This is important because decreasing length of stay can make the anesthesia department more important to the hospital’s administration.

Miller TE, Thacker JK, White WD, et al; Enhanced Recovery Study Group

Anesth Analg. 2014;118:1052-1061

Study Summary

This study investigated the feasibility, clinical effectiveness, and cost savings of a multimodal approach to enhanced recovery after surgery, designed to enable early mobilization and feeding after open or laparoscopic colorectal surgery.

Baseline data were collected on 99 consecutive patients undergoing colorectal surgery and receiving traditional care that included little standardization and was at the discretion of the surgical and anesthesia providers. For example, baseline patients fasted from midnight on the day of surgery, received bowel preparation, and rarely received thoracic epidurals because of a surgical preference for enoxaparin to be given 2 hours preoperatively. Early mobilization and day-of-surgery feeding were not part of the traditional care regimens.

The investigators then implemented a multimodal regimen to enable early mobilization and feeding after surgery. Staff members received training before a 3-month implementation period during which 142 patients were prospectively enrolled, allowing providers to become familiar with the enhanced recovery protocol. A before-and-after comparison of key outcomes was made.

Study Findings

The median length of stay was reduced from 7 to 5 days with the enhanced recovery protocol compared with the traditional group (P less than .001). The reduction in length of stay was significant for both open procedures (median, 6 vs 7 days; P = .01) and laparoscopic procedures (4 vs 6 days; P less than .001). Patients who received the enhanced recovery protocol also had fewer urinary tract infections (13% vs 24%; P = .03) and fewer readmissions (9.8% vs 20.2%; P = .02).

Of interest, even with a shorter length of stay and lower patient ward costs, there was no statistically significant difference in unadjusted total hospital costs for patients who received the enhanced protocol compared with traditional care ($18,377 vs $20,537).

Viewpoint

The 12 investigators who form the Enhanced Recovery Study Group began the article by stating, “Despite lack of evidence for preoperative bowel preparation in colorectal surgery, routine use of nasogastric tubes, and nil by mouth instructions until bowel sounds are heard postoperatively, all 3 are still widely practiced.” In fact, the approach studied here was a bundle of interventions that included:

• No bowel preparation;

• Patients were allowed to drink clear fluids until 3 hours preoperatively; and

• Patients drank a 240-mL beverage (Gatorade™) 3 hours before surgery.

These latter 2 items make sense. If a person is going to run 5 miles at 4 PM, no one would expect that person to go without fluids the entire day. I would assume that running several miles is not unlike the stress to the body of having surgery.

Other aspects of the enhanced recovery bundle included:

• Formally educating patients about what is going to happen and setting expectations for recovery, including walking and eating the evening after surgery;

• Smoking cessation information;

• Two preoperative showers with chlorhexidine sponges;

• Thoracic epidural anesthesia with 5000 U of subcutaneous heparin given after catheter placement (instead of enoxaparin 2 hours preoperatively);

• Goal-directed intravenous fluid therapy;

• Orogastric tube removal before leaving the operating room (it used to be that many of these patients were sent to the ward with a nasogastric tube);

• Urinary catheter taken out in the operating room;

• Diet and ambulation begin the first night of surgery; and

• Head of bed elevated to 30° at all times.

Instead of studying the impact of a single intervention (eg, only thoracic epidural anesthesia, early diet only, or early ambulation), Miller and colleagues used a multimodal perioperative approach that combined a group of interventions. This elegant approach rings true as being relevant and applicable to everyday practice. Thoracic epidural analgesia was used in 92% of recovery group patients compared with 18% of traditional group patients, resulting in reduced use of postoperative morphine and lower pain scores. In the intervention group, 74% of patients began taking clear oral fluids on the day of surgery, compared with 15% in the traditional group.

When you look at the published literature, an often surprising statistic is the complication rate after colon surgery, which can be as high as 25%-40% if one includes pneumonia, urinary tract infection, superficial or deep wound infection, sepsis, and cardiovascular events. In this study, surgical-site infections occurred in 28% of patients receiving the enhanced recovery protocol vs 37% of the traditional group, but this difference did not reach statistical significance.

For patients without complications, length of stay is determined by postoperative ileus. Enhanced recovery programs aim to minimize ileus and facilitate immediate feeding and mobilization on the day of surgery.

This study is another example of how new evidence fundamentally changes traditional best practice in how patients are cared for.

 

The color of a person’s eyes may predict how that person responds to pain.

“There may be certain phenotypes that predict or indicate a person’s response to pain stimuli or drug treatment for pain,” Inna Belfer, MD, PhD, from the University of Pittsburgh School of Medicine in Pennsylvania said.

“Human pain is correlated with multiple factors like gender, age, and hair color,” Dr. Belfer said here at the American Pain Society (APS) 33rd Annual Scientific Meeting. “Researchers have found that red hair is associated with resistance to anesthetics and also to increased anxiety and darker eye color has been reportedly found to correlate with increased physiologic reactivity and drug-induced pupil dilation.”

Dr. Belfer added that her anesthesiology colleagues reported noticing a similar association.

“They said that looking in the eyes of their patients tells them if they can expect more or less trouble during the procedures and they can tell who will develop more severe pain or who will respond differently to anesthesia and analgesia,” she said.

To explore this association further, Dr. Belfer and her group studied eye color and pain-related traits in healthy women who were undergoing labor and delivery.

Dr. Inna Belfer

They assessed antepartum and postpartum pain, mood, sleep, and coping behavior in 58 women who gave birth at UPMC Magee Women’s Hospital. The women were grouped into 2 cohorts based on their eye color: 24 women in the dark group (brown or hazel eye color) and 34 women in the light group (blue or green eye color).

The women were profiled by using standard validated surveys, including the Brief Pain Inventory, PROMIS anxiety/depression/sleep scales, the Pain Catastrophizing Scale, and Quantitative Sensory Testing, to measure their response to pain.

The results showed that women with dark-colored eyes showed increased anxiety compared with women with light-colored eyes (P = .01).

Women with dark-colored eyes also trended toward increased sleep disturbance (P = .19) and less improvement in catastrophizing/rumination (P = .15) compared with women with light eye color.

Those with darker eyes also showed trends toward experiencing more pain than women with light eye color, both at rest (P = .28) and during movement (P = .22) after receiving epidural analgesia.

Darker-eyed women were less tolerant of heat pain and were also more likely to be depressed as a result of their pain than were light-eyed women, Dr. Belfer said.

“Due to the small sample size, we can’t get compelling evidence for our findings, but we do feel that our study has revealed patterns that warrant further studies. We are going to see if there is a link between eye color and clinical pain in part 2 of this project, in men and in women, and in different pain models other than the labor pain model,” Dr. Belfer said.

The reason for any differences in pain response could be genetic, Dr. Belfer said. “I specialize in the molecular physiology of pain and we think that there is a genetic background for these effects,” she said.

Genetic Link Interesting

Dr. Gregory W. Terman

“Essentially what they are looking for are genetic correlates, how genes affect the response to pain,” said Gregory W. Terman, PhD, MD, professor of anesthesiology, University of Washington, Seattle.

“This is interesting. If you can identify different genes that may be important, perhaps we can increase our understanding of the pain picture and why there are differences in the amount of pain some people can tolerate. In this case, they may be looking for yet another gene that is correlated with increased or decreased pain, and there are quite a few of those around,” Dr. Terman, president-elect of the American Pain Society, said.

He agreed that trying to find correlations between patients and pain responses is a promising area of research.

This study was supported by the University of Pittsburgh Department of Anesthesiology Seed Award and New Competitive Medical Research Fund. Dr. Belfer and Dr. Terman have disclosed no relevant financial relationships.

 

Payers and hospitals both expect fee-for-service to dramatically decrease over the next five years, according to a new study commissioned by McKesson and conducted by ORC International.

The study, titled The 2014 State of Value-Based Reimbursement, was based on survey responses from 114 payers and 350 healthcare providers.

The study found 90 percent of payers and 81 percent of hospitals currently offer a mix of fee-for-service and other reimbursement models.

The study also found payers and hospitals anticipate two-thirds of payments will be based on complex reimbursement models with value measures by 2020.

The payers and healthcare providers surveyed had different views on how value-based reimbursement models will impact the financial health of their organization. The study found 60 percent of payers believe making the transition to value-based care will have a positive financial impact on their organizations, while only 35 percent of providers believe value-based models will have a positive impact financially.

Published in Allergy. 2014 Jul;69(7):954-9.

Authors: Reitter M et al

BACKGROUND:

Anaphylactic reactions to neuromuscular blocking agents (NMBAs) can be severe and even fatal. Our aim was to evaluate mortality rate in France from anaphylactic reactions to NMBAs, to identify risk factors for a fatal outcome, and to describe management of the cases that proved fatal.

METHODS:

The French National Pharmacovigilance Database was queried for reports of NMBA anaphylaxis that occurred between January 2000 and December 2011. A questionnaire was sent to regional pharmacovigilance centers to obtain further information on the management of cases with a fatal outcome.

RESULTS:

Two thousand and twenty-two cases of NMBA hypersensitivity were retrieved, of which 84 were fatal (4.1%). Among the 1247 cases of severe NMBA anaphylaxis (grades 3 and 4), independent risk factors associated with a fatal outcome in a multivariate analysis were male gender (female gender: OR = 0.4; 95% CI 0.2-0.7; P = 0.0004), an emergency setting (OR = 2.6; 95% CI 1.5-4.6; P = 0.0007), a history of hypertension (OR = 2.5; 95% CI 1.5-4.4; P = 0.0010) or of other cardiovascular disease (OR = 4.4; 95% CI 2.4-8.1; P less than 0.0001), obesity (OR = 2.4; 95% CI 1.1-5.3; P = 0.0376), and ongoing beta-blocker treatment (OR = 4.2; 95% CI 1.8-9.8; P = 0.0011). All 31 patients with a fatal outcome received epinephrine in a titrated manner according to international guidelines.

CONCLUSION:

Obese males with a history of cardiovascular disease receiving ongoing beta-blocker treatment and undergoing surgery in an emergency setting were at high risk of a fatal outcome after NMBA-induced anaphylaxis. Some epinephrine-resistant cases may play a role in our high mortality rate. New therapeutic approaches need to be developed to treat these cases.

Published in Anaesth Intensive Care. 2014 May;42(3):365-70

Authors: Ogurlu M et al.

Abstract

There is some evidence that propofol may reduce acute postoperative pain; however, the results are inconsistent. Furthermore, there is a paucity of information about the type of anaesthesia and chronic pain.

This study was designed to evaluate the hypothesis that propofol reduces acute and chronic postoperative pain compared with sevoflurane.

In a randomised, prospective, double-blind trial, we assigned 80 patients having open total abdominal hysterectomy surgery to anaesthesia with either sevoflurane or propofol. Anaesthesia was titrated to clinical needs and bispectral index values to between 40 and 60.

Postoperative pain was managed with pethidine and diclofenac. Acute postoperative pain for 24 hours and chronic postoperative pain at one and three months after surgery were evaluated.

The Hospital Anxiety and Depression Scale was used to evaluate patient anxiety and depression after one and three months. There were no significant differences between the groups for opioid consumption or opioid-induced side-effects. Pain scores in the first four hours were significantly higher in the sevoflurane group.

Persistent surgical pain was observed less frequently (7 out of 40 patients in the propofol group and 21 out of 40 in the sevoflurane group at three months post-surgery, P less than 0.01) and pain scores were lower at one and three months in the propofol group (0.78±0.55 versus 2.23±0.73 for the sevoflurane group at three months post-surgery, P less than 0.01). Anxiety and depression scores were significantly lower in the propofol group at three months.

In this study, general anaesthesia with propofol was associated with reduced early acute postoperative and persistent pain, compared to sevoflurane-based anaesthesia, among patients undergoing open abdominal hysterectomy.

Published in Ophthal Plast Reconstr Surg. 2014 Apr 25

Authors: Samimi DB et al.

PURPOSE:

To introduce an elastomeric continuous infusion pump for pain control after outpatient orbital implant surgery.

METHODS:

Retrospective, noncomparative consecutive case series of all patients undergoing enucleation, evisceration, or secondary orbital implantation using the On-Q pain system between August 2004 and January 2006. Postoperative pain score, need for narcotics, and adverse events were recorded. The On-Q catheter is inserted intraoperatively through the lateral lower eyelid into the muscle cone under direct visualization, prior to the orbital implant placement. The On-Q system continually infuses anesthesia (bupivacaine) to the retrobulbar site for 5 days.

RESULTS:

Among 20 patients, mean postoperative period pain score, with On-Q in place, was 1.3 (scale of 0 to 10). Nine patients (45%) did not need any adjunctive oral narcotics. Two patients experienced postoperative nausea. One catheter connector leaked, thereby decreasing delivery of retrobulbar anesthetic resulting a pain level of 6, the highest level in the study. There were no postoperative infections. No systemic toxic effects from bupivacaine were observed clinically.

CONCLUSION:

The On-Q pain pump is widely available, low cost, and requires minimal patient manipulation for the use in orbital implant surgery. The device was safe and appeared to minimize postoperative pain in the authors’ case series.

Published in Clin Orthop Relat Res. 2014 May;472(5):1400-8

Authors: Reinhardt KR et al

BACKGROUND:

Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.

QUESTIONS/PURPOSES:

We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA.

METHODS:

Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded.

RESULTS:

The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p less than 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.

CONCLUSIONS:

A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach.

Published in Arthroscopy. 2014 May;30(5):607-12

Authors: Ravnihar K et al.

PURPOSE:

To evaluate the hypothetical toxic effect of local anesthetics on the articular cartilage using patient data from autologous chondrocyte cultivation with different anesthesia types used for arthroscopic cartilage biopsy specimen procurement.

METHODS:

A retrospective analysis of patient data from the national autologous chondrocyte implantation registry and the corresponding hospital records was approved by the National Medical Ethics Committee. Articular cartilage biopsy specimens from the knees of 49 consecutive patients assigned for autologous chondrocyte implantation (aged 14 to 44 years) were procured from the non-weight-bearing articular surface during arthroscopy under general anesthesia (12 patients), spinal anesthesia (18 patients), or local anesthesia (intra-articular injection of 15 to 20 mL of 2% lidocaine hydrochloride) (19 patients). All the biopsy specimens were further manipulated following the same chondrocyte cultivation protocol. General patient data and surgery-related parameters, together with chondrocyte viability, population doublings, and chondrocyte morphology in biopsy specimens and primary cell cultures, were analyzed and compared across different types of anesthesia.

RESULTS:

Patients in the general, spinal, and local anesthesia groups showed no statistical differences in age (27 years, 29 years, and 32 years, respectively), duration of surgery (36 minutes, 37 minutes, and 39 minutes, respectively), weight of biopsy specimens (110 mg, 178 mg, and 130 mg, respectively), cell viability in cartilage biopsy specimens (67%, 69%, and 78%, respectively) or primary cultures (95%, 95%, and 95%, respectively), and population doublings (5.2, 5.2, and 5.2, respectively). Similar chondrocyte morphology in primary cell cultures was observed among the 3 groups.

CONCLUSIONS:

This retrospective study showed that a single intra-articular injection of lidocaine hydrochloride used for knee arthroscopy did not influence the viability, morphology, and cultivation potential of chondrocytes in articular cartilage biopsy specimens assigned for autologous chondrocyte implantation.

LEVEL OF EVIDENCE:

Level IV, retrospective comparative study.

Hospital charge growth is expected to remain slow in the coming years, according to a Fitch Ratings report.

According to CMS, average hospital charges for most services increased by less than 5 percent in 2011 and 2012, based on data from more than 3,000 hospitals that accept Medicare. Continuing pressure on reimbursements and flattening consumer price index growth for hospital services are expected to keep the growth rate for hospital charges below its historical average, according to Fitch.

Furthermore, Medicare pay cuts resulting from sequestration — which took effect in April 2013 — will slow growth in hospital charges. Sequestration has an estimated annualized impact of $11 billion for healthcare providers, according to the report.

The impact on hospitals will vary depending on reimbursement methodology and payer mix. The report states, “Providers reimbursed under the percentage of charge methodology will likely continue to use charge increases to offset reimbursement pressures from other payers, including Medicare. And providers with a very high exposure to government payers (Medicare and Medicaid) will only have a limited capacity to use charge increases to generate a meaningful benefit to their bottom line.”

Medicare physician payment data reveals some providers are earning inordinate amounts from just one procedure or service, according to an analysis performed by The Wall Street Journal.

Here are five things to know about CMS’ release of physician reimbursement data and unusual billing practices.

1. The Journal’s analysis is based on data CMS released in April including information on more than 880,000 healthcare professionals across the country who received a total of $77 billion in Medicare Part B fee-for-service payments in 2012. With the data, it’s possible to compare 6,000 different types of services, procedures and payments received by individual providers, according to HHS.

2. CMS’ landmark release of physician payment data built on the agency’s decision earlier this year to evaluate Freedom of Information Act, or FOIA, requests from the media on a case-by-case basis for individual Medicare payments made to physicians, effective this past March. Previously, HHS said that “considering the two competing interests of public transparency and privacy,” Medicare physician data could not be provided through FOIA requests. The decision to disclose the data was spurred by a federal judge’s decision last year to lift a 1979 injunction that barred the release of individual physicians’ annual Medicare payments. That court decision stems from a January 2011 request from Dow Jones, publisher of Journal.

3. The Journal’s most recent analysis reveals more than 2,300 physicians received $500,000 or more in Medicare reimbursement in 2012 from a single service or procedure. For instance, the Los Angeles-based practice of physician Ronald S. Weaver, MD, received 98 percent of its $2.3 million in Medicare payments in 2012 for instances of a rarely used cardiac procedure, although Dr. Weaver is not a cardiologist. The procedure — which involves strapping the patient to a bed and using three cuffs to increase blood flow — is seen as a last resort treatment for severe chest pain, and there’s no consensus among cardiologists as to whether it has significant benefits, according to the analysis.

4. The practice of billing mostly for one service isn’t in itself unusual. Physicians can specialize in specific services and build their practices around those treatments. However, according to the Journal, a close examination of those who earn the most from few services shows they are straying from routine medical practice or operating outside their expertise. For example, urologist Evangelos G. Geraniotis, MD, of Hyannis, Mass., received $1 million out of a total of $2.1 million in Medicare payments in 2012 from a cystoscopy and fulguration procedure that isn’t deemed routine in a urological practice, according to the Journal.

5. However, the physicians in question say they aren’t driven by financial incentives and that the treatments they administer help to keep patients healthy. Dr. Weaver said the cardiac procedure he specializes in benefits his patients, and Dr. Geraniotis attributes his billing and treatment practices to a more aggressive approach that keeps patients out of the hospital, according to the Journal.