Value-Based Payment in Ambulatory Anesthesia: MACRA, MIPS, and More

Congress passed the Medicare Access and Chip Reauthorization Act of 2015 to replace the flawed sustainable growth rate system and it consolidates all pay-for-performance programs. These programs are intended to reduce health care costs but do not address the lack of funding for the social networks that (in all other developed countries) support better health and lower health care use and cost. These programs require reporting by providers about performance on quality, cost, and other metrics, leading to bonuses for those who exceed Centers for Medicare & Medicaid Services-determined metrics and financial penalties for those who do not.

Unsolicited Patient Complaints Identify Physicians with Evidence of Neurocognitive Disorders

OBJECTIVES

Determine whether words contained in unsolicited patient complaints differentiate physicians with and without neurocognitive disorders (NCD).

METHODS

We conducted a nested case-control study using data from 144 healthcare organizations that participate in the Patient Advocacy Reporting System program. Cases (physicians with probable or possible NCD) and two comparison groups of 60 physicians each (matched for age/sex and site/number of unsolicited patient complaints) were identified from 33,814 physicians practicing at study sites. We compared the frequency of words in patient complaints related to an NCD diagnostic domain between cases and our two comparison groups.

RESULTS

Individual words were all statistically more likely to appear in patient complaints for cases (73% of cases had at least one such word) compared to age/sex matched (8%, p < 0.001 using Pearson's χ² test, χ² = 30.21, df = 1) and site/complaint matched comparisons (18%, p < 0.001 using Pearson's χ² test, χ² = 17.51, df = 1). Cases were significantly more likely to have at least one complaint with any word describing NCD than the two comparison groups combined (conditional logistic model adjusted odds ratio 20.0 [95% confidence interval 4.9-81.7]).

CONCLUSIONS

Analysis of words in unsolicited patient complaints found that descriptions of interactions with physicians with NCD were significantly more likely to include words from one of the diagnostic domains for NCD than were two different comparison groups. Further research is needed to understand whether patients might provide information for healthcare organizations interested in identifying professionals with evidence of cognitive impairment.

Practice management/role of the medical director

Although the nature of ambulatory surgery has changed over the years, the ideal role of the medical director mirrors its earliest iterations, focusing on excellent customer service and high quality of care. These efforts are supported by 3 modern methods of quality management borrowed from industry: intentional process improvement, standard care pathways, and monitoring outcomes to determine the efficacy of each. These methods are critical to master in order to lead the facility and providers to the highest quality of care and service.

Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery

Optimal evidence-based perioperative blood glucose control in patients undergoing ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for providing suggestions. It was revealed that there is insufficient evidence to provide strong recommendations for the posed clinical questions. In the absence of high-quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, and data from inpatient surgical population, as well as clinical experience and judgment. In addition, areas of further research were also identified.

Management by outcomes: efficiency and operational success in the ambulatory surgery center

Quality of care and service in health care can benefit from the use of algorithm-driven care (standard work) that integrates literature assessment and analysis of local outcome and process data to eliminate unnecessary variation that causes error and waste. Effective management of an ambulatory surgery center requires that leadership emphasize constant improvement in the processes of care to achieve maximum patient safety and satisfaction, delivered with highest efficiency. Process improvement may be achieved by simple measurement alone (the Hawthorne effect). However, as shown in this article, the authors have successfully used the implementation of regular measurement and open discussion of patients' clinical outcomes and other operational metrics to focus active systems improvement projects in ambulatory surgery centers, with excellent results.

Preventing alcohol-impaired driving through community self-regulation training

A community education program was designed to train the individual drinker to self-regulate his or her blood-alcohol concentration (BAC) below a level of impairment (.05 g/dl or 11 mmol/L). Drink calculators (cardboard wheels and wallet cards) were disseminated to customers of bars and licensed beverage outlets; bartenders and counter clerks were trained to demonstrate use of the calculators and demonstrations were presented in television spots. Program components were evaluated in three matched Vermont communities, one receiving the full community education program, one receiving the TV spots only, and one serving as control. After six months of intervention, a roadside survey of nighttime drivers (N = 892) indicated 5.3 per cent fewer drivers with BACs above 0.05 g/dl in the community program group and 1.0 per cent fewer in the TV-only group compared to the control group; however, substantially fewer drivers were found above .00 BAC in either program community than in the control. Drivers reporting heavy drinking and youthful drivers both indicated higher utilization of the materials than did other drivers. Although limited in scale and duration, this study suggests that a community education program can be effective in preventing alcohol-impaired driving.

Antihypertensive efficacy of once daily MK-521, a new nonsulfhydryl angiotensin-converting enzyme inhibitor

The effects of the new nonsulfhydryl-containing oral converting-enzyme inhibitor MK-521 on blood pressure, heart rate, angiotensin-converting enzyme activity, plasma renin activity and plasma aldosterone concentration were assessed in 10 hypertensive patients. After a 2-week no-treatment period, patients received placebo and then 14 days each: MK-521 20 mg once daily, hydrochlorothiazide 50 mg once daily and the latter 2 in combination. During the last day of each treatment, the mean (+/- standard deviation) time-averaged (1- to 12-hour) standing diastolic blood pressure decreased from 106 +/- 8 (placebo) to 95 +/- 10 mm Hg with MK-521, 95 +/- 13 mm Hg with hydrochlorothiazide (p less than 0.05 vs placebo) and 88 +/- 11 mm Hg with the combination (p less than 0.05 vs all other treatments). The antihypertensive effect of MK-521 was maintained 24 hours after dosing. Heart rate did not change significantly after MK-521 treatment. MK-521 caused a marked suppression of converting enzyme activity for over 24 hours; plasma renin activity increased significantly after each active treatment and MK-521 significantly decreased the hydrochlorothiazide-induced elevation of plasma aldosterone concentration. In this short-term trial, MK-521 was well tolerated.

Prolonged toxicity of organophosphate poisoning

A case of poisoning with a new organophosphate (fenthion) is reported in which the initial cholinergic crisis was delayed 5 days and recurred 24 days after ingestion. Psychosis was a persistent and sometimes singular manifestation. Because of the high lipid solubility of this pesticide, toxin analysis of repeated fat biopsies was an essential component of the management of this patient.