July 2014

The best-read anesthesiology publication in the United States

YEARS

THE INDEPENDENT MONTHLY NEWSPAPER FOR ANESTHESIOLOGISTS AnesthesiologyNews.com • J u l y 2 0 1 4 • Volume 40 Number 7

anesthesiologynews @anesthesianews

Group Takes Cues From Manufacturing To Tame OR Inefficiences

T

o be successful in commercial manufacturing, a company has to be efficient, speedy, streamlined.

These attributes help surgical practice, too. So when a group of Cleveland-based endocrine surgeons became frustrated with the number of delays and patient cancellations at their clinic, they turned to experts in commercial manufacturing for assistance.

The results?

Increased patient throughput, reduced wait time for consults and quicker scheduling of surgical procedures.

With these improvements, patient cancellations also dropped significantly.

The $3.5 Million Anesthesiologist Fathalla Mashali, MD, accused of bilking Medicare

A

New England anesthesiologg ist stands high above all otherss in Medicare’s recently released list of how much money it pays providders, and court records help explain why he posted Ruthian numbers in a league of mostly singles hitters.

According to records the Centers for Medicare & Medicaid Services (CMSS) made public in April, the anesthesioloo gist, Fathalla Mashali, MD, billed Meddicare $3.47 million in 2012. The total is twice that of the anesthesiologist who came in second place.

Of the 32,641 providers who appear

see efficiencies page 14

see Medicare page 18

10 Game Changers Articles and events that shaped the anesthesia landscape Robert E. Johnstone, MD

“T

op 10” lists are popular. Read a magazine, watch television or take to the Internet and you’ll find them everywhere: The Top 10 places to retire, the 10 best wines under $10, the 10 sexiest movie stars. Even this magazine produces them. Find in the January issue, “The 10 most-viewed articles of 2013 on AnesthesiologyNews.com.”

FEATURED PRODUCT see page 18 Humbles LapWrap,® From Innovative Medical Products, Inc.

Robert E. Johnstone, MD

Now anesthesiologists have an all-time, double Top 10 list: “Game changers: ers: The 20 most important anesthesia articles ever published.”a Providing clout to the list are the compiler affiliations— Cushing/ Whitney Medical Library (D. Hersey), Wood Library Museum of Anesthesiology (K. Bieterman), and Yale University (P. Barash).

Presented at the PostGraduate Assembly of Anesthesia in 2013, and scheduled see articles page 8

NEW iPAD APP See page 16

11

CLINICAL ANESTHESIOLOGY

Steroids flunk another test in bypass patients.

16

POLICY & MANAGEMENT

Group practices may not equal higher pay for clinicians.

19

PAIN MEDICINE

Finally, a diet that doesn’t hurt.

Be the Owner of the Perioperative Home in Your Facility Practical Application of an Innovative Initiative

The surgical home is a widely discussed but rarely implemented concept in the healthcare industry. The TelePREOP platform is designed specifically to engage all parties of the perioperative process to promote coordination of care for the patient.

TelePREOP leverages an industry leader in the technology platform we selected, ePREOP. TelePREOP can engage all Hospital Information Systems that power your healthcare facilities without the overwhelming burden of implementation.

The power of the TelePREOP service and platform is that we screen nearly all of your patients prior to the procedure. This effort ensures coordinated data flow from Labs, H&P, and clearances from Cardiac and Anesthesia. This combined with our employed nurses dramatically reduces your case cancellations and delays while streamlining your bottom line.

www.TelePREOP.com

Can You Ever Have Too Much of a Good Thing?

We all know that data helps us make better, more-educated decisions. But collecting large amounts of data is ineffective without the proper tools to display those insights. Without understanding the context of a specific metric, it can be easily misunderstood and misrepresented.

Physicians and managers alike require a smooth transition from the clinical, administrative, and operational data sets to better understand the true messages that the data is trying to tell.

Make the Data Work for You F1RSTAnalytics is the ultimate in technical sophistication. It offers data prowess, providing the data to aid in operating your anesthesia practice as an effective clinical organization and successful business. The information you need, provided in a way you can use it.

4 I AnesthesiologyNews.com

JULY 2014

Comment on these and other articles @ AnesthesiologyNews.com.

Heard Here First: There are only so many patients in whom an A-line is otherwise July 2014

indicated. So if you have a mechanism

The five most-viewed articles last month on AnesthesiologyNews.com

that works noninvasively,

it might be useful,

1. Reduce Costs With Selective Pre-Op Testing 2. Current Concepts in the Management of the Difficult Airway (Educational Review)

particularly in the morbidly obese,

3. Lap Chole Rates Surge in Younger Patients (Web Exclusive)

where we have more management

4. Nerve Block Eases Hot Flashes

questions than answers, including

5. A Farewell Letter to Residents

the question of fluid management.

Register for free @ AnesthesiologyNews.com to read these and other articles.

See article on page 14

ACT NOW!

Looking for a PreAnesthetic Assessment CME lesson?

Visit www.mssm.procampus.net.

Renew your free print subscription to

today at AnesthesiologyNews.com/Renew

ROBERT S. LAGASSE, MD, New Haven, CT

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Different situations require different sedative solutions The first and only alpha2 agonist indicated for sedation1-2

Important Precedex Safety Information

Nonintubated patients prior to and during surgical and other procedures.1 Initially intubated and mechanically ventilated patients during treatment in an intensive care setting.1 Administer Precedex™ by continuous infusion not to exceed 24 hours.1

Clinically significant episodes of bradycardia, sinus arrest and hypotension have been associated with Precedex infusion and may necessitate medical intervention.

Moderate blood pressure and heart rate reductions should be anticipated when initiating sedation with Precedex.

Prolonged exposure to dexmedetomidine beyond 24 hours may be associated with tolerance and tachyphylaxis and a doserelated increase in adverse events.

Learn more at precedex.com

A right fit for today’s sedation management practices

Please see the brief summary of Prescribing Information on adjacent page.

References: 1. Precedex [package insert]. Lake Forest, IL: Hospira, Inc; 2013. 2. Kamibayashi T, Maze M. Clinical uses of α2-adrenergic agonists. Anesthesiology. 2000;93:1345-1349.

Hospira, Inc., 275 North Field Drive, Lake Forest, IL 60045 P14-0182-5-10.5x13-Jan., 14 Printed in the USA.

For more information on Advancing WellnessTM, contact your Hospira representative at 1-877-9HOSPIRA (1-877-946-7747) or visit hospira.com.

BRIEF SUMMARY OF PRESCRIBING INFORMATION PLEASE SEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION.

Precedex™ (dexmedetomidine hydrochloride) Injection For intravenous use.

Precedex

™

(dexmedetomidine hydrochloride) in 0.9% Sodium Chloride Injection

Rx Only

6 ADVERSE REACTIONS 6.1 Clinical Studies Experience Because clinical trials are conducted under widely varying conditions, adverse reactions rates observed in the clinical trials of a drug cannot be directly compared to rates in clinical trials of another drug and may not reflect the rates observed in practice.

Use of Precedex has been associated with the following serious adverse reactions: • Hypotension, bradycardia and sinus arrest [see Warnings and Precautions (5.2)] • Transient hypertension [see Warnings and Precautions (5.3)] Most common treatment-emergent adverse reactions, occurring in greater than 2% of patients in both Intensive Care Unit and procedural sedation studies include hypotension, bradycardia and dry mouth.

Intensive Care Unit Sedation Adverse reaction information is derived from the continuous infusion trials of Precedex for sedation in the Intensive Care Unit setting in which 1007 adult patients received Precedex. The mean total dose was 7.4 mcg/kg (range: 0.8 to 84.1), mean dose per hour was 0.5 mcg/kg/hr (range: 0.1 to 6.0) and the mean duration of infusion of 15.9 hours (range: 0.2 to 157.2). The population was between 17 to 88 years of age, 43% ≥65 years of age, 77% male and 93% Caucasian. Treatment-emergent adverse reactions occurring at an incidence of >2% are provided in Table 1. The most frequent adverse reactions were hypotension, bradycardia and dry mouth [see Warnings and Precautions (5.2)].

Table 1: Adverse Reactions with an Incidence >2%—Adult Intensive Care Unit Sedation Population <24 hours*

1 INDICATIONS AND USAGE 1.1 Intensive Care Unit Sedation Precedex™ is indicated for sedation of initially intubated and mechanically ventilated patients during treatment in an intensive care setting. Precedex should be administered by continuous infusion not to exceed 24 hours.

Precedex has been continuously infused in mechanically ventilated patients prior to extubation, during extubation, and post-extubation. It is not necessary to discontinue Precedex prior to extubation.

1.2 Procedural Sedation Precedex is indicated for sedation of non-intubated patients prior to and/or during surgical and other procedures.

4

CONTRAINDICATIONS

None

5 WARNINGS AND PRECAUTIONS 5.1 Drug Administration Precedex should be administered only by persons skilled in the management of patients in the intensive care or operating room setting. Due to the known pharmacological effects of Precedex, patients should be continuously monitored while receiving Precedex.

5.2 Hypotension, Bradycardia, and Sinus Arrest Clinically significant episodes of bradycardia and sinus arrest have been reported with Precedex administration in young, healthy adult volunteers with high vagal tone or with different routes of administration including rapid intravenous or bolus administration.

Reports of hypotension and bradycardia have been associated with Precedex infusion. If medical intervention is required, treatment may include decreasing or stopping the infusion of Precedex, increasing the rate of intravenous fluid administration, elevation of the lower extremities, and use of pressor agents. Because Precedex has the potential to augment bradycardia induced by vagal stimuli, clinicians should be prepared to intervene. The intravenous administration of anticholinergic agents (e.g., glycopyrrolate, atropine) should be considered to modify vagal tone. In clinical trials, glycopyrrolate or atropine were effective in the treatment of most episodes of Precedex-induced bradycardia. However, in some patients with significant cardiovascular dysfunction, more advanced resuscitative measures were required.

Caution should be exercised when administering Precedex to patients with advanced heart block and/or severe ventricular dysfunction. Because Precedex decreases sympathetic nervous system activity, hypotension and/or bradycardia may be expected to be more pronounced in patients with hypovolemia, diabetes mellitus, or chronic hypertension and in elderly patients.

In clinical trials where other vasodilators or negative chronotropic agents were co-administered with Precedex an additive pharmacodynamic effect was not observed. Nonetheless, caution should be used when such agents are administered concomitantly with Precedex.

5.3 Transient Hypertension Transient hypertension has been observed primarily during the loading dose in association with the initial peripheral vasoconstrictive effects of Precedex. Treatment of the transient hypertension has generally not been necessary, although reduction of the loading infusion rate may be desirable.

5.4 Arousability Some patients receiving Precedex have been observed to be arousable and alert when stimulated. This alone should not be considered as evidence of lack of efficacy in the absence of other clinical signs and symptoms.

5.5 Withdrawal Intensive Care Unit Sedation With administration up to 7 days, regardless of dose, 12 (5%) Precedex adult subjects experienced at least 1 event related to withdrawal within the first 24 hours after discontinuing study drug and 7 (3%) Precedex adult subjects experienced at least 1 event 24 to 48 hours after end of study drug. The most common events were nausea, vomiting, and agitation.

In adult subjects, tachycardia and hypertension requiring intervention in the 48 hours following study drug discontinuation occurred at frequencies of <5%. If tachycardia and/or hypertension occurs after discontinuation of Precedex supportive therapy is indicated.

Procedural Sedation In adult subjects, withdrawal symptoms were not seen after discontinuation of short term infusions of Precedex (<6 hours).

5.6 Tolerance and Tachyphylaxis Use of dexmedetomidine beyond 24 hours has been associated with tolerance and tachyphylaxis and a dose-related increase in adverse reactions [see Adverse Reactions (6.1)].

5.7 Hepatic Impairment Since Precedex clearance decreases with severity of hepatic impairment, dose reduction should be considered in patients with impaired hepatic function [see Dosage and Administration (2.2) in full prescribing information].

All Precedex Adverse Event

(N = 1007) (%)

Hypotension Hypertension Nausea Bradycardia Atrial Fibrillation Pyrexia Dry Mouth Vomiting Hypovolemia Atelectasis Pleural Effusion Agitation Tachycardia Anemia Hyperthermia Chills Hyperglycemia Hypoxia Post-procedural Hemorrhage Pulmonary Edema Hypocalcemia Acidosis Urine Output Decreased Sinus Tachycardia Ventricular Tachycardia Wheezing Edema Peripheral

25% 12% 9% 5% 4% 4% 4% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2% 2% 1% 1% 1% 1% 1% <1% <1% <1%

Randomized Precedex (N = 798) (%) 24% 13% 9% 5% 5% 4% 3% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2% 2% 1% 1% 1% 1% 1% 1% 1% 0

Placebo

Propofol

(N = 400)

(N = 188)

(%)

(%)

12% 19% 9% 3% 3% 4% 1% 5% 2% 3% 1% 3% 4% 2% 3% 3% 2% 2% 3% 1% 0 1% 0 1% 1% 0 1%

13% 4% 11% 0 7% 4% 1% 3% 5% 6% 6% 1% 1% 2% 0 2% 3% 3% 4% 3% 2% 2% 2% 2% 5% 2% 2%

* 26 subjects in the all Precedex group and 10 subjects in the randomized Precedex group had exposure for greater than 24 hours.

Adverse reaction information was also derived from the placebo-controlled, continuous infusion trials of Precedex for sedation in the surgical intensive care unit setting in which 387 adult patients received Precedex for less than 24 hours. The most frequently observed treatment-emergent adverse events included hypotension, hypertension, nausea, bradycardia, fever, vomiting, hypoxia, tachycardia and anemia (see Table 2).

Table 2: Treatment-Emergent Adverse Events Occurring in >1% Of All Dexmedetomidine-Treated Adult Patients in the Randomized Placebo-Controlled Continuous Infusion <24 Hours ICU Sedation Studies Adverse Event Hypotension Hypertension Nausea Bradycardia Fever Vomiting Atrial Fibrillation Hypoxia Tachycardia Hemorrhage Anemia Dry Mouth Rigors Agitation Hyperpyrexia Pain

Randomized Dexmedetomidine

Placebo

(N = 387) 28% 16% 11% 7% 5% 4% 4% 4% 3% 3% 3% 3% 2% 2% 2% 2%

(N = 379) 13% 18% 9% 3% 4% 6% 3% 4% 5% 4% 2% 1% 3% 3% 3% 2%

Table 2: Treatment-Emergent Adverse Events Occurring in >1% Of All Dexmedetomidine-Treated Adult Patients in the Randomized Placebo-Controlled Continuous Infusion <24 Hours ICU Sedation Studies (continued) Adverse Event Hyperglycemia Acidosis Pleural Effusion Oliguria Thirst

Randomized Dexmedetomidine

Placebo

(N = 387) 2% 2% 2% 2% 2%

(N = 379) 2% 2% 1% <1% <1%

The mean total dose was 1.6 mcg/kg (range: 0.5 to 6.7), mean dose per hour was 1.3 mcg/kg/hr (range: 0.3 to 6.1) and the mean duration of infusion of 1.5 hours (range: 0.1 to 6.2). The population was between 18 to 93 years of age, 30% ≥65 years of age, 52% male and 61% Caucasian.

Treatment-emergent adverse reactions occurring at an incidence of >2% are provided in Table 5. The most frequent adverse reactions were hypotension, bradycardia, and dry mouth [see Warnings and Precautions (5.2)]. Pre-specified criteria for the vital signs to be reported as adverse reactions are footnoted below the table. The decrease in respiratory rate and hypoxia was similar between Precedex and comparator groups in both studies.

Table 5: Adverse Reactions With an Incidence > 2%—Procedural Sedation Population

Adverse Event In a controlled clinical trial, Precedex was compared to midazolam for ICU sedation exceeding 24 hours duration in adult patients. Key treatment emergent adverse events occurring in dexmedetomidine or midazolam treated patients in the randomized active comparator continuous infusion long-term intensive care unit sedation study are provided in Table 3. The number (%) of subjects who had a dose-related increase in treatment-emergent adverse events by maintenance adjusted dose rate range in the Precedex group is provided in Table 4.

Hypotension1 Respiratory Depression2 Bradycardia3 Hypertension4 Tachycardia5 Nausea Dry Mouth Hypoxia6 Bradypnea

Table 3: Key Treatment-Emergent Adverse Events Occurring in Dexmedetomidine- or Midazolam-Treated Adult Patients in the Randomized Active Comparator Continuous Infusion Long-Term Intensive Care Unit Sedation Study Adverse Event

Dexmedetomidine

Midazolam

(N = 244)

(N = 122)

56%

56%

28%

27%

42%

19%

5%

1%

28%

42%

Hypotension1 Hypotension Requiring Intervention Bradycardia2 Bradycardia Requiring Intervention Systolic Hypertension3 4

Precedex

Placebo

(N = 318)

(N = 113)

(%)

(%)

54% 37% 14% 13% 5% 3% 3% 2% 2%

30% 32% 4% 24% 17% 2% 1% 3% 4%

1

Hypotension was defined in absolute and relative terms as Systolic blood pressure of <80 mmHg or ≤30% lower than prestudy drug infusion value, or Diastolic blood pressure of <50 mmHg.

2

Respiratory depression was defined in absolute and relative terms as respiratory rate (RR) <8 beats per minute or > 25% decrease from baseline.

3

Bradycardia was defined in absolute and relative terms as <40 beats per minute or ≤30% lower than pre-study drug infusion value.

4

Hypertension was defined in absolute and relative terms as Systolic blood pressure >180 mmHg or ≥30% higher than pre-study drug infusion value or Diastolic blood pressure of >100 mmHg.

5

Tachycardia was defined in absolute and relative terms as >120 beats per minute or ≥30% greater than pre-study drug infusion value.

Hypoxia was defined in absolute and relative terms as SpO2 <90% or 10% decrease from baseline.

25%

44%

10%

10%

12%

15%

11%

15%

19%

30%

6

Hypokalemia

9%

13%

6.2 Postmarketing Experience

Pyrexia

7%

2%

Agitation

7%

6%

Hyperglycemia

7%

2%

Constipation

6%

6%

The following adverse reactions have been identified during post approval use of Precedex. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Hypotension and bradycardia were the most common adverse reactions associated with the use of Precedex during post approval use of the drug.

Hypoglycemia

5%

6%

Respiratory Failure

5%

3%

Renal Failure Acute

2%

1%

Acute Respiratory Distress Syndrome

2%

1%

Generalized Edema

2%

6%

Hypomagnesemia

1%

7%

Tachycardia

Tachycardia Requiring Intervention Diastolic Hypertension3 Hypertension

3

Hypertension Requiring Intervention†

Table 6: Adverse Reactions Experienced During Post-approval Use of Precedex Body System

Preferred Term

Body as a Whole

Fever, hyperpyrexia, hypovolemia, light anesthesia, pain, rigors

Cardiovascular Disorders, General

Blood pressure fluctuation, heart disorder, hypertension, hypotension, myocardial infarction

Central and Peripheral Nervous System Disorders

Dizziness, headache, neuralgia, neuritis, speech disorder, convulsion

Gastrointestinal System Disorders

Abdominal pain, diarrhea, vomiting, nausea

Heart Rate and Rhythm Disorders

Arrhythmia, ventricular arrhythmia, bradycardia, hypoxia, atrioventricular block, cardiac arrest, extrasystoles, atrial fibrillation, heart block, t wave inversion, tachycardia, supraventricular tachycardia, ventricular tachycardia

Liver and Biliary System Disorders

Increased gamma-glutamyl transpepsidase, hepatic function abnormal, hyperbilirubinemia, alanine transaminase, aspartate aminotransferase

The following adverse events occurred between 2 and 5% for Precedex and Midazolam, respectively: renal failure acute (2.5%, 0.8%), acute respiratory distress syndrome (2.5%, 0.8%), and respiratory failure (4.5%, 3.3%).

Metabolic and Nutritional Disorders

Acidosis, respiratory acidosis, hyperkalemia, increased alkaline phosphatase, thirst, hypoglycemia

Table 4. Number (%) of Adult Subjects Who Had a Dose-Related Increase in Treatment Emergent Adverse Events

by Maintenance Adjusted Dose Rate Range in the Precedex Group

Psychiatric Disorders

Agitation, confusion, delirium, hallucination, illusion

Red Blood Cell Disorders

Anemia

Renal Disorders

Blood urea nitrogen increased, oliguria

Respiratory System Disorders

Apnea, bronchospasm, dyspnea, hypercapnia, hypoventilation, hypoxia, pulmonary congestion

Skin and Appendages Disorders

Increased sweating

Vascular Disorders

Hemorrhage

Vision Disorders

Photopsia, abnormal vision

†

Includes any type of hypertension.

1

Hypotension was defined in absolute terms as Systolic blood pressure of <80 mmHg or Diastolic blood pressure of <50 mmHg or in relative terms as ≤30% lower than pre-study drug infusion value.

2

Bradycardia was defined in absolute terms as <40 bpm or in relative terms as ≤30% lower than pre-study drug infusion value.

3

Hypertension was defined in absolute terms as Systolic blood pressure >180 mmHg or Diastolic blood pressure of >100 mmHg or in relative terms as ≥30% higher than pre-study drug infusion value.

4

Tachycardia was defined in absolute terms as >120 bpm or in relative terms as ≥30% greater than pre-study drug infusion value.

Precedex mcg/kg/hr Adverse Event Constipation Agitation Anxiety Edema Peripheral Atrial Fibrillation Respiratory Failure Acute Respiratory Distress Syndrome

≤0.7*

>0.7 to ≤1.1*

>1.1*

(N = 95)

(N = 78)

(N = 71)

6% 5% 5% 3% 2% 2% 1%

5% 8% 5% 5% 4% 6% 3%

14% 14% 9% 7% 9% 10% 9%

* Average maintenance dose over the entire study drug administration Procedural Sedation Adverse reaction information is derived from the two trials for procedural sedation in which 318 adult patients received Precedex.

Adapted from: EN-3411; Revised 12/2013 Manufactured and Distributed by: Hospira, Inc., Lake Forest, IL 60045 USA Licensed from: Orion Corporation, Espoo, Finland P14-0164-5-10.5x13-Feb.,14 Printed in USA Hospira, Inc., Lake Forest, IL 60045 USA

8 I AnesthesiologyNews.com

JULY 2014

COMMENTARY ARTICLES

CONTINUED FROM PAGE 1

for journal publication, the list is sure to attract readers, excite academicians and guide historians. The compilers tout 75 years of research experience and describe their selected articles as having creativity, innovation and social impact.

Perhaps they did, but most are old history, not current concerns. They invented the world I started with— one with needles, syringes, cocaine, curare and written records. Our current stressors are more recent, and evidenced by both events and articles.

In fact, the 20-most-importantarticles list contains 22 titles, an apparent bulwark against omissions, but it still misses recent ones. Eleven were published before I was born, and only three since I entered anesthesiology.

Thus, I offer my own Top 10 list of articles and events published or occurring during my lifetime that have changed the practice of anesthesiology—especially my own—and are still influencing the specialty. Incredibly, none made the just-compiled all-time list, so readers can pick from both to build their own.

1.

A fable of anesthesia for our time. J Comm Soc Med 1959;3:47-53. This anonymous essay tells the story of a mouse anesthesiologist, a bear chief of surgery and a fox hospital administrator. The mouse does most of the work, the bear accepts the glory and the fox gets the money. Resonating with readers, numerous journals republished this story, never with an attribution. When someone snuck a copy to me as a resident, to be read out of sight of bears and foxes, it changed my life. Who knew that medical journals could publish stories, written in active voice, with social comments? I trace my commentaries, the expanded fare of journals and the inclusion of socioeconomics in articles today to this essay. Of course, bears still accept undeserved awards and foxes welcome mouse-generated monies, but mice can mock them in authored essays, and keep working. Or perhaps bears and foxes cannot read.

2.

Egbert LD, et al. The value of the preoperative visit by an anesthetist. JAMA 1963;185:553-555. This study determined that a preoperative visit by an anesthesiologist calmed patients more than premedications. After its publication, the American Society of Anesthesiologists (ASA) made preoperative

6.

visits an ethical duty, and Medicare has made it a requirement for payments.

This study changed anesthetic practice forever: beforehand just a premedication shot, afterwards a physician visit with a plan and informed consent.

“The Deep Sleep,” 20/20 program, ABC Television, 1982. This national program gave prime-time coverage to unsafe anesthesia practices, declaring, “6,000 will die or suffer brain damage … from carelessness.” This dramatic exposé caused much public debate and pressure for action. It led to the start of the ASA Closed Claims database in 1983, the founding of the Anesthesia Patient Safety Foundation in 1984, and establishment of monitoring standards in 1986. Ultimately, this show prompted safety reforms that substantially reduced anesthesia malpractice premiums.

3.

Grace Slick. White Rabbit.

1967.

7 Jefferson Airplane released the song “White Rabbit” in 1967, and introduced America to psychedelic rock. It was one of the first songs played on radio that glorified drugs such as LSD, and promoted experimentation with the lyrics, “Feed your head.” “White Rabbit” amplified drug abuse with hallucinogens, including ketamine when it was introduced in 1970. Before “White Rabbit,” abuse of anesthetics was considered low class and dirty. After, it seemed hip and mindexpanding. The explosion of drug abuse among anesthesia clinicians in the 1970s and 1980s, from which the specialty is still recovering, can be traced to this song. Lyrics from “White Rabbit” appeared in the journal Anesthesiology in October 1973.

4.

Gravenstein JS, et al. Analysis of manpower in anesthesiology. Anesthesiology 1970;33:350-357. This is the seminal article justifying anesthesia care teams.

The three authors, physician anesthesiology leaders of the day, one the president of the ASA, wrote: “It is possible to design a system in which one anesthesiologist directs anesthetic procedures in more than one room with the help of an anesthesia team. Members of the team may include nurses.”

Before this article, most anesthesiologists personally administered their anesthetics. Afterward, team-based care with nurses became the predominant delivery mode, and many medical students chose different specialties.

If this leadership article had envisioned and promoted a different future, health care might not have today’s scope of practice confusion.

5.

Standards for ObstetricGynecologic Services. American College of Obstetricians and Gynecologists, Professional Standards Committee, Robert Johnstone,b chair, 1982. This revision of the standards of practice for obstetricians underlay the rapid growth of obstetric anesthesiology in the 1980s. Before these standards, obstetricians often provided both obstetric and anesthesia care to their patients. Afterward, the public expected anesthesiologists to provide anesthesia, while surgeons and obstetricians focused on their work.

7.

Brain A. The laryngeal mask—a new concept in airway management. Br J Anaesth 1983;55:801-806. Dr. Archie Brain developed the laryngeal mask airway, then described it to clinicians as “a new type of airway … which may be used as an alternative to either the endotracheal tube or the face-mask with either spontaneous or positive pressure ventilation.” This invention transformed clinical practice, with several hundred million used since its introduction. Some anesthesia clinicians now work for days at a time without inserting an endotracheal tube.

8.

Hsiao WC, et al. Estimating physicians’ work for a resource-based relative-value scale. N Engl J Med 1988;319:835-841.

Hsiao led a health policy group that assessed physician work—and severely undervalued anesthesia. They asked a sample of physicians to estimate the work involved in nine anesthesia procedures, such as anesthesia for a total hip replacement, as well as some other medical services, like the interpretation of a routine electrocardiogram. They then compared these estimates and extrapolated the differences hundreds of times to produce the work values for anesthesia services in the Medicare fee schedule, greatly magnifying small errors. The resulting underpayments to anesthesiologists, relative to other specialties, has proven impossible to correct, and forced the specialty to depend on institutions for financial support.

9.

Minnesota Association of Nurse Anesthetists Antitrust and Medicare Fraud Lawsuit, 1994. A group of nurse anesthetists stunned the anesthesia community when they filed antitrust and Medicare fraud lawsuits against 65 anesthesiologists and five hospitals. The nurses

JULY 2014

AnesthesiologyNews.com I 9

COMMENTARY apparently kept records to show the anesthesiologists failed to comply with Medicare billing requirements. The trigger for this dramatic action was the retention by Minnesota hospitals of anesthesiologists while laying off nurse anesthetists. The nurse anesthetist president of the Minnesota association stated: “This was all about (anesthesiologist) money, power, and greed.” The result was a decade of enormously expensive lawyering, appeals from both sides for national support and heated rhetoric that created professional disharmony that persists to this day.

Board of Anesthesiology to 10-yearr certifications that boosted lifelong learning.

But the Top 10 discussed here should make most game-changer lists, at least as compiled by mid-careerr clinicians.

Robert E. Johnstone, MD, is professor of anesthesiology at West Virginia University, in Morgantown. This commentary represents his personal opinions. a

Poster 9098. 67th PostGraduate Assembly in Anesthesiology, 2013. b Disclosure: The author’s father.

questions comments story ideas Contact Editor Adam Marcus at

amarcus@mcmahonmed.com

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10.

Anders G. Once a hot specialty, anesthesiology cools as insurers scale back. Wall St J 1995;Mar 17:1.

The Wall Street Journall published a front-page article describing anesthesiology as a specialty with “bleak job prospects,” adding that “some experts think more retrenchment is imminent.” The article related how a recently trained cardiac anesthesiologist was forced to become “a migrant medical worker.”

For several years after this shocking article, few U.S. medical students entered anesthesiology training, and medical schools reduced anesthesiology program support. A decrease in surgeries, one basis for this predicted retrenchment, never materialized.

However, this article and a diminished perception of the future for anesthesiologists led to a severe shortage of clinicians, their recruitment from outside the United States to keep surgical suites open, and a decline in anesthesiology research. Workforce distortion continues to affect supply-and-demand analyses today.

Other articles and events have changed anesthesia practices, and still are changing them—for example, the inadequate anesthetic of Carol Weihrer that led her to found the Anesthesia Awareness Campaign; the report

by Ronald Miller, MD, on future paradigms of anesthesia practice that focused the specialty on perioperative care; and the move by the American

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REFERENCE 1 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society: Major Complications of Airway Management in the United Kingdom. Report and findings: March 2011. Editors: Dr Tim Cook, Dr Nick Woodall and Dr Chris Frerk.

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10 I AnesthesiologyNews.com

JULY 2014

CLINICAL ANESTHESIOLOGY

General Anesthesia Linked to Mortality in Stroke Patients San Francisco—Although general anesthesia and conscious sedation seem to equally affect functional independence at discharge in patients with acute ischemic stroke undergoing endovascular intervention therapy, patients who received general anesthesia experienced significantly greater mortality than their counterparts, researchers have found.

Whether this difference is directly attributable to anesthesia type, however, is unclear, as the duration of intra-arterial therapy and time to revascularization from symptom onset were both significantly longer in patients who received general anesthesia, according to the study.

“Ischemic stroke has an extremely high mortality rate—16%—in patients presenting for first-time stroke,” said Kathryn Rosenblatt, MD, an anesthesiology resident at SUNY Upstate Medical University, in Syracuse, N.Y., who helped conduct the study. “Endovascular clot retrieval helps remove intracranial clot occlusions in ischemic stroke

patients. Although the therapy can be performed under moderate conscious sedation or general anesthesia, the effect of general anesthesia on clinical outcomes has remained controversial.”

In previous work, Jumaa and colleagues reported that general anesthesia resulted in favorable clinical and radiographic outcomes compared with local anesthesia (Stroke 2010;41:1180-1184). However, three recent retrospective studies have suggested that general anesthesia might worsen neurologic outcome and increase mortality in these patients (Strokee 2010;41:1175-1179; J Neurointerv Surgg 2010;2:67-70; Anesthesiology 2012;116:244-245).

To help identify the relationship between type of anesthesia and outcome, senior investigator Fenghua Li, MD, associate professor of anesthesiology and associate director of neuroanesthesia at SUNY Upstate, and his colleagues studied the records of 109 patients, each of whom underwent endovascular therapy between

December 2006 and October 2012.

Thirty-five patients received general anesthesia; 74 received conscious sedation.

The two groups were similar with respect to patient characteristics and clinical conditions on admission, according to the researchers. Patients who required intubation on arrival for surgery were more likely to receive general anesthesia, Dr. Li noted. Duration of intra-arterial therapy and time to revascularization from symptom onset were significantly longer in patients who received general anesthesia (2.1±1.1 versus 1.4±0.7 hours, and 7.1±2.2 versus 6.0±2.0 hours, respectively).

Mortality also was significantly higher in patients who received general anesthesia (40% vs. 22%; P<0.05).

However, the method of anesthesia did not have a significant effect on patients’ functional independence at discharge, the researchers reported.

A regression analysis demonstrated that two of the significant

predictors for mortality in the model were anesthesia type (odds ratio [OR], 2.692; 95% confidence interval [CI], 1.036-6.996; P=0.042) and post-procedure glucose level (OR, 1.014, 95% CI, 1.003-1.024; P=0.011; respectively). “A larger sample size is needed to determine with statistical certainty that the relationship between general anesthesia and mortality is independent of the ability to maintain a patent airway upon admission and the stroke size, location and severity,” Dr. Rosenblatt said.

“This study is very similar to a couple other retrospective studies that showed that general anesthesia did predict worse outcomes,” she added. “We also saw that if you survive the hospitalization, your functional independence level at discharge was no different between general anesthesia and conscious sedation. The reason for this remains unclear, since it would be expected that the longer procedure time and time to revascularization in see stroke page 13

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AnesthesiologyNews.com I 11

CLINICAL ANESTHESIOLOGY

Steroids Fail Another Test in Bypass Surgery

G

iving steroids to reduce inflammation during cardiopulmonary bypass has no benefit, and may in fact harm patients who receive the drugs, new research shows.

An international study of more than 7,500 patients, the largest of its kind to date, is the latest to find that the prophylactic administration of IV steroids during bypass procedures does not reduce mortality or prevent heart attacks in this population. Roughly onefourth of hospitals worldwide use the treatment—suggesting that thousands of patients each year may be at risk from the approach.

Taken with the findings of a 2012 Dutch study, DECS (Dexamethasone for Cardiac Surgery), the new results may mean that the use of steroids to reduce postoperative myocardial infarction (MI) has reached a dead end.

“I want to be careful to avoid throwing the baby out with the bath water here. The crux of the hypothesis was that inflammation is bad, and cardiopulmonary bypass incites a lot of inflammation in these patients,” said Richard Whitlock, MD, assistant professor of cardiac surgery at McMaster University in Hamilton, Ontario, Canada, who led the trial. “Now, with SIRS [Steroids in CaRdiac Surgery trial] and DECS we have more than 12,000 patients for whom a therapy that strongly suppresses that inflammatory response shows no clinical benefit. It does suggest that this is a pathway into which further resources should not be invested.”

What’s more, not only do steroids not appear to help, the studies show an “important signal of harm”—more heart attacks, Dr. Whitlockk said. “This is a novel finding, and it will perhaps open up pathways” to investigate. “This pathway of MI caused by steroids—if it’s glucose-based, maybe some therapy that focuses on glucose control” will help where previous approaches have failed.

The DECS researchers reported no benefit from dexamethasone in patients having coronary artery bypass grafting, although the drug did appear to reduce the risk for death, heart attack and other poor outcomes in the sickest patients. That ambiguity left room for the results of the recent SIRS trial—which experts hoped would definitively answer the question.

The 7,507 patients in SIRS, who were considered to be at high risk for poor outcomes, received either 500 mg of IV methylprednisolone intraoperatively or a placebo injection. The

researchers performed intention-totreat analyses on 3,755 patients in the steroid arm and 3,752 patients in the placebo arm.

The two primary end points were total mortality within 30 days of surgery and a composite of death, MI, stroke, new-onset kidney failure and respiratory failure. Secondary outcomes included transfusion

to occur within the first 72 hours after the procedure, and most were non–QQ wave MIs. requirement within 24 hours of surC. David Mazer, MD, a professor in gery, hospital and ICU lengths of stay, the Department of Anesthesia at the delirium, and two measures of blood University of Toronto, said many censugar: postoperative use of insulin and ters use steroids for patients undergopeak blood glucose concentrations. ing deep hypothermic arrest. The latest More patients in the steroid group data “raise the issue of whether we experienced an MI after surgery than should be using” steroids in this popuin the placebo arm (13.3% vs. 10.9%, lation, Dr. Mazer said. respectively; P=0.001), according to —Adam Marcus the researchers. Those events tended

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12 I AnesthesiologyNews.com

JULY 2014

CLINICAL ANESTHESIOLOGY

Nerve Blocks Linked to Improved Tissue Oxygenation San Franciscoâ&#x20AC;&#x201D;Muscle oxygenation in patients undergoing total knee arthroplasty may be positively affected by neuraxial blockade, a phenomenon that may confer several long-term benefits, researchers have found.

The pilot study, by a team of American and Austrian researchers, showed that muscle oxygenation decreased more in the upper than the lower

extremity, which may be the result of regional sympatholysis in the areas affected by neuraxial block and a subsequent net increase in perfusion in unaffected regions. â&#x20AC;&#x153;Numerous experimental studies have demonstrated a beneficial effect of neuraxial blockade on microcirculation,â&#x20AC;? said Ottokar Stundner, MD, a resident and research fellow

at Paracelsus Medical University in Salzburg, Austria, who helped conduct the study while at the Hospital for Special Surgery, in New York City. â&#x20AC;&#x153;There is also some evidence that muscle oxygenation could be a surrogate parameter for tissue perfusion at the end-organ level.â&#x20AC;?

Clinical information on this phenomenon is scant, however, and how

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Current Symptoms Â&#x2021; Dyspnea Vital Signs Â&#x2021; Height: 175 cm Â&#x2021; Weight: 85 kg 6LJQLÂżFDQW 0HGLFDO +LVWRU\ Â&#x2021; Hypertension Â&#x2021; Congestive heart failure Â&#x2021; Obstructive sleep apnea &XUUHQW 0HGLFDWLRQV Â&#x2021; Metoprolol 100 mg PO Â&#x2021; Ramipril 2.5 mg PO Laboratory Results Â&#x2021; Apnea hypopnea index: 26/h Â&#x2021; Left ventricular ejection fraction: 30%-35% Anesthesia is induced with sufentanil, propofol, and 0.6 mg/ kg rocuronium based on total body weight and maintained ZLWK GHVĂ&#x20AC;XUDQH LQ DLU R[\JHQ DQG VXIHQWDQLO 6XUJLFDO FRQGLWLRQV DUH GLIÂżFXOW ZLWK D ODFN RI DEGRPLQDO ZDOO PXVFOH relaxation and poor paralysis. An extra dose of rocuronium is administered for deeper neuromuscular block (NMB), and fewer than 2 train-of-four (TOF) responses are noted.

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perfusion behaves above and below the level of sympathetic blockade is unclear, Dr. Stundner said. So, he and his colleagues compared tissue perfusion above and below the level of neuraxial blockade in the clinical setting, using noninvasive near-infrared spectroscopy.

The study involved 10 patients, aged 18 to 85 years, all of whom underwent primary total knee arthroplasty under combined spinal-epidural anesthesia. Muscle oxygenation was measured with near-infrared spectroscopy spectra at two locations above and below the level of neuraxial blockade: the deltoid and the quadriceps femoris muscles. The researchers also continuously recorded stroke volume, cardiac output, heart rate, mean arterial blood pressure (MAP) and arterial oxygen saturation.

â&#x20AC;&#x2DC;It would seem that despite intraoperative events such as blood loss that may explain a reduction in overall tissue oxygenation, tissue oxygenation remains more favorable in areas affected by the neuraxial blockade, likely as a result of sympatholysis.â&#x20AC;&#x2122; â&#x20AC;&#x201D;Ottokar Stundner, MD

â&#x20AC;&#x153;We found that during the course of the procedure, oxygenation decreased in both the upper and lower extremities [an average of 9.8%], but more so in the upper extremity,â&#x20AC;? Dr. Stundner said. After adjusting for covariates, muscle oxygenation in the upper extremity was consistently lowerâ&#x20AC;&#x201D;by an average of 8.1% (95% confidence interval, 2.8%-13.5%; P=0.0031)â&#x20AC;&#x201D; than in the lower extremity where the surgery was performed. â&#x20AC;&#x153;When we looked at other cardiovascular parameters, we saw that cardiac output decreased, likely due to blood loss,â&#x20AC;? Dr. Stundner added. â&#x20AC;&#x153;Heart rate decreased slightly

JULY 2014

AnesthesiologyNews.com I 13

CLINICAL ANESTHESIOLOGY throughout the surgery, and arterial pressure decreased at first but reverted to baseline by the end.”

The bottom line, he said: “It would seem that despite intraoperative events such as blood loss that may explain a reduction in overall tissue oxygenation, tissue oxygenation remains more favorable in areas affected by the neuraxial blockade, likely as a result of sympatholysis.”

A possible implication, he continued, is that because increased perfusion may improve wound healing, neuraxial anesthesia might improve oxygen delivery to tissues.

Robert S. Weller, MD, head of regional anesthesia and acute pain management at Wake Forest University in Winston-Salem, N.C., said the findings are consistent with what is known about central neuraxial blockade for many years.

“Sympatholysis causes arteriolar dilation below the level of the block, with compensatory increased sympathetic tone and arteriolar constriction above. This would be expected to improve tissue perfusion below the block, particularly if mean arterial pressure and cerebral oximetry [CO] are maintained, as they were in this study,” Dr. Weller told Anesthesiology News.

“Although the authors suggest increased tissue oxygenation in the legs, it is important to note that there was an overall reduction in tissue oxygenation—arms more than legs— which the authors suggest may have been due to anemia or hemodilution,” Dr. Weller continued. “I would like to see the investigators collect data on patients having this procedure under general anesthesia, and would expect tissue oxygenation might be even more reduced in the general anesthesia group, whose CO and MAP would be likely to be lower than in these 10 patients.”

Potential advantages of improved tissue oxygenation in the surgical extremity, he added, might include improved wound healing and reduced wound infection rates. “But since the effect of the sympathetic block would only be for a period of the block itself, it is speculative that the relatively short intraoperative benefit would translate to the full period of wound healing and infection risk.”

Dr. Stundner presented the findings at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 2114).

—Michael Vlessides

STROKE

studies. “Unaccounted-for confounders are always a concern with studies the general anesthesia group would with relatively low patient numbers. have resulted in more extensive Specifically, those patients requirinjury, as every minute after isch- ing general anesthesia may have had a emic stroke results in the loss of poorer preoperative neurologic conalmost 2 million neurons.” dition that itself may have led to the Hilary P. Grocott, MD, profes- higher mortality rate,” Dr. Grocott sor of anesthesia and surgery at the told Anesthesiology News. “Alternatively, University of Manitoba in Win- general anesthesia may have had an nipeg, Canada, called the research impact on blood pressure, with inad“interesting” but said it suffers the equately treated hypotension resultlimitations of most retrospective ing in worse neurologic outcome—and CONTINUED FROM PAGE 10

subsequent death—in some patients.

Although functional outcome in the survivors was not affected by anesthesia, these results warrant further study as to the factors that led to the higher mortality signal with general anesthesia.”

The researchers reported their findings at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 1076).

—Michael Vlessides

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JULY 2014

TECHNOLOGY

Alternative to A-Line? Device Offers Noninvasive View of Pulse Pressure Variation To that end, Dr. Schumann and his colleagues compared an A-line with the ccNexfin (Edwards Lifesciences).

The device has a small cuff that goes on the patient’s finger and monitors blood

pressure, cardiac output, pulse pressure variability and other hemodynamic parameters.

To compare the measurements of the two modalities, the investigators

10 8 6

ccNexfin - A-line [%]

San Francisco—Knowing a patient’s intraoperative pulse pressure variation (PPV) is a desirable goal for anesthesiologists, but one that comes at a cost: the invasiveness of the arterial line (A-line). Technological innovations might be changing that landscape, however, as new research has found a good correlation between a new noninvasive device and the A-line in a series of morbidly obese patients.

“PPV derived from an A-line tracing during surgery can assess a patient’s fluid responsiveness and assist in intraoperative fluid management,” said Roman Schumann, MD, associate professor of anesthesiology at Tufts Medical Center, in Boston, who led the study. “But there are only so many patients in whom an A-line is otherwise indicated. So if you have a mechanism that works noninvasively, it might be useful, particularly in the morbidly obese, where we have more management questions than answers, including the question of fluid management.”

4 2 0 0

5

10

15

20

25

-2 -4 -6 -8 -10

(ccNexfin + A-line)/2 [%]

Figure. Bland Altman analysis: ccNexfin PPV versus A-line PPV.

30

enrolled 68 men and women undergoing bariatric surgery (mean age, 46±13 years; mean body mass index, 48±7 kg/m2) into the trial. Each participant received a radial A-line in the left arm and the ccNexfin finger cuff on the left hand. PPV values from both monitors were recorded simultaneously at six different time points during general anesthesia with mechanical ventilation.

As Dr. Schumann reported at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 2216), 337 PPV data pairs were available for investigation. Using a BlandAltman analysis applied to the patient averages of measurements at all six time points, bias was 0.48%±2.75% (limits of agreement 5.84% and –4.89%; Figure). The Pearson correlation coefficient of the data pairs was 0.82 (95% confidence interval, 0.78-0.85; P=0.0001). “These data seem to indicate that although they are not exactly matching, [the ccNexfin] is a fairly useful modality ... in this population,” he said.

“It was a real eye-opener to everybody as we learned The group also altered their system for patients how complex the system was, how many redundan- waiting for surgery after an initial consult. Low-risk “The entire process hums along much more effi- cies there were,” Dr. Siperstein said. patients are scheduled for surgery within a two-week ciently now, so we can handle an increased number of Based on that meeting, a list of inefficiencies was cre- period. Surgeons no longer have set OR and clinic patients and in a lower overall time,” said senior study ated. That list led to several major but simple changes. days per week. Instead, their schedules are flexible, author Allan Siperstein, MD, chair of the Department Now, when a patient first calls the office, the sec- ensuring that OR blocks do not go unfilled because of Endocrine Surgery at Cleveland Clinic, in Ohio. retarial service uses a script to categorize the patient’s someone is out of town.

“It’s a better system for everyone.” disease, determine what labs and studies are needed, Wait times from the initial consult to surgery fell David Reznick, MD, a surgical outcomes fellow and assess the patient’s likelihood of needing surgery. from 39.9 to 33.9 days for the overall practice and to at Cleveland Clinic, presented the study at the 2014 annual meeting of the Central Surgical Association.

Since the changes were put in place, the number of days from In the past decade, a number of health care organizations, including Cleveland Clinic, adapted techthe initial call to scheduling of a patient’s first appointment niques from industry. Published reports describe how hospitals use “process improvement methoddecreased from 14 to 0.8±0.3. The percentage of patients who ologies” from manufacturing industries to reduce cancelled their appointments fell from 27.9% to 17.3%. operating room (OR) time, turnover time and time in the postanesthesia care unit, and improve office efficiency.

This is the first report of commercial manufactur- Patients receive online health information and risk 15 days for low-risk patients. Today, the clinic busing processes put to use in a surgical clinic. assessment forms that stratify them for surgery. The tles with an increased patient flow, from 30.9 to 53.1 The program started in 2012, when first appointment is scheduled during that phone call. consults per month.

As a result, patients experience fewer delays in the Dr. Siperstein and his partners called on process The results should stimulate surgeons around the engineers from Cleveland Clinic to work with their process of getting to surgery, and more patients are country to look for novel ways to reorganize their surgical clinic. Engineers arranged a meeting with seen in the clinic each month. Since the changes clinics, said L. Michael Brunt, MD, professor of surstaff members involved at every point of patient were put in place, the number of days from the ini- gery and co-director of the Washington University care, including the secretarial service, scheduling tial call to scheduling of a patient’s first appointment Institute for Minimally Invasive Surgery, in St. Louis. service, nursing staff and surgeons. At that meeting, decreased from 14 to 0.8±0.3 (P<0.01). The per“This was an interesting and novel approach, and I attendees described their duties and outlined their centage of patients who cancelled their appointments like the fact that the authors took a business model frustrations with the system. fell from 27.9% to 17.3%. to problems that are fairly universal in surgery:

EFFICIENCIES

CONTINUED FROM PAGE 1

JULY 2014

AnesthesiologyNews.com I 15

TECHNOLOGY As Dr. Schumann described, the differences in PPV between the invasive and noninvasive approaches likely reflect the specific technologies and algorithms used by each monitor. “The whole discussion, when you start looking at the noninvasive and invasive modalities, boils down to the fact that you may Roman Schumann, MD still come to the point when a patient’s instability may overwhelm shaped like noninvasive technology and algorithms, which is when they become largely unreliable,” he said. “That’s when you’re still better off with your invasive A-line.

“On the other hand, the noninvasive device could be a pretty good alternative to an A-line, and maybe serve as an early warning system that allows clinicians to see things developing,” he continued. “This will allow us to decide whether we need invasive measurements or not. But it may be a useful alternative for routine clinical care. So I think it’s exciting, and we’ll see where it goes in the future.”

Ashish C. Sinha, MD, PhD, vice chair of research in the Department of Anesthesiology and Perioperative Medicine at Drexel University College

maintaining efficiency in our clinic visit process, case scheduling and management.”

After reviewing the study, Dr. Brunt said he and his colleagues plan to revamp their own system of OR scheduling to better coordinate surgeons’ schedules and optimize OR time.

Cleveland Clinic’s approach was set up for a high-volume tertiary care center with a highly specialized practice, Dr. Brunt noted. Smaller, general practices may need to adjust some of the processes. “Still,” he said, “this kind of approach could work in many places where we need to minimize unused OR time.”

Teamwork and commitment from management are essential for the program to succeed, Dr. Siperstein said.

Everyone contributed to brainstorming ideas and identifying previously unknown areas of duplication.

“By working together, duplicate steps were eliminated, and steps that were overlooked could be addressed and reworked efficiently into the system,” he said.

—Christina Frangou

of Medicine, in Philadelphia, said he was excited about the technology. “It’s very difficult to place a blood pressure cuff on morbidly obese patients and get accurate blood pressure readings,” Dr. Sinha said. “The arm may be too big for a cuff to work accurately and the forearm may be a cone, making it difficult

to wrap a cuff without it constantly slipping. This is what makes this technology attractive.

“However, the artery is much smaller when you get to the finger. Yes, you can get a pulse and a pulse oximeter reading, but can you get a good blood pressure reading? I don’t know. But it would be nice to have one device that we put on a patient’s finger that gives us all the answers.”

Dr. Sinha also questioned whether the traditional pulse oximeter might

serve the same purpose. “The pulse oximeter’s waveform can tell you the quality of the pulse,” he said. “When the patient takes a deep breath, it affects the venous return to the heart, which changes the volume of the pulse and the size of the trace. This serves as an early warning system of the patient’s volume status. So maybe there’s already another technology out there that we could be using for this very purpose.”

—Michael Vlessides

16 I AnesthesiologyNews.com

JULY 2014

POLICY & MANAGEMENT

For Anesthesiologists, Bigger Group Practices Don’t (Necessarily) Mean Higher Pay

T

he economics of market consolidation usually are clear: The fewer entities dominating a given market, the more power those players have in determining pricing and payment for their goods and services.

But when it comes to the health care industry and anesthesiologists in particular, the effects of market consolidation are far less straightforward.

Recent research suggests that increasing consolidation among anesthesiology groups does not increase income.

“We wanted to look at this because this consolidation in health care markets is going to continue to happen,” said Eric Sun, MD, PhD, an anesthesiology resident at Stanford University, in Stanford, Calif., who led the study.

“The Affordable Care Act encourages

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physicians to join together and form accountable care organizations [ACOs]. What we’re trying to look at is whether the benefits from improved coordination of care are outweighed by the ability of ACOs to potentially negotiate higher prices from insurers.”

Dr. Sun and his colleagues examined more than 3.5 million claims from private insurers across nearly 400 regional markets throughout the United States, then compared payments for the most commonly billed anesthesia services between 2001 and 2007. In the sixyear period, anesthesia groups generally became more consolidated, with more markets becoming dominated by a few large groups over time.

To control for regional differences and other possible confounders, Dr. Sun’s team compared payments within individual markets, using linear regression to determine the effect of increased consolidation on anesthesiologists’ payments.

They found that common economic principles do not seem to apply to anesthesiologists in particular. Compared with anesthesiologists in unconsolidated markets, payments were 2.3% lower in moderately consolidated markets (95% confidence interval [CI], –4.9% to 0.2%), 0.8% lower in highly consolidated markets (95% CI, –4.35% to 2.73%) and 2.4% higher in maximally consolidated markets (95% CI –2.3% to 7.2%).

“Overall, consolidation [within markets] increased over time, but we didn’t find an increase in the price for anesthetic services,” Dr. Sun said.

A possible explanation for this finding is that while other physicians and surgeons tend to have established 100% 90% 80% 70% 60% 50%

Optimized p for f mobile devices

40% 30% 20% 10%

Always available online

0% 2001 Non-consolidated @anesthesianews anesthesiologynews

2002

2003

Moderately consolidated

Figure. Market concentration in anesthesiology, 2001-2007.

JULY 2014

AnesthesiologyNews.com I 17

POLICY & MANAGEMENT ‘Because people don’t choose their anesthesiologists, we’re somewhat replaceable and we have less leverage. Hospitals and insurers may feel that it is easy to change the anesthesia groups they do business with, as patients may not notice the difference.’

—Eric Sun, MD, PhD

relationships with patients, anesthesi- affected by increasing consolidation ologists rarely do. Patient demand for in medical markets, pay varied widely particular providers gives insurers and hospitals a strong incentive to negotiate with those individuals.

Lower patient demand means less ability to negotiate. “Because people don’t choose their anesthesiologists, we’re somewhat replaceable and we have less leverage,” Dr. Sun explained.

“Hospitals and insurers may feel that it is easy to change the anesthesia groups they do business with, as patients may not notice the difference.”

Another factor may be that as physician groups have consolidated over time, so have hospitals and insurers, clouding the effects of consolidation within any one entity. “There are two types of consolidation that can occur,” said Anupam Jena, MD, PhD, assistant professor of health care policy and medicine at Harvard Medical School, in Boston. “One is the consolidation among providers such as hospitals. When hospitals consolidate, their prices rise because they have more market power,” Dr. Jenaa said. “On the other hand, increasing insurance concentration can act to offset provider concentration.”

Dr. Sun’s research also revealed that although anesthesiologists’ pay was not

2004

2005

Highly consolidated

2006

2007

Maximally consolidated

between markets—a 40% difference in pay between the upper and lower quadrants of the overall market. “Regional discrepancies in the time for different procedures could explain some of that difference, but not all,” he said. “It’s an area for further investigation.”

The outcome of increasing consolidation in health care markets for anesthesiologists is still unknown, particularly as the Affordable Care Act undoubtedly will shift the landscape. Dr. Sun said that as the law encourages the

formation of ACOs, physicians’ pay will likely become increasingly based on patient outcomes rather than procedures performed. “Now that you are getting these large groups of doctors, they can negotiate together for higher payments. It’s a little unclear at the end of the day, what the net effect will be.”

The researchers presented their findings at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 2060).

—Keely Savoie

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POLICY & MANAGEMENT MEDICARE

CONTINUED FROM PAGE 1

on the list, only nine in the United States billed Medicare more than $1 million that year.

Dr. Mashali, who owns pain management clinics in Massachusetts and Rhode Island, is facing nine federal counts of both health care fraud and aiding and abetting fraud. He was arrested at Boston’s Logan International Airport in February while attempting to travel to his native Egypt, carrying with him a job reference letter signed by his nephew, who is a doctor based in Michigan. According to court documents, the letterhead was from a health care clinic in Hawaii, where the nephew never lived or worked.

A grand jury returned an indictment against Dr. Mashali in March. In April, U.S. Magistrate Judge Leo Sorokin deemed Dr. Mashali a flight risk and ruled that the clinician may be freed on $5 million bond secured by property he, his wife and children own, and that he must remain at his home in Dover, Mass., and wear an electronic monitor.

With a fraud investigation pending but before his arrest, Dr. Mashali in 2013 surrendered his licenses to prescribe controlled substances both in Massachusetts and Rhode Island.

The indictment alleges that Dr. Mashali’s scheme to defraud Medicare lasted from October 2010 to March 2013. “I cannot comment on any connection at this time” between the indictment and the Medicare billing list, said Christina Sterling, a spokeswoman for the Justice Department’s Boston office.

She instead referred a reporter to documents related to his arrest.

“I don’t think there’s any relationship between the indictment and the amount of money he billed Medicare,” said Dr. Mashali’s attorney, Jeffrey Denner of Boston. When asked why Dr. Mashali billed

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Medicare substantially more than any other anesthesiologist in the country, Mr. Denner explained that his client had many patients across two states. He noted that Dr. Mashali also performed many lab tests and “processes a lot of data.”

Medicare records show that Dr. Mashali was reimbursed hundreds of thousands of dollars for tens of thousands of assays, but the indictment does not mention lab testing as part of the alleged fraud.

When all the work is tallied, “you’ll find that it’s not an extraordinary number at all,” Mr. Denner said. He would not make the doctor available for comment.

Dr. Mashali, 59, who received his medical degree from Kasr El-Aini School of Medicine in Cairo, owned and operated New England Wellness and Pain Management, Inc., also known as New England Pain Associates (NEPA), which had three clinics in Massachusetts and one in Rhode Island. He had a license from the Drug Enforcement Administration to dispense narcotics.

Health care providers doing business with Medicare submit bills for their patients using one of five evaluation codes for office visits, depending on the complexity of the visit and time spent with the patient. The codes cover time limits from between five and 25 minutes; the more time spent with a patient, the higher the bill to Medicare.

Norman Dozier, MD, who operates a pain clinic in Abilene, Texas, billed Medicare for $1.17 million in 2012, according to the records—good for fifth place nationwide on the anesthesiology list. “I don’t know how a person can possibly receive more patients than I do,” he said. Dr. Dozier employs a physician assistant, but otherwise “I’m by myself,” he said. “I’m very, very busy. I see 60 patients, five days a week. Our population is 60% Medicare. Some of these people come [from] 100, 120 miles away.”

Flood of Data Medicare released the records on payments after a prolonged standoff with the Wall Street Journal,l which had filed Freedom of Information requests for the data.

The records show that Dr. Mashali, who was the only physician at his clinics until 2013, conducted 7,086 office visits with Medicare patients alone at his clinics. According to an affidavit signed by FBI Special Agent Clayton Phelps, former NEPA employees said that the anesthesiologist “would sometimes see up to 150 patients per day. Patients waited hours to see Mashali, not only because so many patients were booked in one day but also because Mashali regularly arrived to work between 11 a.m. and noon.” He often booked four patients to a single appointment slot.

The indictment further alleges that Dr. Mashali trained nurses and physician assistants (PAs) to bill Medicare for detailed (and more expensive) examinations when those services were not provided. Former workers approached authorities in 2012.

Briefest of Visits A former PA told FBI agents that Dr. Mashali would often spend no more than two or three minutes with patients, usually in an office instead of a

room w i th medical equipment and without the patient changing clothes. He also would change the Medicare code on a patient’s record to reflect “a more fulsome examination than actually occurred,” according to the affidavit. The PA confronted Dr. Mashali, who insisted he had done a thorough examination, and the PA “replied that she had never even seen him wear a stethoscope around his neck.” The next day, Dr. Mashali removed the PA from seeing patients, switching her to desk work. He also started wearing a stethoscope.

Another PA asserted that Dr. Mashali “regularly told her to hurry up and keep printing prescriptions for him to sign to keep the patients moving forward,” the affidavit said.

The affidavit states that Dr. Mashali sent Medicare 27,283 total claims in the first half of 2012 for a total of $4.8 million (the figures depart substantially from Medicare’s total, which was for the entire year), a 588% increase over the last six months of 2011.

Mr. Denner said that lab work and repayment for drugs Dr. Mashali administered take up a substantial amount of the billing. He added that Medicare never questioned the invoices. “If they felt that this was not appropriate, given that the number was so big, then they would have done something,” he said. “They don’t want to spend money they don’t have to.”

Calls to the press office at CMS were not returned.

The indictment said that Medicare has the right to reject claims, but does not always do so—at least until after a provider has been paid. “Medicare presumed the truth of each claim,” the indictment said.

“In other words, Medicare entrusted their enrolled providers to only submit claims for the services that they actually performed.”

Theresa Hill, a spokeswoman for the American Society of Anesthesiologists, said infractions like the ones alleged against Dr. Mashali are usually left to state medical boards. Calls and emails to several members of the society’s Committee on Professional Affairs were not returned.

—John Dillon

JULY 2014

AnesthesiologyNews.com I 19

PAIN MEDICINE

Finally, a Diet That Doesn’t Hurt San Francisco—Can surgery patients eat their way to less postoperative pain?

A recent study by French researchers suggests that a diet low in polyamines can reduce pain after spinal surgery, with few side effects.

“There have been some data to show that a polyamine-deficient diet decreased pain in rats,” said JeanPierre C. Estebe, MD, PhD, professor of anesthesiology at University Hospital of Rennes in Rennes, France, who led the latest work. “This effect is likely due to polyamine’s modulation of the NN methyl-D-aspartate (NMDA) receptors. But no data are available on the potential efficacy of a polyaminedeficient diet on perioperative pain, so we decided to undertake a prospective, randomized trial with chronic pain patients with high levels of pain.”

Dr. Estebe and his colleagues enrolled 64 spine surgery patients into the study. Patients were randomized to one of two diets. Those on the polyamine-deficient diet ate a lowpolyamine breakfast supplemented with six 250-mL low-polyamine drinks per day.

“One thing is for sure: We generally do not pay close enough attention to the diets of our perioperative patients. Perhaps careful preoperative and postoperative feeding may have a far greater impact than we ever imagined.”

The diets were initiated seven days before spine surgery and continued until five days after the procedure. The primary end point was pain at rest and with motion. Researchers also monitored compliance, side effects and quality-off life scores.

Patients in both groups were demographically similar, and had comparable levels of preoperative pain.

As Dr. Estebe reported at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 2067), patients in the study group demonstrated a trend of decreasing pain at rest in the seven days before surgery (P=0.144), which became significant thereafter (P=0.022). The French team found a trend toward decreased postoperative pain with

motion in these patients, but it did not reach statistical significance (P=0.128).

The effect of the low-polyamine diet became significant when the investigators analyzed the subset of patients experiencing more severe pain at rest and with motion (P=0.0135 and 0.0093, respectively). see diet page 22

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“Just to drink that, they received around 10,000 kcal per day,” Dr. Estebe said. Controls had a partial polyamine-deficient diet comprising two of the drinks each day plus regular food. “The study group received less than 10 micromoles per day of polyamine, while controls received an average of more than 400 micromoles per day,” Dr. Estebe explained.

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20 I AnesthesiologyNews.com

JULY 2014

PAIN MEDICINE

Washington State Pain Center Helps Injured Workers Get Their Lives Back

By Tom McDonough

I

n 1984, a psychologist, an orthopedic surgeon, a nurse and a physical therapist came together to found Northwest Spinal Rehabilitation in Renton, Wash. They had one mindset—if they could treat injured workers and people with chronic pain as early as possible with a multidisciplinary/interdisciplinary treatment approach, they could help them get their lives back.

Today, this freestanding, unaffiliated pain management clinic, which became known as United Back Care but recently changed its name to Pacific Rehabilitation Centers to better reflect the full scope of Michael Harris, PhD the pain management services it provides, has stayed true to the founders’ mission.

“Our guiding principle is that excellent, compassionate interdisciplinary treatment and rehabilitation services, which means physical and occupational therapy, psychological and vocational counseling, quality nursing and medical—all working together— can help patients fight chronic pain and improve the quality of their lives,” said Regine Neiders, PhD, and CEO. Pacific Rehabilitation is Washington’s only pain management center with multiple locations, as well as telemedicine capabilities, allowing it to bring pain management solutions to more than 1,000 patients annually.

The 2012 American Pain Society Clinical Center of Excellence Award winner’s Workk Hardeningg Program was the first in the state to receive Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation. Its Return-to-Work /Pain Management Program also is CARF-accredited and, combined with Pacific Rehabilitation’s other comprehensive, goal-oriented rehabilitation services, it continues to produce tangible, effective chronic pain outcomes.

Returning Workers to Wellness Since its founding, the bulk of Pacific Rehabilitation’s patient population has been injured workers, referred by physicians, vocational counselors, nurse case managers and claims managers. Chronic pain often has a significant effect on these workers’ lives in terms of their careers, finances and family life.

“Chronic pain can become a vicious cycle where perceptions of pain can contribute to increased stress and frustration, which often lead to more pain,” said Niriksha Malladi, MD, one of Pacific Rehabilitation’s board-certified physiatrists. “We want to interrupt the cycle and help these patients manage their pain, and improve their overall well-being.”

Pacific Rehabilitation’s core program is its Returnto-Work /Pain Management Program, a full-time, four- to six-week, six-hour daily interdisciplinary program.

Patients build strength, flexibility and endurance through trunk strengthening and stabilization regimens that can include Eagle weights, therapy

Niriksha Malladi, MD

Regine Neiders, PhD

balls, mat exercises, walking, free weights and more.

Patients learn ergonomics, posture, body mechanics and injury prevention.

Hand-in-hand with physical therapy is psychological counseling from Pacific Rehabilitation’s Behavioral Health Program. “Licensed psychologists at each clinic provide individual evaluation and treatment services to patients,” said psychologist Michael Harris, PhD, the program’s clinical director. “It is our role to highlight particular risk areas or barriers that we see for an individual.”

Psychological treatments are critical because many patients have tried a variety of interventions, from

physical therapy to complex multilevel fusions, and they are still in pain.

“Unless you intervene with something that allows them to change their relationship with pain, you won’t be successful,” Dr. Harris explained. “We have at our disposal excellent, science-based cognitivebehavioral intervention strategies that are wonderful opportunities for people to change the way they interact with their pain and their physical circumstances.”

Psychological techniques range from individual and group therapy, focusing on the perceptions, reactions and catastrophic beliefs toward pain, to

JULY 2014

AnesthesiologyNews.com I 21

PAIN MEDICINE biofeedback that teaches patients how to control responses to pain.

For example, a key biofeedback technique is using noninvasive surface electromyography to help patients identify tension and gain control over muscles in and around injured areas.

“We also use a variety of general relaxation and breathing techniques, plus a lot of stretching,” Dr. Harris said.

“Our patients probably learn five or six different kinds of stretches while in treatment to keep muscles relaxed and functioning well.”

Pacific Rehabilitation’s selff management skills classes are another integral component of treatment.

“Many patients come in with the belief they need high-flyingg specialized health care providers to manage their conditions, but our selff management skills training is all about helping them see that they have the skills, or can acquire the skills, to manage their physical well-beingg over the long term,” Dr. Harris said. “It is crucial in that it allows patients to go from being dependent on health care providers to running their own show.”

Rounding out Pacific Rehabilitation’s programs are its complex regional pain syndrome and opioidelimination programs, which continue to expand to an ever-wideningg patient population.

Outside the Clinic Pacific Rehabilitation’s services continue after patients leave the program.

Its Community Reintegration Services contacts employers and primary care physicians to help patients make smooth transitions back into their jobs, homes and communities. These services even go so far as to provide resources for finding appropriate work; low- or no-cost English as a second language classes; housing; and lowcost health care and prescription coverage. Monthly family support groups with Pacific Rehabilitation psychologists assist past and present patients and their families in the ongoing management of chronic pain and its effect on life, work and wellness.

In addition to community reintegration, Pacific Rehabilitation has a strong tradition of community participation and education. Its physicians often serve in medical advisory roles, assisting state lawmakers with pain management treatment guidelines and protocols. They provide local employers with training and education on prevention and management of industrial injuries. Educational in-services

by Pacific Rehabilitation clinicians are

conducted with employer groups; at health care and workers’ compensation conferences; and with physicians and vocational counselors.

Recently, Pacific Rehabilitation partnered with Washington’s Department of Labor and Industries, as well as other leading health care systems and clinics in the area, to establish a Center of Occupational Health and Education (COHE) for western Washington.

COHE will seek to improve injured worker outcomes and reduce disability

through education, implementing occupational health best practices and support care provided by health service coordinators.

“Executive functioning relates to the way the brain operates in managing what’s going on within itself,” said Dr. Harris. “It turns out that in at least 10 or 12 areas, chronic pain patients Advancing Treatments tend to demonstrate some executive Pacific Rehabilitation staff is actively dysfunction—meaning there are difinvolved in research that focuses ferences between non–chronic pain on monitoring and analyzing out- and chronic pain patients with the way comes and advancing treatment. One the frontal lobe works. This investiga300-patient study is examining “execu- tion is the first time someone looked tive functioning” among patients with at the structure of the brain meeting chronic pain. see wellness page 22

Highlights include: Plenary Sessions about “must know topics”: including the appropriate utilization of opioids with the Deputy Director of the United States Drug Enforcement Agency

Full and Half Day Workshop Sessions: pain and musculoskeletal ultrasound taught by leading experts

Refresher Course Lectures from International Pain Experts: covering critical topics including discogenic back pain, complex regional pain syndrome, epidural steroid injections, advancements in neuromodulation, and neuroimaging based pain detection

Advance Practice Management Special Session Physician Assistant/Nurse Practitioner Program Dedicated Resident and Fellow Educational Program

22 I AnesthesiologyNews.com

JULY 2014

PAIN MEDICINE DIET

CONTINUED FROM PAGE 19

No reduction in pain was observed in controls.

Quality-off life scores were significantly improved in the lowpolyamine diet patients immediately before surgery (P=0.046), and continued as a trend five days after surgery (P=0.0629). Hospital length of stay was similar for both groups of patients.

“In terms of compliance, it’s very interesting to note that 100% of the study group completed the diet for the seven days before surgery, compared with 83% thereafter,” Dr. Estebe said. “By comparison, 83% and 71% of controls consumed both drinks each day before and after surgery,

WELLNESS

respectively. The only familiar pathway involvside effect was minor gasing the NMDA receptrointestinal intolerance. tor, which is well known to have a role in chronic So a low-polyamine diet could be useful for surgery pain, particularly in the because pain is decreased, presence of chronic opioid compliance is high and use. There is a resurgence adverse effects show no of interest in ketamine— a potent NMDA recepdifference between the two Jean-Pierre C. Estebe, tor antagonist—in patients groups.”

MD, PhD with opioid tolerance, and Eugene R. Viscusi, MD, professor of anesthesiology and direc- this drug is now commonly used in tor of acute pain management at this setting. So it is entirely possible Thomas Jefferson University, in Phila- that modulation of diet in a way that delphia, called the study “fascinating.” modulates the NMDA receptor might “Some diets can promote inflamma- have an effect on pain.” tion, which might have a role in pain.

Yet Dr. Viscusi raised several Here, the authors identified another questions about the study. “The

CONTINUED FROM PAGE 21

the content of the mind in a cohort of chronic pain patients.”

A second study investigated whether outcome measures differed between high-use opioid patients (n=21) who underwent a 30- to 45-dayy tapering protocol and patients (n=200) on lower doses of opioids.

“Patients in the high-dose opioid group did not demonstrate statistically significant differences in outcomes,” said Dr. Malladi, who conducted the study. “They showed similar improvements with physical capacities in midrange lifting, and reductions in disability conviction, perceptions of general health, activities for daily living, pain catastrophizing and fear-avoidance beliefs. The only statistically significant result was the degree of improvement in body mechanics, which was greater for the comparison group.

“The study showed that interdisciplinary pain management programs aimed at improving functional abilities and pain-copingg skills are reasonable options for patients struggling with pain, even as they taper off opioid use,” she added.

What’s Next?

Currently, Pacific Rehabilitation is in the process of evaluating ways to offer rehabilitation services for patients with cancer-related pain. “There is a federal mandate that hospital systems must have cancer rehabilitation/survivorship programs in place by 2015,” Dr. Neiders said. “We have observed that large hospital systems are waiting to determine how the Affordable Care Act and accountable care organizations shake out. We plan to develop an interdisciplinary cancer rehabilitation program over the next two years.

“The field of pain management is in need of durable solutions for the millions of people living with chronic pain,” she continued. “The last few decades have shown a growing understanding of the limited value of pursuing a curative model. Rather,

interdisciplinary rehabilitation has much to offer any patient struggling with the physical and emotional consequences of living with pain. Patients find their quality of life is vastly improved when they learn to defy the restrictions of pain in their lives and regain productive, healthy lifestyles. Pacific Rehabilitation sees its future path laid out in contributing to a better understanding of the many chronic pain states we treat through active clinical research, using technology to reach patients without ready access to skilled pain professionals, and continuing to challenge ourselves to provide an unparalleled level of care that goes beyond treating just the physical condition.”

experimental group not only had polyamine restriction but also received what appears to be a markedly different caloric load during the study,” he said. “One has to question whether this alone, or perhaps the type of calories, made the difference.

“One thing is for sure: We generally do not pay close enough attention to the diets of our perioperative patients,” added Dr. Viscusi, who is a member of the editorial board of Anesthesiology News. “Perhaps careful preoperative and postoperative feeding may have a far greater impact than we ever imagined.”

—Michael Vlessides

American Society for Enhanced Recovery (ASER), Duke Department of Anesthesiology and Department of Surgery PRESENT

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Topics include: t History and Fundamentals of Enhanced Recovery t Preoperative Education and Optimization t Perioperative Fluid Management. How Little, How Much? t Hemodynamic Management. Is it Cost Effective? t Successful Pain Management Strategy t The Role of Regional Anesthesia in Enhanced Recovery t Enhanced Recovery Strategy in Laparoscopic Colectomy. Should I Adopt it? t How Do You Get Your Team Together and Reaching Consensus? t Enhanced Recovery Beyond Colorectal Surgery t Debate: Performance metrics are an efficient way to promote enhanced recovery t Enhanced Recovery Case Studies

Activity Co-Chairs Tong J Gan, MD, MHS, FRCA Timothy E Miller, MB, ChB Julie K Thacker, MD Confirmed Speakers Solomon Aronson MD, MBA, FACC, FCCP Maxime Cannesson, MD, PhD Lee A. Fleisher, MD Stuart A. Grant, MB ChB Stefan D. Holubar MD, MS, FACS Monty Mythen, MD, FRCA Edward N. Rampersaud Jr., MD Roy G. Soto, MD Robert H. Thiele, MD

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