (AQI) to report the U.S. anesthesia workload by time of day and day of the week. We consider the extent to which first case starts, rather than durations of workdays and weekend cases, influence the number of anesthesia providers nationally.

METHODS

The ASA AQI data were from all the U.S. anesthesia groups that submitted cases to the National Anesthesia Clinical Outcomes Registry (NACOR) for all 12 months of 2013. For each of the n = 2,075,188 cases, we identified the local date and time of the start of anesthesia care, duration of anesthesia care, and the local time zone. Anesthesia workload was measured as the time from the start to the end of continuous anesthesia care. Data are reported as mean ± SEM with 95% confidence intervals (CIs).

RESULTS

Half (53.0% ± 0.6%) of the ASA AQI-reported weekly anesthesia workload was completed by 1:00 PM, local time, on regular workdays. The busiest 8-hour interval was from 7:30 AM to 3:30 PM and accounted for 70.3% ± 0.7% of anesthetic minutes. Although most facilities completed the majority of their weekly anesthesia workload in the mornings of regular workdays (P < 0.0001; 62.3%; CI, 58.6%-66.1%), just 24.4% of the University and large community hospitals did so (P = 0.0008 relative to half; CI, 13.8%-38.4%).

CONCLUSIONS

The results are inconsistent with widespread use of surgical facilities (i.e., anesthesia providers) in mornings only, especially at University and large community hospitals. The observed national work hours match with what would be expected if most anesthesiologists work at least 8 hours on regular workdays. Opportunity for greater use of the capital (building and equipment) probably would involve the use of additional anesthesia providers representing a second shift or use of weekends.

Integration of academic and clinical performance-based faculty compensation plans: a system and its impact on an anaesthesiology department

BACKGROUND

The current economic environment makes it difficult for academic institutions to maintain academic activities with necessary clinical coverage. Productivity-based faculty compensation is reported to improve clinical work output; however, the impact on academic productivity has not been fully described.

METHODS

An academic anaesthesiology department has used a comprehensive clinical and academic performance-based faculty compensation programme as fiscal year (FY) 2004. Faculty choosing to pursue an academic track can devote up to 80% of their time to non-clinical activities. Payment for this time is 'salary at risk', which is earned through a merit matrix system, which was newly developed to award points for various academic activities. Unclaimed portions of the salary at risk are absorbed into the department budget at the conclusion of the FY. Clinical activities are measured chiefly based on total hours of anaesthetic care.

RESULTS

Academic full-time equivalents (FTEs) decreased by 12.0% in FY2005 (FTE of 16.0-14.1) but recovered to the baseline level in FY2006 and remained stable. Clinical FTE also decreased by 6.6% in FY2005 (FTE of 109.1-101.9), then increased in FY2006-FY2010. Increased clinical work output was observed among the clinical and academic faculty members. Each academic faculty member successfully earned their salary at risk in each FY. The annual number of peer-reviewed publications per academic FTE in original research increased from 0.31 (0.18) (FY2001-FY2003) to 0.73 (0.14) (FY2006-FY2011), P=0.024.

CONCLUSIONS

Integration of clinical and academic performance-based faculty compensation systems is feasible and can be efficacious in a large academic anaesthesiology department.

Perspective: Hospital support for anesthesiology departments: aligning incentives and improving productivity

Anesthesiology groups, particularly academic departments, are increasingly dependent on hospital support for financial viability. Economic stresses are driven by higher patient acuity, by multiple subspecialty service and call demands, by high-risk obstetric services, and by long case durations attributable to both case complexity and time for teaching. An unfavorable payer mix, university taxation, and other costs associated with academic education and research missions further compound these stresses. In addition, the current economic climate and the uncertainty surrounding health care reform measures will continue to increase performance pressures on hospitals and anesthesiology departments.Although many researchers have published on the mechanics of operating room (OR) productivity, their investigations do not usually address the motivational forces that drive individual and group behaviors. Institutional tradition, surgical convenience, and parochial interests continue to play predominant roles in OR governance and scheduling practices. Efforts to redefine traditional relationships, to coordinate operational decision-making processes, and to craft incentives that align individual performance goals with those of the institution are all essential for creating greater economic stability. Using the principles of shared costs, department autonomy, hospital flexibility and control over institutional issues, and alignment between individual and institutional goals, the authors developed a template to redefine the hospital-anesthesiology department relationship. Here, they describe both this contractual template and the results that followed implementation (2007-2009) at one institution.

Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the United States: role of anesthesia availability, productivity, guidelines, and patient safety

The rate of vaginal birth after cesarean delivery (VBAC) has been steadily decreasing in the United States. What is not clear, however, is what part the availability of anesthesia personnel has played in this reduction. We review the role of anesthesia services in the trend of the decreasing rates of VBAC. Three areas of particular interest to anesthesiology services are addressed: (1) the current ability of anesthesiologists in the United States to provide "immediate" availability for VBAC at all delivery locations; (2) the workforce estimates for anesthesiology staffing in the future; and (3) the barriers to the immediate availability of anesthesiologists in all hospitals that provide obstetrical care. The concept of "immediate availability" is discussed, and examples of ways to reduce the risks to patients are provided. Finally, possible solutions that may improve patient safety without a dramatic increase in number of anesthesiologists available to work on labor and delivery units are highlighted.

Continuous lumbar plexus block for postoperative pain control after total hip arthroplasty. A randomized controlled trial

BACKGROUND

Continuous femoral or lumbar plexus blocks have been demonstrated to provide effective postoperative analgesia of the lower extremity following total joint arthroplasty. The purpose of this study was to compare these two techniques when used with intravenous patient-controlled analgesia and the use of patient-controlled analgesia alone for postoperative pain management following unilateral primary hip arthroplasty.

METHODS

Two hundred and twenty-five patients undergoing unilateral total hip arthroplasty for a diagnosis of osteoarthritis were randomly allocated into one of three postoperative treatment groups: continuous lumbar plexus block with patient-controlled analgesia, continuous femoral block with patient-controlled analgesia, and patient-controlled analgesia alone. Scores on a visual analog pain scale administered during physiotherapy twenty-four hours postoperatively were used as the primary outcome measured. Secondary outcomes included scores on a visual analog pain scale at rest, hydromorphone consumption, opioid-related side effects, complications, sensory and motor blockade, and patient satisfaction.

RESULTS

Continuous lumbar plexus block significantly reduced pain scores during physiotherapy on postoperative day 1 (p < 0.0001) and day 2 (p < 0.0001) compared with either continuous femoral block or patient-controlled analgesia alone. There were no significant differences for pain at rest between the two regional analgesic techniques. Both regional anesthesia techniques significantly reduced total hydromorphone consumption (p < 0.05) and delirium (disorientation to time and/or place) compared with patient-controlled analgesia alone (p < 0.023). In addition, the use of continuous lumbar plexus block was associated with fewer patients with opioid-related side effects (p < 0.05), greater distances walked (p < 0.05), and enhanced patient satisfaction (p < 0.05) compared with the use of a continuous femoral nerve block with patient-controlled analgesia or with patient-controlled analgesia alone.

CONCLUSIONS

Continuous lumbar plexus and femoral blocks significantly reduce the need for opioids and decrease related side effects. Continuous lumbar plexus block is a more effective analgesic modality than is a continuous femoral block or patient-controlled intravenous administration of hydromorphone alone during physical therapy following primary unilateral total hip arthroplasty.

A mission-based productivity compensation model for an academic anesthesiology department

INTRODUCTION

We replaced a nearly fixed-salary academic physician compensation model with a mission-based productivity model with the goal of improving attending anesthesiologist productivity.

METHODS

The base salary system was stratified according to rank and clinical experience. The supplemental pay structure was linked to electronic patient records and a scheduling database to award points for clinical activity; educational, research, and administrative points systems were constructed in parallel. We analyzed monthly American Society of Anesthesiologist (ASA) unit data for operating room activity and physician compensation from 2000 through mid-2007, excluding the 1-yr implementation period (July 2004-June 2005) for the new model.

RESULTS

Comparing 2005-2006 with 2000-2004, quarterly ASA units increased by 14% (P = 0.0001) and quarterly ASA units per full-time equivalent increased by 31% (P < 0.0001), while quarterly ASA units per anesthetizing location decreased by 10% (P = 0.046). Compared with a baseline year (2001), Instructor and Assistant Professor faculty compensation increased more than Associate Professor and Professor faculty (P < 0.001) in both pre- and postimplementation periods. There were larger compensation increases for the postimplementation period compared with preimplementation across faculty rank groupings (P < 0.0001). Academic and educational output was stable.

DISCUSSION

Implementing a productivity-based faculty compensation model in an academic department was associated with increased mean supplemental pay with relatively fewer faculty. ASA units per month and ASA units per operating room full-time equivalent increased, and these metrics are the most likely drivers of the increased compensation. This occurred despite a slight decrease in clinical productivity as measured by ASA units per anesthetizing location. Academic and educational output was stable.

Predicting orthopedic surgeons' preferences for peripheral nerve blocks for their patients

BACKGROUND

A 2002 survey of 468 Canadian orthopedic surgeons found that the "two principal reasons regional anesthesia is not favored" are "delays in operating rooms" and "unpredictable success." We reanalyzed the data from the study to evaluate whether these concerns were the best predictors of an individual surgeon's willingness to use peripheral nerve blocks for their patients.

METHODS

Of the five procedures included in the survey, three had relevant questions for our reanalysis of the results: arthroscopic shoulder surgery, arthroscopic anterior cruciate ligament reconstruction, and total knee replacement.

RESULTS

A surgeon's preference for peripheral nerve block for him or herself strongly predicted his or her anesthetic preference for patients (all P < 0.001). Concordance rates were 89% for arthroscopic shoulder surgery, 87% for anterior cruciate ligament reconstruction, and 93% for total knee replacement. There was almost no incremental predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (P > or = 0.27) or perception of block success rate (P > or = 0.30). There was also almost no direct predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (Kendall's tau < or = 0.04, P > or = 0.28) or perception of block success rate (Kendall's tau < or = 0.02, P > or = 0.24). An economically important percentage of surgeons (37%, 95% confidence interval: 32%-41%) would choose a peripheral nerve block for their own surgery for some, but not all, of the procedures (i.e., for 1 or 2 versus 0 or 3).

CONCLUSIONS

A surgeon's preference for peripheral nerve blocks for his or her own surgery predicted a surgeon's preference for his or her patients. Perceptions of delays and success rate did not add sufficient incremental information to the surgeon's preferences to be of economic importance. These results are important to better forecast the net economic impact on an anesthesia group of a regional block team.

The Impact of Service-Specific Staffing, Case Scheduling, Turnovers, and First-Case Starts on Anesthesia Group and Operating Room Productivity: A Tutorial Using Data from an Australian Hospital

BACKGROUND

In this tutorial, we consider the impact of operating room (OR) management on anesthesia group and OR labor productivity and costs. Most of the tutorial focuses on the steps required for each facility to refine its OR allocations using its own data collected during patient care.

METHODS

Data from a hospital in Australia are used throughout to illustrate the methods. OR allocation is a two-stage process. During the initial tactical stage of allocating OR time, OR capacity ("block time") is adjusted. For operational decision-making on a shorter-term basis, the existing workload can be considered fixed. Staffing is matched to that workload based on maximizing the efficiency of use of OR time.

RESULTS

Scheduling cases and making decisions on the day of surgery to increase OR efficiency are worthwhile interventions to increase anesthesia group productivity. However, by far, the most important step is the appropriate refinement of OR allocations (i.e., planning service-specific staffing) 2-3 mo before the day of surgery.

CONCLUSIONS

Reducing surgical and/or turnover times and delays in first-case-of-the-day starts generally provides small reductions in OR labor costs. Results vary widely because they are highly sensitive both to the OR allocations (i.e., staffing) and to the appropriateness of those OR allocations.

Observational study of operating room times for knee and hip replacement surgery at nine U.S. community hospitals

Knee (N = 185) and hip (N = 140) replacement cases were studied at nine community hospitals in the midwestern United States to determine whether certain management interventions could decrease case durations and reduce labor costs. Substantive (10 min) reductions in operating room (OR) time per case were not associated with: 1) increases in OR staffing, such as the addition of a surgical assistant; 2) complete elimination of all delays; or 3) increases in anesthesiologists' presence in the ORs. Substantive (10 min) increases in OR time per case were not associated with: 1) reductions in anesthesiologists' presence in the ORs or 2) changes in case scheduling to run fewer ORs, with some cases starting later in the day. Even if these factors had been associated with differences in OR time per case, any changes resulting from management interventions would still not have reduced labor costs. At these hospitals, OR nursing and anesthesia labor costs were fixed costs, because the OR workload averaged only 5.6 hr of cases per day.

Methods for Understanding Super-Efficient Data Envelopment Analysis Results with an Application to Hospital Inpatient Surgery

We compare two techniques for increasing the transparency and face validity of Data Envelopment Analysis (DEA) results for managers at a single decision-making unit: multifactor efficiency (MFE) and non-radial super-efficiency (NRSE). Both methods incorporate the slack values from the super-efficient DEA model to provide a more robust performance measure than radial super-efficiency scores. MFE and NRSE are equivalent for unique optimal solutions and a single output. MFE incorporates the slack values from multiple output variables, whereas NRSE does not. MFE can be more transparent to managers since it involves no additional optimization steps beyond the DEA, whereas NRSE requires several. We compare results for operating room managers at an Iowa hospital evaluating its growth potential for multiple surgical specialties. In addition, we address the problem of upward bias of the slack values of the super-efficient DEA model.

The Prevalence and Characteristics of Incentive Plans for Clinical Productivity Among Academic Anesthesiology Programs

Performance-based compensation is encouraged in medical schools to improve faculty productivity. Medical specialties other than anesthesiology have used financial incentives for clinical work. The goal of this study was to determine the prevalence and the types of clinical incentive plans among academic anesthesiology departments. We performed an electronic survey of the members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors in the spring of 2003. The survey included questions about departmental size, presence of a clinical incentive plan, characteristics of existing incentive plans, primary quantifiers of productivity, and factors used to modify productivity measurements. An incentive plan was considered to be present if the department measured clinical productivity and varied compensation according to the measurements. The plans were grouped by the primary measure used into the following categories: None, Charges, Time, Shift, Late/Call (only late rooms and call), and Other. Eighty-eight (64%) of 138 programs responded to the survey, and 5 were excluded for incomplete data. Of the responding programs, 29% had no system, 30% used a Late/Call system, 20% used a Shift system, 11% used a Charges system, 6% used a Time system, and 3% fit in the Other category. Larger groups (>40 faculty members) had a significantly more frequent prevalence of incentive plans compared with smaller groups (<20 faculty members). Incentives were paid monthly or quarterly in 85% of the groups. In 90% of groups, incentive payments accounted for <25% of total compensation. Adjustments for operating room schedule supervisors, personally performed cases, day surgery preoperative clinics, pain-management services, and critical care services were included in less than half of the programs that reported incentive plans. Call and late room compensation was based on varied formulas. Sixty-nine percent of academic anesthesiology departments did not vary compensation according to clinical activity during regular hours. Most did vary payments on the basis of call and/or late rooms worked. Larger departments were more likely to use clinical incentive plans.

Increasing the value of time reduces the lost economic opportunity of caring for surgeries of longer-than-average times

Anesthesiology groups that provide care for surgical procedures of longer-than-average duration are economically disadvantaged by both increased staffing costs and reduced revenue. Under the current billing system, anesthesia time is valued the same regardless of the total case duration. In this study, we evaluated the effect on four academic anesthesiology departments of two hypothetical scenarios by changing the anesthesia care billing system to make more valuable either 1) all time units or 2) just second-hour and subsequent time units. From the four departments, case-specific data (anesthesia Current Procedural Terminology code and minutes of care) were collected for all anesthesia cases billed for 1 yr. Basic units were determined from the American Society of Anesthesiologists (ASA) relative value guide. The average time for each case was defined as the average anesthesia time for that specific Current Procedural Terminology code, as published by the Center for Medicare and Medicaid Services (CMS). The actual total ASA units per hour (tASA/h) was determined by adding all the basic units and time units and dividing by hours of anesthesia care (minutes of anesthesia care divided by 60). We then calculated a hypothetical CMS tASA/h for each group by substituting the CMS average time for each anesthesia procedure time for the actual time reported by each group and using 15-min time units. For each group, the Actual (Act) tASA/h and CMS tASA/h were calculated for both options-changing the interval for all time units or only for second and subsequent hours. Intervals were 15, 12, 10, 7, 6, or 5 min. When changing all time units, Act tASA/h and CMS tASA/h were never equal for all groups. The two productivity measures became approximately equal if only time units after the first hour were changed to 6- to 7-min intervals. When changes were applied only to the Act tASA/h (with CMS tASA/h remaining at 15-min intervals), at the 12-min interval either option resulted in a similar or higher Act tASA/h than CMS tASA/h. Both options increase the value of time and help compensate for the lost economic opportunity of longer-than-average surgical durations.

IMPLICATIONS

Longer-than-average surgical durations result in less potential revenue per hour under current billing methodology. This study quantifies the increase in billing productivity when the value of time is increased, when evaluating the billing productivity of four academic anesthesiology groups.

Is Physician Anesthesia Cost-Effective?

One of the most controversial issues in anesthesia is whether nonmedically directed nurse anesthetists are relatively more cost-effective than anesthesiologists in the provision of anesthesia care. We electronically surveyed anesthesia practices throughout the United States to estimate the range in anesthesia professional costs from the payer perspective. Using this survey data on anesthesia reimbursement and published outcomes studies, we developed an ad hoc model to estimate the cost-effectiveness of physician-directed anesthesia relative to a nonmedically directed nurse anesthetist model of care from the payer perspective. Cost-effectiveness ratios were defined as the ratio of incremental costs associated with physician anesthesia relative to the estimated incremental life expectancy gains with this model of care (i.e., dollars per year of life saved [US dollars /YLS]). Reference case results suggest that physician anesthesia is cost saving with an estimated incremental cost-effectiveness ratio of -US dollars 2601/YLS for a younger privately insured patient and an estimated cost-effectiveness ratio of -US dollars 4410/YLS for an elderly Medicare insured patient. Cost-effectiveness ratios ranged from -US dollars 4410 to US dollars 38778/YLS in univariate and multivariate sensitivity analyses across payer types. Results were most sensitive to assumed differences in reimbursement (commercial conversion factors) and to mortality rate assumptions by provider type. This analysis offers economic evidence in support of the physician anesthesia model of care.

IMPLICATIONS

Recent outcome studies suggest improved patient outcomes when physicians medically direct nurse anesthetists versus anesthesia care delivered with nonmedically directed nurses. The relative cost-effectiveness of this practice model is, however, unknown. This economic analysis suggests that outcome gains with physician anesthesia may be obtained at cost savings or, under conservative assumptions, at a cost deemed reasonable by society.

The effects of surgical case duration and type of surgery on hourly clinical productivity of anesthesiologists

Surgical duration (hours per case; h/case) and type of surgery (ASA base units per case; base/case) determine the hourly clinical productivity (total ASA units per hour of anesthesia care; tASA/h) for anesthesiology groups. In previous studies, h/case negatively influenced tASA/h, but base/case did not differ significantly. However, when cases are grouped by surgical service, the mean base/case varies. In this study we evaluated the effect of h/case and base/case on tASA/h when these are grouped by surgical services. Data from one calendar year were collected from an academic anesthesiology department's billing database. All surgical cases for which the anesthesiology department provided care were included. Cases performed outside the main operating room, e.g., remote sites or obstetrics, were excluded. Any care not billed with ASA units was also excluded. Mean base/case and h/case were determined. For each service, tASA/h was calculated by dividing the sum of base/case and (4 x h/case) by h/case. A total of 12,769 cases were performed by 19 different surgical services. Mean base/case was 6.1 U, with a range of 4.0 U (orthopedics) to 16.0 U (cardiothoracic). Mean h/case was 2.9 h, with a range of 0.9 h (otolaryngology pediatric) to 5.4 h (orthopedic spine). Mean tASA/h was 6.35 U/h, with a range of 5.01 U/h (plastic surgery) to 9.71 U/h (otolaryngology pediatric). The services with high base/case did not necessarily have high tASA/h because of the longer h/case. The services with the shortest h/case had the highest tASA/h. The accurate prediction of both clinical and billing productivity requires inclusion of both base/case and surgical duration data. Anesthesiology groups should consider surgical duration when making strategic decisions.

Organizational factors affect comparisons of the clinical productivity of academic anesthesiology departments

Productivity measurements based on "per operating room (OR) site" and "per case" are not influenced by staffing ratios and have permitted meaningful comparisons among small samples of both academic and private-practice anesthesiology groups. These comparisons have suggested that a larger sample would allow for clinical groups to be compared using a number of different variables (including type of hospital, number of OR sites, type of surgical staff, or other organizational characteristics), which may permit more focused benchmarking. In this study, we used such grouping variables to compare clinical productivity in a broad survey of academic anesthesiology programs. Descriptive, billing, and staffing data were collected for 1 fiscal or calendar year from 37 academic anesthesiology departments representing 58 hospitals. Descriptive data included types of surgical staff (e.g., academic versus private practice) and hospital centers (e.g., academic medical centers and ambulatory surgical centers [ASCs]). Billing and staffing data included total number of cases performed, total American Society of Anesthesiologists units (tASA) billed, total time units billed (15-min units), and daily number of anesthetizing sites staffed (OR sites). Measurements of total productivity (tASA/OR site), billed hours per OR site per day (h/OR/d), surgical duration (h/case), hourly billing productivity (tASA/h), and base units/case were compared. These comparisons were made according to type of hospital, number of OR sites, and type of surgical staff. The ASCs had significantly less tASA/OR site, fewer h/OR/d, and less h/case than non-ASC hospitals. Community hospitals had significantly less h/OR/d and h/case than academic medical centers and indigent hospitals and a larger percentage of private-practice or mixed surgical staff. Academic staffs had significantly less tASA/h and significantly more h/case. tASA/h correlated highly with h/case (r = -0.68). This study showed that the hospitals at which academic anesthesiology groups provide care are not all the same from a clinical productivity perspective. By grouping based on type of hospital, number of OR sites, and type of surgical staff, academic anesthesiology departments (and hospitals) can be better compared by using clinical productivity measurements based on "per OR site" and "per case" measurements (tASA/OR, billed h/OR/d, h/case, tASA/h, and base/case).

IMPLICATIONS

Organizational factors, including type of hospital, number of operating rooms, and type of surgical staff, influence the clinical productivity of academic anesthesiology departments. Reporting quartile data by focused grouping variables allows anesthesiology groups to compare their clinical productivity with groups practicing in similar clinical settings.