The November 2011 Digital Edition of Anesthesiology News by McMahon Group

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The Independent Monthly Newspaper for Anesthesiologists AnesthesiologyNews.com • N o v e m b e r 2 0 1 1 • Volume 37 Number 11

Nagging Drug Shortages Defy Easy Fixes

s the crisis over the nation’s drug shortage deepens, responses are coming from two major fronts: legislators and regulators, and clinicians who have implemented several innovative strategies for mitigating the impact of the ever-tightening supplies on patient care. Although some might debate which approach is best, there’s general agreement that the scope of the problem is widespread. “By the end of the year, the number of drug shortages for the year will probably be close to 280,” said Erin Fox, PharmD, manager of the Drug Information Service at the University of Utah Hospitals & Clinics, in Salt Lake City. Dr. Fox added

‘Herculean’ Study of Airway Complications Finds Room For Improvement irway management experts are hailing a large-scale review of

airway-related complications in the United Kingdom as “herculean,” saying it yields important insights into the nature of airway management complications. Based on the results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4), up to 75% of the 184 serious airway complications reported could have been averted if better airway management practices were used (Br J Anaesth 2011;106:617-631).

see shortages page 26

see NAP4 page 16

Most Anesthesiologists Believe LMA ProSeal INside And Flexible Unsafe for MRI (Tip: They’re Not) 08 | COMMENTARY Physician, unplug thyself!

s many as 90% of anesthesi- others are safe for use in the scan“Most providers likely don’t have ologists erroneously believe ning machines. a good understanding of the labelthe LMA ProSeal ing terms used to describe and LMA Flexible cannot MRI compatibility for these be used during MRI scans, devices,” Richard Galgon, according to results of a new MD, MS, faculty anesthesisurvey. ologist at the University of However, according to Wisconsin School of Medthe researchers, who preicine and Public Health, in sented their findings at the Madison, and a collaborator 2011 annual meeting of the on the study, told AnesthesiSociety for Airway Manageology News. ment (abstract 13), these Dr. Galgon, a former metal-reinforced supraglotFDA scientific reviewer for tic airways, both from LMA medical devices, and his see mri page 30 North America, and some

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28 | Pain Medicine Major review probes mysteries of post-op analgesics.

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4 I AnesthesiologyNews.com

November 2011

Discuss these and other articles @ AnesthesiologyNews.com.

Heard Here First: Anesthesiology has been at the

forefront of accepting a rigorous academic

November 2011

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

approach to management and economic decision making. ... It was natural to start this in our specialty.

1. Mounting Board Demands Foster Growing Unease

See article on page 34.

2. A New Way To Lose a Bundle 3. Anesthesiologists and Pharmacists Partner To Improve OR Outcomes 4. Program Encourages Reporting Accidents Waiting To Happen 5. Resident Burnount—You’re not Alone

Robert S. Lagasse, MD, New Haven, CT Alex Macario, MD, MBA, Stanford, CA ALIX MATHIEU, MD, MBA, MS, Cincinnati, OH The Independent monthly Newspaper for Anesthesiologists

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Not Receiving Anesthesiology News? All U.S. anesthesiologists should receive Anesthesiology News free of charge. If you are not receiving the publication, or if you are changing your name or address, please follow these instructions: 1) Contact the American Medical Association (AMA) at (800) 262-3211 or the American Osteopathic Association (AOA) at (800) 621-1773, and notify them of your name, address and professional specialty. You need not be a member of the AMA or AOA to receive the publication. 2) For added assurance of uninterrupted service, you may also mail or fax a copy of your current mailing label, along with your change of name or address to: Circulation Coordinator, Anesthesiology News 545 West 45th Street, 8th Floor New York, New York 10036 Fax: (212) 664-1242 Email: circulation@mcmahonmed.com Please sign and date all requests. If you are not a U.S. anesthesiologist and would like to subscribe, please send a check payable to Anesthesiology News to the Circulation Coordinator. Annual subscription: $70 (outside U.S.A., $90). Single copies: $7 (outside U.S.A., $10). Please allow 8-12 weeks for delivery of the first issue. McMAHON PUBLISHING, Sales, Production and Editorial Offices: 545 W. 45th St., 8th Floor, New York, NY 10036, Tel. (212) 957-5300.

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AnesthesiologyNews.com I 5

COR R E SPON D E N CE

Letter: ‘Surgical Home’ Hardly Sweet

or decades, a principal goal of our profession was acknowledgment by other medical specialists and payers of our value as anesthesiology professionals. Ironically, the American Society of Anesthesiologists’ recent letter to the Centers for Medicare & Medicaid Services (CMS) recommending the creation of a “surgical home” reverses that tradition and asks for us to be appreciated as everything but anesthesiologists. In the surgical home, as we bring our unique perioperative insight and wisdom to the total nonoperative care of the surgical patient, we will presumably replace surgeons, internists, residents, physician’s assistants, registered nurses, even psychiatrists. Our leaders assure us that the surgical home model represents the future of anesthesiology. Perhaps. There are, however, some questions that must first be addressed: Do current anesthesiologists have the skills to assume these very different new roles? How, and with whom, will we fill them? What will the doctors and ancillary people we replace think about being pushed out of their roles? Why would a medical student choose a career in a

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specialty that is struggling to define itself ? Exactly how will Renaissance anesthesiologists be paid for running around and doing everything? In the October issue of Anesthesiology News (page 6), Dr. Robert E. Johnstone justifiably rails against the CMS proposal of bundling all patient services into a lump sum that would then be divided among the providers. But

he goes on to suggest that the surgical home model would serve as the perfect alternative. I don’t get it. It is improbable that we can be paid for each of the multiple services offered by the surgical home in a manner or amount remotely similar to current reimbursement. It is more likely that we would become salaried, clock-punching employees of an entity such as an accountable

care organization, which would then get the bundled payment and allocate the crumbs as it chooses. To me, this looks less like the Promised Land than the demise of private practice anesthesiology. —Steven S. Kron, MD Dr. Kron is a retired anesthesiologist.

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C OMM E NT A R Y

Managed Care and the Massacre Of Private Practice in America

am a doctor who has something to say about the part of our health care industry that’s tearing our whole system apart. My hope in doing so is to encourage everyone who cares about their health to view this indispensable system in a light with which they may not be familiar. I’d like to tell you a bit about why I eventually quit my job as a doctor. I worked as a general surgeon in Sacramento for about two decades, serving thousands of average citizens who found themselves facing a wide range of health problems—gallbladder trouble, breast cancer, hernias and appendix ruptures to name a few. I also patched up individuals with traumatic injuries in operating rooms and assisted them in getting back to normal, healthy lives afterward. This was my life’s work, and I loved every minute of it. Unfortunately, between the time I began working as a doctor and when I quit medicine, the health care industry changed drastically in ways that were not better for my patients or me. Early in my experience as a surgeon, the term managed care began to evolve into something that would be seen as much more commonplace down the road. Managed care was a plan contrived by health insurance companies and bought into by growing government. The pitch was that medical care was costing people too much, and this plan would effectively Advertisement

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solve that problem. This money-saving strategy posited by crafty insurers was that insurance companies knew the best ways to “administer” health care. At the same time, the insurers also knew how to improve the “quality of care” for all patients. Our government loved this idea: decreased cost, increased quality. Some doctors conceded to the notion, too. I watched tentatively as various private practice physicians began to approve of this strategy and were essentially bought out by health insurance companies. Unfortunately, as this happened, doctors also began to evolve into something different as well. Instead of serving as professionals whose primary goal was the better good of their patients, many doctors began to follow a new set of rules laid out by the insurance companies. The old code of ethics that had framed the profession for so long became something that doctors managed to ignore more and more often. As the health care industry shifted its focus from ethical standards of care to the money it would cost to provide it, our social insurance programs began to change as well. Medicare—our government’s way of making sure older patients receive the medical assistance they need—slowly started to corrode. I first began to notice this steady decline while being paid for the operations I performed on patients. For example, in 1987, I operated on a 67-year-old woman with breast cancer, and Medicare paid me about $800. For the same operation 14 years later, Medicare paid me $400. I once asked my brother, Kirk, a cabinetmaker, what he thought about this scenario. He said that he couldn’t think of another service or goods industry where a worker is paid less as time goes on, especially when considering standard inflation. This problem began to really rub on me, not just because I was making less money, but because I felt like Medicare was getting flakey as a social service. My colleagues began to agree. Somehow, we physicians had allowed Medicare to get away with this. As the government continued to further buy in to the insurance companies’ managed care strategy, it became tougher and tougher for doctors and other medical professionals to make a living. We were being managed as well. Sadly, this type of management, not just of “care” but of people, became even more egregious as time went on. Do you remember a time when there were no advertisements for medicines on TV? No ads about medicines for heartburn, high cholesterol, impotence, obesity or sleeplessness? Or billboards and radio ads pitching HMOs, PPOs, IPAs, even specific hospitals like Sutter Health or Mercy or Catholic Healthcare West or UCD or Kaiser? I certainly do. It was during this growing propaganda phase, when commercials began urging patients to “ask [their] doctor” about the best “care” available, that insurance companies also started radically decreasing the amount of money they paid physicians and other medical professionals for their services. For instance, in 1987, an insurance company paid me $800 for a

It becomes important for all Americans to begin questioning the unfairness that exists for many sick patients, and for the workers who strive to care for them in hospitals across our country. patient’s hernia repair. Fourteen years later, I was paid $160. During some months near the end of my career, I never got paid at all. In addition to the issue of the exorbitant amount of money being made by these companies at the expense of medical professionals and patients is the unethical nature of business conducted in the health care industry. As health insurance companies have increasingly contained their costs, and as government has allowed this to happen, doctors and other medical professionals have found their clinical judgment short-circuited for the sake of insurance savings. Insurance companies demand that doctors cut the days patients can stay in the hospital after an operation. They demand that we ignore our patients’ risky medical symptoms or pain or sickness so that the company won’t have to pay for the patient’s hospital bed. They tell us these situations don’t matter.

November 2011

AnesthesiologyNews.com I 7

COMME N TA R Y pocket for a $500,000 car accident, HMO patients rarely see that sort of bill. Many of my HMO patients were schoolteachers, state workers, public employees and other civil servants who felt protected by the health care offered by their jobs. Despite this comfort shared by some, however, it becomes important for all Americans to begin questioning the unfairness that exists for many sick patients, and for the workers who strive to care for them in hospitals across our country. We need

As a doctor, I disagree. That’s why I got out. As I see it, our health care system needs to change in a big way. But one of our obstacles to reforming this system seems to involve the confusion insurance companies have created for patients about the plans they provide, HMOs versus PPOs. HMOs are cut-rate insurance plans for huge organizations of workers. According to HMOs, employees save on their health care because insurance companies pay a flat rate for services rendered. The PPO, administered by the same insurance company, is designed for folks who own small businesses, for whom the insurance companies pay around 80% of the bills for services, leaving the patient a huge deductible and 20% of the bill. Although PPO patients have likely noticed a drastically negative change in American health care over the past couple of decades, HMO patients have largely been kept in the dark by insurance companies about how things really work. Although a PPO patient could end up paying $100,000 out of

to question the way these insurance companies run their businesses and pay attention to the political practices that allow these companies to extend their negative influence. Managed care has left us with decreased quality and increased cost. And as a result, things are getting less safe, folks. Really less safe. At the same time, however, this system cannot be sustained unless we sustain it. Piece by piece, we’ve got to knock down this house of cards that’s

been strategically constructed over time by business executives and politicians who aimed at, and succeeded in, making lots of money for themselves at the expense of patients and medical professionals. It’s time to reverse this scenario by not only questioning our destructive status quo, but by rejecting it as unsuccessful, unethical and un-American. —Patrick Wagner, MD Dr. Wagner is a surgeon in Sacramento, Calif.

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November 2011

C OMM E NT A R Y

Electronic Distraction: An Unmeasured Variable in Modern Medicine

he supervising attending comes onto the ward passing the unit secretary, who is texting on her smartphone. She passes the nurse, who is surfing the Web. She then stops to watch the resident, who is gaming on his tablet. As farcical as it might seem, this digital nightmare is increasingly common on hospital wards throughout the country and the world. Unfortunately, we have almost no data on how electronic distraction affects worker productivity and dedication to repetitive tasks in health care. In my formative years of training during the late 1970s and 1980s, it was routine for residents to be barred from studying or reading in the operating room or on the ward. Journals and professional newsletters printed humorous cartoons of a physician skimming the financial news while alarms around him blared. Health care workers were routinely taught that their primary role was total dedication to patient care. It was an era of direct face-to-face or telephone communication between patients and the providers of that care. Distraction from given tasks was minimal, so caregivers were focused on the patient and directly collected and reviewed the data. The modern hospital environment presents a radical departure from those days. The time-honored way we cared for patients, communicated among ourselves and answered questions is no longer the norm. The new health care model is one of electronic records and patient care data downloaded from a distant server. Generational changes mandate that we

educate 20- and 30-year-olds about how to speak to patients—but these individuals have grown up communicating through secondhand electronic media without direct contact. The health care workers of today rarely receive information directly from their patients. They review a downloaded health history on their computers. They do not speak to patients to get the subtle feeling for a disease in evolution or any new “minor” change that occurred since the patient was last seen. They must follow checklists that meet Medicare and other guidelines or risk billing challenges, reprimands from the department head, lawsuits and other opprobrium. Individuals can argue that this type of medicine is better, but put yourself in the patient’s shoes: Your nurse or physician is looking into the computer screen while typing answers and cutting and pasting and filling out a checklist. What does all this have to do with your current complaint? The environment, as patients observe it, also has changed. They no longer are at the center of their care—their data are. Their health care providers are fixated on computer screens; they might be doing medical work—or not. And don’t think anesthesiologists are immune to digital diversion in the operating room. A study

presented at the 2011 annual meeting of the American Society of Anesthesiologists found that nurse anesthetists and residents were distracted by something other than Peter J. Papadakos, MD patient care in 54% of cases—even when they knew they were being watched! Most of what took their time were pleasure cruises on the Internet (abstract 1726). An ever-growing body of evidence shows that the explosion of computers, smartphones, tablets and other devices, along with the omnipresent social media, has an addictive element. The psychology of this constant need to get information and be entertained has not been fully studied. Whereas in the past, triggers for distraction in the operating room were relatively rare, technological changes and the accompanying societal shift have created an environment in which the health care worker constantly is tempted to surf the net, check social media and send emails. Our administrators and political leaders reinforce this behavior with their endless daily emails that must be answered, their regulatory hoops to jump through and the centrality of computers in hospitals. So take a good look at that smartphone. How many of those emails need to be answered the moment they pop up on the screen? How about that long case last week? Was it really necessary to check the stock market, play the latest word game or do the daily crossword puzzle online? Experts continue to lecture us on medical error rates that in many ways are computer models with made-up ranges of errors. (The endlessly cited 2001 Institute of Medicine report, “To Err is Human,” for example, rounded up the estimated number of hospital-related deaths from between 26,000 and 96,000 to a barely plausible 100,000.) They develop plans to address them based on shared responsibility and separate the health care worker from personal responsibility to protect their psyches. But no studies have looked at how the attentions of these protected clinicians are lured away by inescapable electronic distraction. Research has clearly demonstrated that the addictive quality of these devices has increased accidents each day on our roads. How can we ignore this phenomenon in health care workers as a component of errors and near misses? Anesthesiologists have led the way in the past with our introduction of monitoring and best-practice guidelines, which have been the keystone of patient safety. We must help train the next generation of health care providers to deal better with the evergrowing explosion of electronic devices that have become so common in our modern world. —Peter J. Papadakos, MD Dr. Papadakos is professor of anesthesiology, surgery and neurosurgery at the University of Rochester, in Rochester, N.Y., and a member of the editorial board of Anesthesiology News.

November 2011

AnesthesiologyNews.com I 9

I N BR I E F

t’s comforting to think that medical professionals treat all patients equally. Comforting, but false. A new study found that when observers do not like a patient, they tend to judge the patient’s pain intensity to be lower and take the complaint less seriously (Pain 2011;152:2342-2347). Researchers from Ghent University in Belgium preconditioned 40 participants by asking them to look at photographs of six different patients. Each patient was tagged with simple descriptions, ranging from negative (egoistic, arrogant or hypocritical), neutral (reserved, true to tradition or conventional) or positive (friendly, honest or faithful).

Tune in to

Likeable Patients Receive Better Pain Care The volunteers watched short videos of the patients having their shoulder pain assessed and then rated their pain severity, which varied from “no pain” to “pain as bad as could be.” At the end of the experiment, the participants ranked patients with negative traits to be the least likeable and those with positive traits

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the most likeable. The participants also determined that the least likeable patients had less intense pain than their more endearing counterparts, even though both groups reported the same high pain intensity. Moreover, the participants could not discriminate between different pain levels expressed by the disliked patients as well as they

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could among the liked patients. “These findings suggest that we take the pain of patients we do not like less seriously than the pain of patients we like,” wrote the study authors, who added that these findings could have implications for pain management.

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November 2011

PRN

Negative Studies Scarce in Anesthesia Journals

he premier journals in anesthesiology are far more likely to publish positive results than negative findings, according to a new study. Anesthesiologist Gildasio Deoliveira, MD, and Robert McCarthy, PharmD, at Northwestern University in Chicago analyzed 1,169 studies published in 14 anesthesia journals between 2008 and 2009. They found that as a journal’s impact factor—a measure of how often articles in a particular journal are cited, and thus of that publication’s influence on the field—rose, the likelihood that it would publish negative studies fell. The mean impact factor for all the journals was 2.1. Positive findings were at least 2.67 times more likely to appear in titles with higher impact factors, the researchers said (Table). Anesthesiology News asked the editors of the two specialty journals with the highest impact factors, Anesthesiology and Anesthesia & Analgesia (which will be publishing the new study in an upcoming issue) about the results. (Irony alert: We probably wouldn’t be covering this research if the results had been negative.)

Timothy Houle, PhD, statistical editor of Anesthesiology: The issue of bias for positive findings has been called the “file drawer problem” in the social science arena, and has been found in almost all fields of publication. This is probably the case for two reasons: 1. Authors tend not to submit negative studies to journals (i.e., they sit in a file drawer). 2. Journals tend not to publish negative studies. In terms of the first issue, authors should be reminded that they have an ethical duty to disseminate all of their research findings, especially given the risks that were imposed on the participants in randomized controlled trials (RCTs).

The second issue is a little more complicated. Anesthesiology, like most high-impact journals, does not have explicit statistical significance criteria for publication; no reviewer or handling editor is ever instructed to suppress negative findings. However, Anesthesiology does have a definitive criterion that asks reviewers to rate how definitive a study was. Stated differently, the criterion assesses whether a study was able to resolve the research question. This assessment is easier to make in studies with statistically significant primary outcomes because in these studies, a hypothesis was definitively rejected in favor of an alternative one. Studies with negative primary results do not necessarily convey the same information and care must be taken in interpreting the findings. This interpretation is often difficult to make because negative studies have a tendency to be poorly designed. A good RCT provides definitive information, whether or not the primary outcome is statistically significant. Because high-quality trials carefully define the primary outcome and include clinical significance in the interpretation along with statistical significance, a negative finding can be properly interpreted as a low probability that the intervention under study meaningfully impacts clinical outcomes. All too often, negative studies are also poorly designed studies in which this distinction cannot be made—we cannot distinguish between there being no meaningful difference between the interventions versus a simple lack of statistical power to detect it. The analysis by Deoliveira and McCarthy appears to have been thoughtfully conducted. However, without a corresponding measure of RCT quality

(the JADAD score [which assesses the methodological rigor of a study]), it is difficult to disentangle how many of these negative studies were also poor studies with suspect statistical power analyses and controlling for Type I errors [false-positive results]. It is likely that a positive bias exists in nearly all fields, including anesthesiology. However, it is also important to partition the factors that lead to negative studies finding their way in lower-impact journals. Steven Shafer, MD, editor-in-chief of Anesthesia & Analgesia: I make a conscious effort to publish negative studies, provided they are adequately powered and the study addresses an important question. If the question is not important, then I really don’t care if the finding is positive or negative—I would rather see it published elsewhere. James Eisenach, MD, editor of Anesthesiology: The issue isn’t whether we publish negative results. For example, we published a study with an editorial that failed to find an association between anesthesia exposure in childhood and school performance in adolescence, in contrast to some studies that did find such see pub bias page 13

Table. Multinomial Regression Odds Ratios for Factors Associated With Publication Comparing Anesthesiology Journals With an Impact Factor >2.1 With Aggregate of Publications in Anesthesiology Journals With an Impact Factor <2.1 Anesthesiology

Br J Anaesth

Anesth Analg

Odds Ratio (95% CI)

P Value

Reg Anesth Pain Med

Odds P Ratio Value (95% CI)

J Neurosurg Anesth

Odds Ratio (95% CI)

Odds P Ratio Value (95% CI) 0.006

P Value

Can J Anesth P Value

Negative study findings

0.28 <0.005 (0.16-0.48)

0.23 <0.005 (0.14-0.34)

0.41 0.009 (0.21-0.80)

0.49 <0.005 (0.35-0.67)

0.41 <0.005 (0.25-0.68)

0.12 (0.03-0.55)

Non-U.S. origin

0.20 <0.005 (0.11-0.26)

2.68 0.03 (1.08-6.68)

0.43 0.06 (0.18-1.03)

0.24 <0.005 (0.15-0.37)

—a

1.51 0.71 (0.18-12.58)

0.42 0.08 (0.16-1.11)

Single center study

0.27 0.02 (0.09-0.81)

0.25 0.02 (0.08-0.77)

0.34 0.21 (0.06-1.82)

0.43 0.08 (0.16-1.13)

0.14 0.003 (0.04-0.51)

—b

—

0.26 0.12 (0.05-1.44)

No sample size calculation

0.68 0.16 (0.40-1.16)

0.49 0.002 (0.32-0.77)

0.36 0.01 (0.17-0.80)

0.86 0.40 (0.62-1.22)

0.41 0.001 (0.24-0.71)

0.32 (0.10-1.07)

0.06

0.14 0.002 (0.04-0.48)

Nonreporting of treatment blinding

0.76 0.32 (0.43-1.31)

0.66 0.07 (0.42-1.03)

0.51 0.08 (0.24-1.09)

0.52 <0.005 (0.36-0.75)

0.81 0.43 (0.48-1.37)

0.26 (0.19-1.99)

0.42

1.19 0.67 (0.53-2.67)

No report of subject withdrawals

0.52 0.14 (0.31-0.88)

0.57 0.008 (0.38-0.86)

1.46 0.26 (0.80-2.81)

0.65 0.01 (0.47-0.01)

1.16 0.55 (0.70-1.03)

1.96 (0.61-6.38)

0.26

1.53 0.29 (0.69-3.41)

Sample size ≤100

0.87 0.59 (0.51-1.48)

1.02 (65-1.61)

1.16 0.71 (0.54-2.48)

1.02 0.93 (0.93-1.47)

1.48 0.22 (0.78-2.80)

4.47 0.16 (0.55-36.26)

0.57 0.57 (0.27-1.23)

0.91

Odds ratio <1 indicates reduced likelihood of the journal to contain study-related factor compared with anesthesiology journals with an impact factor <2.1. a

P Value

Anaesthesia

No articles attributed to U.S. origin were included in the analyzed articles. b No multicenter studies were included in the analyzed studies.

—

0.57 0.16 (0.28-1.23)

These programs are currently archived and available for credit for 1 year at

http://video.webcasts.com/events/apce001/39551 There are no prerequisites

Current and Emerging Therapies in Chronic Pain This fall, national experts in chronic pain management met for a series of live, complimentary, interactive webinars. These programs are currently archived and available for credit for 1 year at http://video.webcasts.com/ events/apce001/39551

Supported by educational grants from Covidien, Millennium Laboratories, and Pfizer Presented by the Johns Hopkins School of Medicine, in collaboration with Applied Clinical Education

Course Director Michael R. Clark, MD, MPH, MBA Associate Professor and Director Chronic Pain Treatment Programs Department of Psychiatry and Behavioral Sciences The Johns Hopkins Medical Institutions Baltimore, Maryland

Schedule

All Sessions 2:00

- 3:00

EST

October 5, 2011 • Multimodal therapy Faculty Presenter Charles E. Argoff, MD

Professor of Neurology Albany Medical College Director, Comprehensive Pain Center Albany Medical Center Albany, New York

Article

Multimodal Analgesia for Chronic Pain: Rationale and Future Directions Argoff CE, Albrecht P, Irving G, Rice F. Pain Med. 2009;10(suppl 2):S53-S66.

October 12, 2011 • Psychosocial comorbidities Faculty Presenter Dennis Turk, PhD

John and Emma Bonica Professor of Anesthesiology and Pain Research University of Washington School of Medicine Seattle, Washington

Article

Assessment and Treatment of Psychosocial Comorbidities in Patients With Neuropathic Pain Turk DC, Audette J, Levy RM, et al. Mayo Clin Proc. 2010;85(3 suppl):S42-S50.

October 19, 2011 • Pain management in older patients Statement of Need Four key areas in which clinicians have significant knowledge gaps are: • The knowledge of pain mechanisms and of the mechanisms of action of therapies • Recently approved therapies for chronic pain • Recently published or revised chronic pain treatment guidelines • Novel pain therapies in late-stage development that may be available soon

Faculty Presenter Perry G. Fine, MD

Professor of Anesthesiology University of Utah School of Medicine Salt Lake City, Utah

Sponsorship Statement Presented by the Johns Hopkins University School of Medicine

Statement of Responsibility The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

Intended Audiences Primary care physicians, physician pain specialists, neurologists, and other health care professionals with an interest in improving their professional skills relative to the treatment and management of chronic pain. The audience also may include nurses, nurse practitioners, physician assistants, and pharmacists.

Accreditation Statement The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement The Johns Hopkins University School of Medicine designates this live activity for a maximum of 7 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Policy on Faculty and Provider Disclosure It is the policy of the Johns Hopkins University School of Medicine that the faculty and provider disclose real or apparent conflicts of interest relating to the topics of this educational activity, and also disclose discussions of unlabeled/ unapproved uses of drugs or devices during their presentations. The Johns Hopkins University School of Medicine Office of Continuing Medical Education has established policies in place that will identify and resolve all conflicts of interest prior to this educational activity. Detailed disclosure will be made in the course handout materials.

Pharmacological Management of Persistent Pain in Older Persons: American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons Ferrell B, Argoff CE, Epplin J, et al. Pain Med. 2009;10(6):1062-1083.

Learning Objectives After completing this activity, the participant will demonstrate the ability to: • Elucidate the pathophysiology of chronic pain and how treatment approaches can target chronic pain appropriately by mechanism of action. • Review currently available therapies, particularly recently approved treatments, for common chronic pain conditions (eg, rheumatologic disorders such as osteoarthritis and other musculoskeletal conditions; neuropathic pain and fibromyalgia; chronic low back pain; and chronic pain associated with other medical conditions). • Apply recommendations from recent evidence-based guidelines to inform the treatment of chronic pain. • Describe emerging therapies for chronic pain that are in late-stage development.

Article

October 26, 2011 • Interventional therapies Faculty Presenter Richard Rosenquist, MD

Clinical Professor Director, Center for Pain Medicine and Regional Anesthesia University of Iowa Carver College of Medicine Iowa City, Iowa

Article

Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society Chou R, Loeser JD, Owens DK, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.

November 2, 2011 • Urine drug testing Faculty Presenter Charles E. Argoff, MD

Professor of Neurology Albany Medical College Director, Comprehensive Pain Center Albany Medical Center Albany, New York

Article

The role of urine drug testing for patients on opioid therapy. Pergolizzi J, Pappagallo M, Stauffer, J, et al. Pain Practice. 2010;10(6): 497-507.

November 9, 2011 • Neuropathic pain Faculty Presenter Vera Bril, MD

Professor of Medicine Department of Neurology University Health Network Toronto General Hospital Toronto, Ontario, Canada

Article

Evidence-Based Guideline: Treatment of Painful Diabetic Neuropathy Bril V, England J, Franklin GM, et al. Neurology. 2011;76(20):1758-1765.

November 16, 2011 • Opioid therapy Faculty Presenter David A. Fishbain, MD

Professor, Department of Psychiatry & Behavioral Sciences Adjunct Professor, Neurological Surgery and Anesthesiology Miller School of Medicine Miami, Florida

Article Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. Chou R, Fanciullo GJ, Fine RG, et al. J Pain. 2009; 10(2):113-130.

12 I AnesthesiologyNews.com

November 2011

PRN

Projects Tackle Trainee Inexperience in Airway Management

wo academic pilot projects aim to address what many consider to be a paucity of learning opportunities for residents in airway management. In one project, third- and fourthyear medical students with an interest in anesthesiology participate in an elective anesthesiology rotation with an airway management focus. Details

of the initiative were presented by Crystal Jean-Louis, MD, a resident in the Department of Anesthesiology at Montefiore Medical Center in New York City, at the 2011 annual meeting of the Society for Airway Management (SAM; abstract 8). The rotation comprises two parts: an initial two-week period during residents’ third year when they are introduced to

basic concepts in airway management through assigned readings and lectures; a four-week rotation in their fourth year includes simulated intubations and delivering an oral presentation they develop in collaboration with an anesthesiology mentor. The top presenter wins a trip to the SAM annual meeting. Dr. Jean-Louis said she hopes the early exposure to airway management

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will ease the transition to becoming an anesthesiology resident and ensure at least a subset of residents is familiar with airway management procedures. “Our first-year residents are still doing a great job at attaining airway management skills, but some take a little bit longer than others to pick up these skills,” she said. Dr. Jean-Louis and her research supervisor Tracey Straker, MD, MPH, attending anesthesiologist at Montefiore, will be measuring program outcomes during the coming academic year to determine its effectiveness in teaching practical and theoretical knowledge. “The hope is that if they have early exposure, it will just be a little bit easier to pick up those skills as first-year residents and reduce some of the anxiety related to starting residency,” Dr. JeanLouis told Anesthesiology News.

‘How do we define proficiency? How does a trainee learn a skill that

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is both cognitive and physical? What makes someone proficient or expert? These are difficult questions.’ —Mark Nunnally, MD Among first-year anesthesiology residents, there is significant variability in the degree of exposure to airway management, said Gail Randel, MD, assistant professor of anesthesiology at Northwestern University Feinberg School of Medicine, in Chicago. At the SAM annual meeting, she reported early results of a pilot program (abstract 17) in which airway management experiences of the residents are electronically documented. (Dr. Straker at Montefiore developed the program.) Earlier this year, Dr. Randel and her colleagues asked the 11 first-year clinical anesthesiology residents to electronically track their direct laryngoscopy experiences over the course of their initial six-week rotation. They found residents averaged only 28.3 intubations during the six-week period, with the number of procedures per resident ranging widely from eight to 48 (Table).

November 2011

AnesthesiologyNews.com I 13

PR N Table. Number of Direct Laryngoscopies During Introductory Six-Week Rotation

Resident

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Total

Median intubations, 25; average, 28.3.

Dr. Randel said she was surprised by the disparity in the number of intubations that the pilot project revealed. Moreover, she said, the highest number of intubations was still lower than it should be. “None of our first-year residents reached the criteria number of intubations required to achieve competence in direct laryngoscopy,” she said. As the program continues, Dr. Randel said she and her colleagues will redistribute assignments as needed

in real time according to her residents’ logs, so that they receive adequate training in airway management. Ensuring that trainees conduct a minimum number of procedures is a good starting point for ensuring competence, said Mark Nunnally, MD, associate professor of anesthesia and critical care at the University of Chicago. However, “the ways people pick up skills—especially complex airway skills—undoubtedly vary,” he said.

“I think these projects raise some interesting questions,” said Dr. Nunnally, who was not involved in either project. “How do we define proficiency? How does a trainee learn a skill that is both cognitive and physical? What makes someone proficient or expert? These are difficult questions.” —David Wild

Pub Bias continued from page 10 an association. The problem is that one would expect, given the rationale for performing experiments, that the ratio of positive to negative results is greater than 1 to 1. Karl Popper was important in defining scientific method in the 20th century, and his position was that the purpose of performing an experiment was to falsify an hypothesis. So, we come up with an idea, like ibuprofen will reduce opioid use after surgery, then design an experiment to show that this is not true. When we fail, the idea remains standing, but is never proved. Popper’s point was that it is more practical and feasible to find out what was not true rather than proving what is true. If we have a strong hypothesis, say that ibuprofen does reduce opioid use after surgery, then most likely our experiment will support that idea—we fail to falsify it. Sounds like a double negative, but failing to falsify it means that it’s a positive study—ibuprofen did reduce opioid use. Assuming we have reasonable hypotheses, we will only occasionally be successful in falsifying them—a negative result. 

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C LI N I C A L A N ES THES IO LO GY

When Gulls Take Wing, So Do Resistant Bacteria

ulls may be a source for the spread of multidrug-resistant enteric bacteria into the environment, according to new research presented at the 2011 Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). Researchers collected 52 fecal samples from gulls in Miami Beach, Fla., and found that 8% of the Escherichia coli

and Enterobacter cloacae isolates carried extended-spectrum β-lactamase (ESBL)producing enzymes (abstract C2-1560). “They [gulls] could be an important vector for the spread of drug-resistant bacteria,” said Patrice Nordmann, MD, PhD, chief of the Department of Bacteriology-Virology at Bicetre Hospital in Paris, during a press briefing at the conference.

The investigators cultured 83 enterobacterial isolates and 20 non-enterobacterial isolates overall. Among the enterobacteria, nine carried ESBL enzymes: Seven E. coli isolates produced CTX-M (five were CTX-M-15, two were CTX-M-32) and two Enterobacter cloacae isolates expressed SHV7. In addition, 14 E. coli isolates carried CMY-2, an AmpC-type β-lactamase.

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Although the sample size in this study was small, Dr. Nordmann added that “two years ago, we found similar rates of ESBL-producing bacteria in the feces of seagulls in Porto, Portugal.” The specific types of ESBLs uncovered in the study were consistent with those commonly isolated from humans. This relationship underscores the potential for gulls to disperse these drug-resistant bacteria elsewhere. “These birds may fly up to 1,000 km [620 miles] with very little water and food, so they could spread these resistant bugs to many different environments,” Dr. Nordmann said. Currently, no empiric evidence links gulls with the transmission of these bacteria to humans, he added. Scavengers by Nature Gulls are scavengers, eating and drinking whatever they come across. Urban species often feed on discarded food or standing water that may be contaminated with pathogenic bacteria. They can shed these bacteria in their feces, which end up on the sandy beaches they share with humans. However, the ability to harbor ESBL-producing bacteria is not limited to gulls. Dr. Nordmann mentioned that a study in Istanbul, Turkey, identified pigeons with similar resistance genes to those found in the Miami Beach study. But he pointed out that gulls may pose a larger risk for more widespread dissemination of resistant organisms because of their ability to fly hundreds of miles at a clip. Because E. coli infections primarily occur within the community, an increased incidence of drug-resistant strains could have serious public health consequences. “This is a real problem,” said Dr. Nordmann. “It is a worldwide phenomenon that may enhance the problem of [drug-resistant bacteria] ... for patients in the community.” —Seth Kandel

November 2011

AnesthesiologyNews.com I 15

CL I N I CA L A N E STH E SI OL OG Y

Management Strategies for Ambulatory Surgical Patients Paying Off

ardiac and respiratory complications, along with other problems not directly related to surgery, were the most common causes of unplanned hospital admissions after ambulatory surgery, according to a retrospective study at Duke University Medical Center, in Durham, N.C. Surgical-related reasons, including complications or necessary additional procedures, were the next most common. The study was presented at the 2011 annual meeting of the American Society of Anesthesiologists (ASA; abstract 849).

23-hour observation unit. Demographic variables were obtained from the medical center’s electronic records; hospital charges attributed to inpatient admissions were pulled from an internal financial database. During the study period, unplanned hospital admissions accounted for 127

patients, a rate of 0.45%, which is comparable to previously published findings. The average age of the patients was 48 years; average body mass index was 30 kg/m2. Fifty-one percent were classified as ASA physical status I/II; the remainder of the patients were classified as ASA III/IV and were obese.

Medical-related issues accounted for 32% of admissions (41 cases) and were associated with the highest total charges ($356,392); treating cardiac complications was the most expensive ($177,283). Surgical-related reasons accounted for 22% of admissions

‘We’re doing a better job of identifying appropriate patients for ambulatory surgery, and identifying and managing risk factors beforehand.’ —Steve Melton, MD The investigators reviewed the charts of 28,456 patients who underwent ambulatory surgery between May 2006 and May 2010 at a freestanding surgical center adjacent to Duke University. They included all cases admitted directly after the procedure and cases from the ambulatory center’s

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see ambulatory page 17

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C LI N I C A L A N ES THES IO LO GY

Inside the Anesthesia Awareness Registry

he method of anesthesia does not appear to affect the type of experiences reported by patients who claim to have episodes of awareness during procedures, according to an analysis of the Anesthesia Awareness Registry (www.awaredb.org). Researchers at the University of Washington, in Seattle, presented their findings at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 003). Non–general anesthetics involved monitored anesthesia care, sedation and, in a few instances, regional anesthesia.

100 Awareness Experiences in Group, %

Contrasting Findings Dr. Cooper said the nearest equivalent study in the United States to NAP4 was the retrospective analysis in 2005 of malpractice claims associated with difficult airway cases in the American Society of Anesthesiologists (ASA) Closed Claims Project (Anesthesiology 2005;103:33-39). The analysis included 179 claims filed with 35 insurance companies between 1985 and 1999. One key difference between NAP4 and the 2005 closed claims analysis, according to Dr. Cooper, is the high level of enrollment in the U.K. National Health Service, which yields an estimate of the overall incidence of anesthesiarelated airway complications of about one in every 22,000 general anesthesia procedures. By contrast, because there is no national health care registry in the United States, it is unclear whether the number of complications in the American setting matches the U.K. rate. “All complications do not result in litigation, and thus may go undetected by the closed claims analysis,” Dr. Cooper said. “Furthermore, closed claims take years to run their course, and thus we may awaken to trends long after they have been addressed. So, the NAP4 findings need to be taken very seriously.”

 General anesthesia (n=57)  Non–general anesthesia (n=26) P<0.05

Tactile

Pain/Burning Paralysis

Fear/Anxiety Psychological Sequelae

Figure. Sensations and psychological sequelae.

Poor Quality, n

Not Classified, n

Table. Reviewers’ Assessments of Quality of Airway Management and Degree of Harm Mixed Qualitya, n

“The amount of information here is a treasure trove,” said Richard Cooper, MD, professor in the Department of Anesthesia at the University of Toronto, in Canada, and president-elect of the Society for Airway Management. Lead investigator Tim Cook, MBBS, and his team analyzed data from a United Kingdom national registry that included 2.9 million general anesthesia procedures conducted between September 2008 and September 2009. The data included 184 serious airway complications that led to death, brain damage, emergency airway surgery, unanticipated admission to the intensive care unit (ICU) or prolonged ICU stay. Two panels, each including at least five physicians from a range of clinical specialties, reviewed each complication and determined the precipitating factors, severity of the event and quality of airway management. Of the complications, 133 occurred during anesthesia; 36 occurred in the ICU; and 15 events took place in an emergency department. Sixteen cases of anesthesia-related airway complications resulted in death; three led to brain damage; six were associated with a partial recovery; and 106 ended with complete recovery. Two patients with anesthesia-related airway complications died from complications not related to the airway. Dr. Cook, consultant in the Department of Anaesthesia at Royal United Hospital, in Bath, England, said that approximately 40% of anesthesiarelated airway complications developed in patients with acute or chronic head, neck or tracheal disease, and 70% of those occurred in patients with obstructive lesions. Perhaps the most striking finding was that the quality of airway management was rated “good” in just 18% (24) of the 133 anesthesia-related airway complications (Table). “While bad things happen despite good care, in the NAP4 study too frequently

did bad outcomes result from poor care,” Dr. Cooper said. The findings point to a need for better airway management in obese patients. Specifically, 40% (53 of 133) of individuals with anesthesia-related airway complications had a body mass index more than 30 kg/m2. In this patient subpopulation, the investigators judged that airway management quality was “good” in 12 patients, “mixed” in 23 cases and “poor” in 15 cases; the quality of airway management was unclear in the remaining three cases. “With obesity rates in the United States being considerably higher than in the U.K., this finding would be of particular interest to American physicians,” Dr. Cook told Anesthesiology News.

Good Quality, n

NAP4 continued from page 1

All serious airway complications (N=184)

All complications during anesthesia (n=133)

Anesthesia-related deaths and brain damage (n=19)

Mixture of both good and poor elements.

‘Closed claims take years to run their course, and thus we may awaken to trends long after they have been addressed. So, the NAP4 findings need to be taken very seriously.’ —Richard Cooper, MD One contrasting finding between the two countries’ analyses was that in the NAP4 study, 50% of airway-related deaths resulted from aspiration, Dr. Cooper said. “This is between three and five times higher than reported by the closed claims analysis.” Carin Hagberg, MD, professor and chair of anesthesiology at the University of Texas Medical School at Houston, and executive director of the Society for Airway Management, said that claims in the Closed Claims Project were more likely to result from airway injury and pneumothorax. She said she was particularly struck by the 70% of airwayrelated deaths in the U.K. study that occurred in the ICU that were at least partly caused by failure to use capnography in ventilated patients. “The researchers noted that increasing use of capnography in ICU patients is the single change with the greatest potential to prevent deaths such as those reported to NAP4,” Dr. Hagberg told Anesthesiology News. “Perhaps we should follow suit with the Association of Anaesthetists of Great Britain and Ireland, which recently published a statement urging that continuous capnography be used in all patients whose airways are being maintained.” (To access the guidelines, go to www. aagbi.org.) Some of the findings of NAP4 are likely not applicable to the U.S. health care setting, Dr. Cooper said. For example, 56% of all general anesthesia procedures in NAP4 involved use of supraglottic airway devices, compared with 38% and 5.3% of procedures in which tracheal tubes and face masks, respectively, were used. “Supraglottic airway devices are likely used more often in the U.K., and thus there may be differences in the incidence of complications related to these devices,” he said.

November 2011

AnesthesiologyNews.com I 17

CL I N I CA L A N E STH E SI OL OG Y Ambulatory continued from page 15 (28 cases) and were associated with the next highest charges ($311,311); treating surgical complications was the most expensive ($137,367). Other reasons for admission included need for additional pain control (27 cases), postoperative antibiotics (13 cases), postoperative bleeding (11 cases), anesthesia-related complications (four cases) and adverse drug reactions (three cases). Steve Melton, MD, assistant professor of anesthesiology at Duke and a co-author of the study, said the results were more confirmatory than surprising. “It shows we’re doing a better job of identifying appropriate patients for ambulatory surgery, and identifying and managing risk factors beforehand,” Dr. Melton said. Risk identification should be a team approach from surgeons and anesthesiologists, although “some of this stuff you can’t always prepare for,” he added. Tracey Stierer, MD, medical director for the Johns Hopkins Outpatient Center Surgical Programs, in Baltimore, agreed that the low unplanned admission rate means the Duke staff chose patients appropriately. However, she said, she would have liked to see different variables studied to measure the financials of unplanned admissions. “Things like adverse drug events, postop bleeding and surgical complications

Dr. Cooper also noted that in NAP4, 81% of adult patients with anticipated difficult airways received IV induction, whereas only 10% underwent awake bronchoscopic intubation. “This is a significant departure from the recommendations of the ASA algorithm for the management of the difficult airway.” Still, although differences may exist between NAP4 and the ASA Closed Claims Project—and indeed between American and British airway management practices, in general— these should not detract from the take-home message of both analyses, Dr. Hagberg said. “At both individual and institutional levels, we need to become better educated, better skilled and better able to face the inevitable challenges of our practice,” she said. The complete NAP4 report, as well as presentations and podcasts, can be found online at www.rcoa.ac.uk/index. asp?PageID=1089. —David Wild

could happen in any setting,” she said. “What I want to see is the cost that patient incurred to the medical system.” Examples would include case delays, backups in the postanesthesia care unit, taking an anesthesiologist away from another case and upgrades in nursing care. Dr. Stierer noted that a larger study at ambulatory surgical centers in New York in 2007 by Fleisher and colleagues found that risk factors for unplanned hospital admissions

included surgical time of more than two hours; the use of general anesthesia; and the presence of HIV, cancer or peripheral vascular disease. Obesity was not a risk factor in that study (Arch Surg 2007;142:263-268). Peter Glass, MD, president of the Society for Ambulatory Anesthesia, who practiced at Duke for 15 years, said that overall the study was a good example of quality assurance. He said that costs are highly individual to each institution.

Also, because Duke’s ambulatory surgical center has a 23-hour observation unit, surgeons there may have selected more complicated cases compared with most ambulatory centers. “From my perspective,” Dr. Glass said, “the numbers look good; they have an excellent preoperative clinic and anesthesiologists review patients to make sure they’re appropriate.” —Karen Blum

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picture of ventilation. 1 ASA Standards for Basic Anesthetic Monitoring, Committee of Origin: Standards and Practice Parameters (Approved by the ASA House of Del egates on October 21, 1986, and last amended on October 20, 2010 with an effective date of July 1, 2011) - Viewed 3-21-11 at ww.asahq.org/.../Standards%20 Guidelines%20Stmts/Basic%20Anesthetic%20Monitor ing%202011.ashx 2 Stoelting R and Overdyk F. Anesthesia Patient Safety Foundation, Conclusions and Recommendations from June 08, 2011 Conference on Electronic Monitoring Strategies to Detect Drug-Induced Postoperative Respiratory Depression. Accessed August 25, 2011 at http://www.apsf.org/announcements. php?id=7. 3 Standards for Basic Anesthetic Monitoring. American Society of Anesthesiologists. Accessed 6/20/11 at http://www.asahq.org/For-Healthcare-Professionals/~/media/For%20Members/documents/Standards%20Guidelines%20Stmts/Basic%20Anesthetic%20Monitoring%202005.ashx

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C LI N I C A L A N ES THES IO LO GY

For Bier Block, the Ties That Bind Dictate Pain

hen using Bier block anesthesia during hand surgery, placing the tourniquet on the forearm instead of the upper arm can lead to significantly less ischemic pain for patients, according to a new study from St. Luke’s-Roosevelt Hospital Center, in New York City. The forearm placement also can significantly lower drug use and costs, as fewer patients require sedation, and fast-track recovery. And the procedure reduces hospital costs because patients who do not require sedation can bypass the postanesthesia care unit (PACU) and be discharged fully awake. The results were presented at the American Society of Anesthesiologists 2011 annual meeting in Chicago (abstract 236). With the conventional technique for Bier block, ischemic pain from tourniquet pressure is so severe that many patients require IV sedation, said Junping Chen, MD, PhD, assistant professor of anesthesiology at St. Luke’s, who led the study. “After 10 or 20 minutes, patients often complain of tourniquet pain and they cannot tolerate it without help. We have to administer additional analgesics and anesthesia. This undermines the benefit of the Bier block, as additional analgesics and anesthesia may impact postoperative side effects. It will affect cognitive function and slow down quick recovery and discharge.” Dr. Chen and his colleagues observed that when they put a tourniquet on the forearm for minor surgeries, rather than on the upper arm, as is conventional, many patients did not complain of tourniquet pain (Figure). For their study, the researchers compared tourniquet placement while performing Bier blocks on 56 patients undergoing hand surgery at St. Luke’s. The average age of the patients was 41 years. The 28 patients who had tourniquets placed on the forearm received 8 mL of 2% lidocaine plus 10 mg of ketorolac; the 28 patients with upperarm tourniquets received 15 mL of 2% lidocaine plus 20 mg of ketorolac. After exsanguinating the arm with an Esmarch bandage, the clinicians inflated the tourniquet to a pressure of 150 mm Hg above the patients’ systolic blood pressure. An anesthesiologist unaware of the study goal measured patients’ pain every five minutes using a visual analog scale (VAS). If the VAS score rose above 4, the anesthesiologist administered 50

mcg of IV fentanyl. If the VAS score remained higher than 4 despite initial treatment, additional fentanyl could be administered at the discretion of the anesthesiologist. Patients whose VAS scores were higher than 6 despite fentanyl received deep sedation with propofol. After surgery, patients who received neither propofol nor fentanyl were able to bypass the PACU and go

straight to Phase II recovery. The researchers found that 64% of patients who had the tourniquet placed on the forearm had a VAS score of 3 or less, compared with just 4% in the other group. They also used significantly less fentanyl on average than did the other patients, 31 versus 104 mcg, respectively. Roughly 80% of patients with an upper-arm tourniquet

required propofol, compared with just 4% of the forearm group. Nearly half (46%) of patients who had the forearm technique were able to bypass the PACU; none of the patients receiving the upper-arm tourniquet was able to do so. Dr. Chen said the forearm technique may reduce pain because of the anatomic differences. In the forearm, the

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November 2011

AnesthesiologyNews.com I 19

CL I N I CA L A N E STH E SI OL OG Y

Figure. Bier block with a forearm tourniquet.

tourniquet envelops the radius and ulnar, but the upper arm has only the humerus to absorb the pressure. “The forearm placement may be more cost-effective and suitable in the office and surgical center settings, where there are limited PACU facilities and staff,” Dr. Chen said. Still, he added, it is helpful mostly for simpler procedures performed on the hand or fingers, and some surgeons may feel the tourniquet is too close to the operating field.

Jean-Louis Horn, MD, director of regional anesthesia at Oregon Health & Science University in Portland, said the study “compared something a lot of us knew, but had not been well defined.” However, Dr. Horn said, the majority of anesthesiologists now use a double tourniquet, with two cuffs and two ports. The cuffs can be separated and placed on different parts of the arm, so if after 10 minutes a patient complains of pain, the anesthesiologist can deflate one tourniquet and inflate another tourniquet located in an already-anesthetized part of the arm. Another way to reduce patient pain is to prep the arm before the block using a sterile tourniquet, which can be located adjacent to the operating field. Dr. Horn said he also would have liked to see the researchers use a scientific measure, like an Aldrete score, to evaluate which patients can safely bypass the PACU. “Although it is more objective to evaluate the PACU bypass with an Aldrete score, our hospital policy is to admit all patients who have any sedation or narcotic medication during their procedure to the PACU,” Dr. Chen said. —Karen Blum

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C LI N I C A L A N ES THES IO LO GY

Another Wake-up Protocol Improves ICU Outcomes Pittsburgh—A pharmacist-led sedation program designed to standardize wake-up assessments for mechanically ventilated patients in the intensive care unit resulted in a statistically significant mortality reduction, as well as a trend for decreased duration of ventilation, according to a presentation at the American College of Clinical Pharmacy annual meeting.

Although daily wake-up assessments were supposed to be standard procedure for intubated patients who did not have contraindications, “I realized that the nurses here didn’t really understand how to do wake-up assessments,” said lead author Lisa Lederhouse, PharmD, clinical pharmacist at New Hanover Regional Medical Center, in Wilmington, N.C. In many cases,

sedation (usually with propofol) was continued at high levels for patients who likely could have done well with a lower dose.

(Awakening and Breathing Controlled) trial (Lancet 2008;371:126-134), a key multicenter study, found that a daily sedation and ventilator-weaning protocol reduced ventilator time and ICU Earlier Research Established length of stay, preserved cognitive Protocol’s Efficacy function and reduced mortality rates. Previous research showed that daily Yet, the authors noted that the protowake-up assessments conferred sev- col is used in fewer than half of U.S. eral important benefits. The ABC hospitals. In Dr. Lederhouse’s retrospective/ prospective study, the retrospective control arm consisted of 50 patients admitted over a two-month period prior to initiation of the wake-up program. The prospective arm consisted of 50 patients admitted after the program was initiated. All patients were in the medical or general surgical ICU, were receiving mechanical ventilation and continuous sedatives and/or analgesics. Neurosurgery patients; patients on

‘Most ICU pharmacists have a role to play aside from just picking and dosing medications. In this case, it was driving a quality initiative and optimizing outcomes.’ —Ishaq Lat, PharmD

November 2011

AnesthesiologyNews.com I 21

CL I N I CA L A N E STH E SI OL OG Y neuromuscular blockers; and patients with active seizures, withdrawal symptoms, evidence of increased intracranial hemorrhage or profound neurologic deficits were excluded from the study. Dr. Lederhouse trained the intensive care nurses on detailing daily wake-up assessment procedures; the nurses also completed an online training module. The wake-up assessment was the same for all patients, and involved interruption of sedatives to determine if they were ready for liberation from the ventilator. Pharmacists would ensure that the assessments were performed daily and made recommendations related to sedation and analgesia. Prior to the study, the computerbased chart contained a single check box for nurses to record whether or not an assessment was done. The updated chart included fields for details such as whether the sedative was turned off, what the result was, if it was turned back on and at what rate. In addition, a poster describing the wakeup assessment protocol was placed in the ICU. After initiating the training program, Dr. Lederhouse observed an 18% decrease in the primary outcome of duration of ventilation, although the result was not statistically significant. The average duration of ventilation decreased from 138.45 hours among those treated before the protocol was initiated to 113 hours among those treated after (P=0.6675). Improvements in secondary outcomes also were reported: The mortality rate dropped from 36% to 14% (P=0.0111)

and the number of wake-up assessments performed correctly increased from 12.5% to 67.8% (P<0.001). Although the change in the primary outcome measure was not statistically significant, the hospital updated its nursing documentation system to provide further guidance and ensure that the protocol is practiced every day. “Something we thought was being done correctly really wasn’t done to the best standard of care,” Dr. Lederhouse said. “It was a combination of both

education and changing the computer system so that any new nurse who came in could see how the protocol was supposed to be done.”

research findings into clinical practice to improve patient care. That further reinforces the fact that most ICU pharmacists have a role to play aside from just picking and dosing medicaABC Participant Comments tions. In this case, it was driving a qualIshaq Lat, PharmD, clinical coordi- ity initiative and optimizing outcomes.” nator of critical care/emergency medHe added that a larger sample size icine at the University of Chicago would add more weight to the findings Medical Center, participated in the and provide additional evidence that earlier ABC trial. “What’s novel is they could be applied to most hospital that in this study, a clinical phar- settings. macist is driving the translation of —Steve Frandzel

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P OLI C Y & M A NAGEMENT

‘Incident-to’ Billing: Making It Work for You Dear Arizona Pain Specialists, 8. Billing must be done under the billing number I have a small pain medicine practice, but we’re of the physician who is actually on site providing expanding fast. Our model for patient care relies supervisory services rather than the physician who heavily on the work of nurse practitioners and physiinitiated and provides ongoing monitoring of the cian assistants. I recently read about a Medicare billpatient’s care. ing practice known as “incident-to” billing, but the 9. The qualified practitioner must act under the guidelines seem complicated. What do you know supervision of a physician and must be an about “incident-to” billing? employee, leased employee or independent conThank you, tractor of the physician or of the legal entity that Incidentally Confused employs or contracts with the physician (“Incident To Terminology and Billing by Qualified PractiDear Incidentally Confused, tioners—Revised” 2010 Noridian Administrative Congratulations on your success and growing pracServices, LLC, posted Dec. 15, 2010). tice. There is indeed a Medicare guideline known as Admittedly, this seems cumbersome and overincident-to billing. This is when a qualified mid-level whelming. However, Arizona Pain Specialists has provider (MLP; physician assistant [PA], nurse practitioner [NP], clinical nurse specialist, certified nurse midwife, clinical psychologist, clinical social worker, physical therapist, speech-language pathologist or occupational therapist) provides patient care, but bills the visit under the physician’s National Provider Identifier (NPI) rather than his or her own. Medicare pays MLPs at 85% of the physician’s fee schedule. But when billed as incident-to, Medicare pays at 100% of the physician’s fee schedule because the visit falls under the physician’s NPI. The Medicare criteria for incident-to billing are not well understood by most physicians, so we will try to clear up any confusion. According to Medicare, nine criteria must be met to qualify for incident-to billing: 1. The patient treated by auxiliary staff must be an established patient of some physician and cannot Figure 1. New patients. be a new patient. 2. The physician must have seen the patient first and initiated the plan of care, including subsequent services by auxiliary staff. 3. It is recommended that the physician inform the patient that a qualified practitioner will be caring for the patient under the physician’s direction and monitoring. 4. Services provided and billed incident-to must be for office or home services and ordered by a physician. Incident-to billing does not apply to hospital inpatient, comprehensive outpatient rehabilitation facility or rehabilitation agency services. (Note, however, that incident-to billing does apply to outpatient hospital clinics and outpatient skilled nursing facility services.) 5. The physician must be present on site, either in the office suite or in the patient’s home, during the time that the patient is seen and immediately available to provide assistance and direction when the qualified practitioner is performing services. 6. The physician must remain actively involved in the patient’s care and must periodically see the patient for the ongoing disease or illness. It is also recommended that the physician review the qualified practitioner’s chart notes in order to monitor treatment progress. 7. Incident-to rules do not apply if there is a new illness or problem for which the physician has not previously seen the patient and there is not an Figure 2. Established patients. established plan of care.

developed a set of easy questions to ask a patient at each visit to accurately and quickly determine if a visit is eligible for incident-to billing status. Before revealing these questions, two terms must be defined: the rendering provider and the billing provider. The practitioner who renders service is the rendering provider. The practitioner under whom the service is billed is the billing provider. In a practice unconcerned with incident-to billing, these two would be the same. With incident-to billing, however, only three possible situations allow for incidentto billing: 1. The physician is both the billing and rendering provider. 2. The MLP is both the billing and rendering provider. 3. The physician is the billing provider and the MLP is the rendering provider. This is the only situation in which a visit can be billed incident-to the physician. Arizona Pain Specialists has created a logic tree based on billing office visits that automatically determines rendering provider and billing provider (and implicitly incident-to billing). Because the office visit is always billed, regardless of other services performed during the visit, this logic tree is attached to the sections indicated on the superbill associated with the office visit codes (e.g., 99203-99205 and 99211-99215). On the top of all clinic superbills is a section for both new patient office visits and established patient office visits. This organization creates an immediate dichotomy between the two and helps simplify the process of determining the billing and rendering provider. The new patient section of the superbill definitively establishes that the visit cannot be billed incident-to because a physician has not established a plan of care (Figure 1). Either the MLP is both the billing and rendering provider, or if the physician saw the patient, he or she is both the billing and rendering provider. Notice how this is explicitly indicated as a reminder to the provider while he or she completes the superbill. Determining the rendering and billing provider for an established patient can be more complex as this is where incident-to billing is possible. Nevertheless, with a few easy questions built right into the superbill, this can be deciphered without any headaches. Notice in the established patient form (Figure 2), the separate boxes for the rendering and billing provider, an indicator to the provider that it is possible for the two to differ (whereas with new patients the two must always be the same). If the physician saw the patient, he or she is the rendering and billing provider. If not, two possibilities remain: Either the MLP is both the rendering and billing provider, or the MLP is the rendering provider and the physician is the billing provider. Three questions listed below the initial query will help determine which case is correct. If, and only if, all three questions are answered “yes,” can the visit be billed incident-to the MLP as the rendering provider see Incident page 24

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P OLI C Y & M A NAGEMENT Incident continued from page 22

Was the patient seen and examined by a physician?

and the physician as the billing provider. If “no” is the answer to any of the questions, then the MLP must be both the rendering and billing provider. This scenario is further detailed in a single logic tree and flowchart that follows:

If yes, the physician is both the billing and rendering provider. It is important to note that when billing incident-to the physician, the visit should be billed under the onsite supervising physician, even if this is not the same physician who established the plan of care.

Is the patient new or established?

Established.

If no, was the current plan of care established by a physician?

Was the plan of care followed without change? Is there an on-site supervising physician?

If “no” is the answer to any of these questions, the MLP is both the billing and rendering provider. If all of these questions are answered “yes,” the MLP is the rendering provider and the onsite supervising physician is the billing provider. These are the tools you will need to determine if a visit should be billed incident-to. We have included several

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examples of hypothetical patients here to further illustrate how to bill properly. These sample patients are not real people, and their names are fictitious. Many insurance companies handle billing under MLPs differently from Medicare and some don’t recognize incident-to billing at all. Before billing these insurance companies, make sure you understand how each insurance company wants you to bill with MLPs. New Patients Scenario 1: Howard Rorek arrived at our pain clinic with complaints of low back pain. He was seen initially by an NP, but a physician was consulted and came into the room to perform an evaluation on him. The physician then determined the course of treatment for Mr. Rorek. In this case, the physician saw the patient, and thus he should be both the rendering and billing provider. Scenario 2: Domineek Frankon was a new patient who had been suffering from severe pain in her left leg. There was no physician on the premises during Ms. Frankon’s first visit and she was seen by a PA who determined her plan of care. The patient never saw a physician and so the PA was both the rendering and billing provider. Scenario 3: Francysko D’Ankoniya was a new patient seeking treatment for foot and ankle pain in both of his legs. He was seen by an NP. There was an onsite physician and the NP briefly consulted the physician outside the exam room about Mr. D’Ankoniya’s plan of care. The physician did not, however, enter the room or perform an examination on the patient. Because the physician did not see the patient, the NP is both the billing and rendering provider.

November 2011

AnesthesiologyNews.com I 25

POL I CY & M A N A G E ME N T should be billed incident-to the doctor: The MLP is the rendering provider and the on-site supervising physician is the billing provider. In this case, the patient would be eligible for incidentto billing for future visits. Scenario 4: Gayle Wyenend first met with a physician who established a plan of care. To help with his back pain, the plan involved double diagnostic medial branch blocks. Mr. Wyenend returned to the clinic and saw an NP. Mr. Wyenend had a fall and

Established Patients Scenario 1: Dagnee Taggert was a patient who had been on a continued plan of care for three months. She recently had a successful lumbar radiofrequency ablation procedure and was being seen in follow-up to that procedure. A physician saw Ms. Taggert, so the physician is both the billing and rendering provider, and the patient would not be eligible for incident-to billing. Scenario 2: Jon Gahlt was seen for an initial visit two weeks ago and then came in for his first follow-up appointment. He did not see a physician at his initial visit, and only saw the PA at today’s visit. An on-site supervising physician was present. The visit should be billed with the PA being the rendering and billing provider because the physician did not establish the patient’s plan of care. Had the on-site physician seen the patient that day, and established a new or different plan of care, the visit would be billed with the physician as billing and rendering provider, and the patient would be eligible for incident-to billing for future visits. Scenario 3: Peetur Qiteeng met with a physician in his first office visit and has been working on slowly decreasing the amount of medication he is on. He came in for a follow-up appointment to assess his progress. During this visit he saw an NP. The on-site supervising physician was not the original doctor who examined Mr. Qiteeng. Nonetheless, because there was a supervising physician present, and the patient’s plan of care was both established by a physician and the MLP followed that plan of care without change, the visit

complained of new pain in his left arm. The physician was present, but did not visit or examine the patient about his new complaint. Because a new pain complaint was presented and a new plan of care was established, the visit could not be billed incident-to. The MLP was both the billing and rendering provider, so the patient is not eligible for incident-to billing. —Tory McJunkin, MD, Paul Lynch, MD, Sagar Gondalia, and Ryan Tapscott, PhD

Drs. McJunkin and Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations, seven pain physicians, 10 mid-level providers, three chiropractors, on-site research and behavioral therapy. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country. For more information, visit ArizonaPain.com and BoostMedical.com.

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P OLI C Y & M A NAGEMENT Shortages continued from page 1

5% were a result of problems obtaining reliable raw materials. Many drugs in short supply are low-profit that the number of shortages up to September of this generic injectables, which are susceptible to contamyear was triple what it was in all of 2005. “There are ination and also are costly to produce because the many causes to this problem, and because we don’t manufacturing process needs to ensure against this. know what all of these are, it is very difficult to target “A variety of solutions will be needed, including responses,” she stressed. regulatory changes, manufacturing changes and ways Indeed, as Edward Cox, coordinator of the drug to make sure people aren’t hoarding drugs and divertshortage program at the FDA, told attendees of a ing them to the gray market to sell at much higher public workshop held on Sept. 26 by the adminis- prices,” Dr. Fox said. tration, there are several reasons for the increasing The number of drug shortages would be even shortages: 54% of the shortages in 2010 were due to higher if not for FDA action. At the public workquality or manufacturing issues; 21% were a result shop, the agency said that it helped avert 99 drug of delays and capacity issues; 11% were due to man- shortages in 2010 by acting on manufacturers’ ufacturer discontinuation of unprofitable drugs; and advance notice of imminent shortages. Specifically, they sought out alternative manufacturers who were able to ramp up production and also helped manuTable. Summary of Conservation Measures facturers source raw materials in cases where these Implemented by Duke MDSRT materials were in short supply or contaminated. Dr. Fox said she holds out hope that FDA efforts, Phase I: Initial notification of supply disruption along with Senate Bill 296, which will require that manufacturers notify providers six months in 1. Cease prophylactic preparation of succinylcholine advance of an anticipated drug shortage, will help 2. One vial used for multiple doses stakeholders manage these shortages, if not limit them in number. 3. Use rocuronium as alternative for RSI when clinically appropriate

4. Use vecuronium or rocuronium if RSI is not needed

Phase II: Second notification of shortage and critically low supply at Duke University 1. Succinylcholine no longer permitted for elective cases 2. Limit succinylcholine use to emergent airway rescue where other techniques not appropriate 3. Reduce drug stock to 1 ampule per anesthesia cart (1 full vial or 2 partial vials) 4. Distribution of succinylcholine not permitted without approval from attending anesthesiologist 5. Use of succinylcholine no longer permitted for routine ECT

Phase III: Additional supply received but no national notification of full market resupply 1. Succinylcholine permitted as primary agent for life flight, in the emergency department and in critical ICU situations 2. Routine use of succinylcholine in ECT permitted

Phase IV: Full supply resumption and national notification of market resupply 1. Use in elective surgery permitted 2. Use as single-dose vial permitted 3. Prophylactic preparation of succinylcholine discouraged in adult population 4. Encourage use of nondepolarizing alternatives when clinically appropriate 5. Continue to supply only one vial per cart 6. No longer need attending anesthesiologist approval for distribution ECT, electroconvulsive therapy; ICU, intensive care unit; MDSRT, multidisciplinary drug shortage response team; RSI, rapid sequence induction

Coping Skills From the Trenches For their part, clinicians and pharmacists are doing what they can to mitigate the impact of drug shortages on the quality of care at their institutions. For example, Duke University Medical Center, in Durham, N.C., has formed a multidisciplinary drug shortage response team (MDSRT), which convenes at the first sign of an impending shortage, devising ways of scrimping, saving—and practically scraping together—whatever stocks of essential drugs are available. The MDSRT includes anesthesiologists, senior pharmacy managers, procurement and distribution staff, medication policymakers, pharmacy informaticians, clinical pharmacists, intensivists and emergency physicians. During more severe shortages, the team broadens to include the chair of the ethics committee, director of risk management, chief medical officer or the chief nursing officer. “This team has put together a coherent policy on drug shortages, how staff are notified, what action items need to be carried out, what measures need to be taken and also how to address ethical concerns,” said Christopher Murray, PharmD, pharmacy manager for perioperative services at Duke. Dr. Murray and his anesthesiologist colleagues Thomas Hopkins, MD, and Holly Muir, MD, shared the Duke approach to managing shortages at the 2011 annual meeting of the American Society of Anesthesiologists (ASA; abstract 368). By way of illustration, the team managed a recent succinylcholine shortage using a four-phased approach, initially implemented at the first notification of the shortage and continuing through to full resumption of supply (Table). Before the team’s intervention, Dr. Murray said, perioperative use of succinylcholine stood at 50 vials daily. After the most conservative measures were implemented, daily use of the drug fell to seven vials. Although a regular supply of the drug had resumed at press time, Dr. Murray said the team was maintaining some conservative measures and use of succinylcholine remained low, at

Drug shortages caused $216 million in labor costs last year.

approximately 18 vials daily. Not surprisingly, the overall cost of succinylcholine use at Duke dropped from $83 to $26 per day over the same period, amounting to an estimated $42,000 in annual cost savings, Dr. Murray reported. The conservative measures also have kept the number of canceled or postponed procedures low and helped Dr. Murray’s team avoid looking to the gray market for “expensive and potentially unsafe drugs. “We’ve managed to do OK by just reducing our use of drugs in short supply,” he said. “Occasionally, we’ve had to purchase directly from manufacturers, and this has resulted in significant costs increases.” A Nationwide Effort Scott Knoer, MS, PharmD, chief pharmacy officer in the Department of Pharmacy at Cleveland Clinic, in Ohio, said in an interview that the effort at Duke is typical of what is being done at institutions across the country. “In addition to a similar team of providers, we now have a full-time pharmacist closely monitoring shortages, redistributing supplies and seeking out alternative sources of medications when possible,” said Dr. Knoer, who also spoke at the FDA public workshop. The Duke financial analysis did not account for the added costs of labor associated with managing drug shortages, Dr. Knoer noted. He cited an article in the Oct. 1 issue of the American Journal of HealthSystem Pharmacists (2011;68:1811-1819) which estimated that the additional labor costs associated with drug shortages nationally in 2010 were $216 million. Dr. Fox echoed that point. “If you consider how

November 2011

AnesthesiologyNews.com I 27

POL I CY & M A N A G E ME N T the Sept. 26 FDA workshop, sharing results from an ASA survey conducted in April. The survey found that 48% of the 1,373 anesthesiologist respondents said the shortage of anesthesia-related drugs—most commonly propofol, succinylcholine, neostigmine and epinephrine—had compromised “optimal patient outcome. “In most cases, these have included prolonged awakening, longer stays in the recovery room and increased nausea and vomiting, but there have been

reports of significant adverse events, including deaths in some critically ill patients,” Dr. Berry, who is also professor of anesthesiology at Emory University School of Medicine, in Atlanta, added in an interview. Like Dr. Fox, Dr. Berry said Senate Bill 296, the legislation requiring a six-month advance notice of impending shortages, will ensure that institutions are given the lead time they need to ready themselves and conserve existing stock. “Adequate warning on

the scope and duration of an upcoming drug shortage is critical for implementing management approaches like Duke’s,” Dr. Berry said. “Using these measures will help prolong the availability of existing stocks of the drug in short supply and will lower the chances that a provider will need to purchase from alternate sources at high prices and minimize the impact on patient care.” —David Wild

STOP

Anesthesiologist Survey: Shortages Compromise Patient Care Arnold Berry, MD, MPH, vice president for scientific affairs at the ASA, also delivered a presentation at

much time the Duke team took to manage their succinylcholine shortage, and how much time they spent being pulled away from their regular duties to do so, and you multiply that by 30 or 40, you can begin to understand the impact this is having on labor availability and labor cost,” she said. A recent impact report by the Associated Press also estimated the costs of purchasing pharmaceuticals during a drug shortage (“AP Impact: Hospital Drug Shortages Deadly, Costly,” AP Sept. 24, 2011). The report cited a survey of 549 hospitals, which found that more than half had procured scarce drugs from alternative distributors, paying an average of 650% more than usual. Drug shortages also have human costs, the AP report found. It said improper preparation and errors in administering unfamiliar gray-market medications contributed to 15 reported deaths over the past 15 months.

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P A I N M E DI C I NE

Researchers Look To Unlock Mysteries of Effective Post-Op Pain Relief With Oral Analgesics

ractitioners know that oral analgesics offer patients pain relief, but they are less confident about which drugs and which doses offer optimal analgesia. To help quantify which combinations and doses of oral analgesics are most effective for relieving pain, researchers at Oxford University’s Pain Research Unit in the United Kingdom analyzed 35 previously published Cochrane Reviews of randomized clinical trials (RCTs) involving common oral medications used to treat severe to moderate postoperative pain. The researchers found a wide range of efficacy, with no single drug producing high levels of pain relief for all patients. “If the first painkiller a person tries doesn’t seem to work, then a doctor should look to find an alternative reliable drug and see if it is more effective in that patient,” said R. Andrew Moore, MD, lead author of the study published online Sept. 7 (Cochrane Database Syst Rev 2011;9:CD008659). “We do need lots of analgesic medicines. Pain is so complex in its pathways, in its genetics, in the modulation by the brain, and in the way in which our bodies handle and respond to drugs [that] it is inevitable that to do good for everyone, we need access to a range of therapies.” The meta-analysis examined 35 Cochrane Reviews involving 38 analyses of single-dose oral analgesics tested in acute postoperative pain settings. The analysis covered about 45,000 participants and 350 placebo-controlled RCTs. Results were obtained for 46 drug–dose combinations used in dental pain and Advertisement

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other painful postsurgical conditions. The primary outcome was percentage of patients who experienced at least 50% pain relief over four to six hours. Efficacy rates ranged from about 30% to more than 70%, and the time to remedication varied from two hours to more than 20 hours for the same pain condition. The results varied significantly. For example, 600 mg of ibuprofen reduced postoperative pain by at least 50% for 77% of patients, whereas 600 mg of aspirin produced the same effect in only 39% of patients. Codeine 60 mg showed the worst results, producing effective pain relief in only 26% of those treated for all pain conditions. The researchers also determined the number needed to treat (NNT) for each drug–dose combination. Drug–dose combinations with good (low) NNTs included ibuprofen 400 mg (NNT, 2.5; 95% confidence interval [CI], 2.4-2.6), diclofenac 50 mg (NNT, 2.7; 95% CI, 2.4-3.0), etoricoxib 120 mg (NNT, 1.9; 95% CI, 1.7-2.1), codeine 60 mg plus paracetamol 1,000 mg (NNT, 2.2; 95% CI, 1.8-2.9), celecoxib 400 mg (NNT, 2.5; 95% CI, 2.2-2.9) and naproxen 500/550 mg (NNT, 2.7; 95% CI, 2.3-3.3). Most drug–dose combinations also had NNTs of less than 3, and higher doses of the same drug tended to produce lower NNTs. Long duration of action (at least eight hours) was found for etoricoxib 120 mg, diflunisal 500 mg, oxycodone 10 mg plus paracetamol 650 mg, naproxen 500/550 mg and celecoxib 400 mg. Reported adverse events were few and generally not different between active drug and placebo, except for aspirin and opioids. Reviews but no trial data were available for acemetacin, meloxicam, nabumetone, nefopam, sulindac, tenoxicam and tiaprofenic acid. Insufficient data were available for dexibuprofen, dextropropoxyphene 130 mg, diflunisal 125 mg, etoricoxib 60 mg, fenbufen and indomethacin, the authors reported. “Pain relief doesn’t have to be a mystery,” Dr. Moore said. “There is a body of reliable evidence about how well 46 different drug–dose combinations work against acute pain, but the review also shows there are many examples of drugs for which there is insufficient evidence, and the drugs in question should probably not be used to treat acute pain.” Adapting Findings to Patient Care The findings can be useful for consumers and physicians, Dr. Moore added. “The consumer who wants to purchase analgesics for common painful events like a headache or period pain might find a message that relatively simple cheap analgesics are effective. They would be surprised, perhaps, that their expensive branded analgesic was not on the list. That’s because there are no trials published [for these drugs],” he explained. “A medical practitioner might want to prescribe an analgesic that is most likely to provide good pain relief to a large proportion of her or his patients, rather than a small proportion,” Dr. Moore added. “A hospital might be interested in duration of analgesia

‘Pain is so complex in its pathways, in its genetics, in the modulation by the brain, and in the way in which our bodies handle and respond to drugs [that] it is inevitable that to do good for everyone, we need access to a range of therapies.’ —R. Andrew Moore, MD as a key element for designing an effective postoperative care pathway, because pain-free patients get better faster and are happier.” Dominic J. Aldington, BSc, a consultant in anesthesiology and pain medicine and clinical director of the Oxford Regional Pain Relief Unit at Oxford Radcliffe Hospitals in the United Kingdom, said the study shows that there are simple agents that can significantly reduce acute pain for significant periods of time. “This is important because it shows we can do something with the tools we have available now,” Mr. Aldington said. “An NNT of less than 2 really is outstanding, and I will certainly reach for the etoricoxib as Plan A,” he said. Mr. Aldington is a colleague of Dr. Moore, but was not involved in the study. This study on acute pain is part of a larger effort in pain in general, Dr. Moore said. Next year, he and his colleagues plan to publish a study examining migraine and assessing over-the-counter medicines because most people with migraine do not visit a doctor for it. Also in the works are studies comparing chronic pain medications involving musculoskeletal, as well as nerve injury, pain. “Here, there are major methodological issues that mean that we have to look at chronic pain results with a cold and fishy eye,” Dr. Moore said. “To be honest, there are results coming here that really will surprise and will require substantial rethinking by all sorts of regulatory and clinical bodies.” —Ted Agres

November 2011

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Pa in M e d ic ine

Anti-Drug Campaigns May Be Ineffective for Teens

ublic service advertising campaigns designed to discourage prescription drug abuse among high school students may be having the opposite effect, according to a study presented at the 2011 annual meeting of the American Society of Anesthesiologists in October. The study analyzed data extracted from the Monitoring the Future (MTF) project, a National Institute on Drug Abuse (NIDA)–funded self-reported drug use survey designed to monitor changes in values, behaviors and lifestyle related to drug use among schoolaged children (abstract 721). A team of researchers at Rush University in Chicago reviewed responses to a section of the MTF questionnaire that dealt with exposure to anti-drug ads and perceptions of those ads among 12th-grade students. Their analysis, which tracked drug use and exposure to anti-drug ad campaigns from 1999 to 2009, showed illicit drug use among the 12th-graders surveyed increased with increased exposure to anti-drug advertising up until 2003. The investigators also found that a campaign targeted at “prescription pain medication” initiated in 2008 had little or no effect on narcotic abuse rates the following year. “Our findings indicate that overexposure or possible overemphasis on the consequences of drug abuse may be counterproductive,” said Asokumar Buvanendran, MD, professor of anesthesiology and pain medicine at Rush and one of the authors of the study. “Attacking the issues from a slightly different perspective may produce better results.” Concerns over the effectiveness of anti-drug advertising campaigns come as government agencies, including the NIDA and the Office of National Drug Control Policy, have begun to implement President Barack Obama’s Prescription Drug Abuse Prevention Plan. The plan includes the use of anti-drug educational and advertising campaigns but, according to the Rush study, the majority of high school students believe that such outreach efforts overstate the dangers of drug abuse and are biased. Thus, other tactics may be necessary to dissuade young adults from using drugs. “Emphasizing the skills and experience required for the safe use and management of these drugs may not create the mistrust and bias that more forceful ‘scare tactics’ may engender, yet still communicate the dangers of illicit use,”

Dr. Buvanendran noted. As a family practitioner and parent of two young adults, Louis Kuritzky, MD, agreed. He has seen firsthand that messages regarding the dangers associated with prescription drug misuse can fall on deaf ears. “Such campaigns might experience a lack of success initially for a variety of reasons, not the least of which may involve distrust of

‘the establishment’ by young adults,” said Dr. Kuritzky, clinical assistant professor at the University of Florida in Gainesville, who was not involved in the Rush research. “The so-called ‘War on Drugs’ has generally been a failure because young adults often do not find messages to be credible. Few [young adults] know anyone who has suffered serious toxicity from prescription agents and few

are familiar with the hard data indicting prescription opioids as the culprit in the deaths of their age compatriots.” Dr. Kuritzky added that although the Rush project was only an initial trial, it is a research area worthy of further study. “It may take some time for awareness of the consequences of opioid misuse to exert a meaningful impact,” he said. —Brian P. Dunleavy

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T E C H NO L O G Y

Do You See What US Hears?

MRI continued from page 1 collaborators asked 20 anesthesiologists if they would use these devices during MRI. They found 85% (17 of 20) were unwilling to use a ProSeal and 90% (18 of 20) said they would not use the Flexible in that setting. Following the survey, subjects were given text from the device’s instruction manual, which labels the two devices as “MRI-conditional”—terminology with which they were unfamiliar. Claims of MRI compatibility are based on testing three criteria, Dr. Galgon explained: the degree to which a device heats during a scan, whether the device affects the quality of the image and whether the supraglottic airway shifts during the scan as a result of magnetic pull. A label of “MRI-conditional” means the device may be used safely under the specific conditions included in the labeling. Devices also can be designated “MRI Safe” or “MRI Unsafe,” depending on their behavior in all MRI environments. According to Dr. Galgon, the ProSeal and Flexible, which are labeled MRI-conditional, are safe for use in a typical 3-Tesla MRI machine with a maximum spatial gradient magnetic field of 720 Gauss/cm or less. Despite reading through the manufacturer’s instruction manual, most clinicians did not alter their perceptions, Dr. Galgon reported. Threefourths (15 of 20) indicated they would still be unwilling to use either device during a scan. “We think the numbers may have changed more if there was additional education for providers to Advertisement

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onclinical testing demonstrated that the LMA ProSeal™ is MR Conditional. A patient with this device can be scanned safely immediately after placement under the following conditions:

Static Magnetic Field • Static magnetic field of 3-Tesla or less • Maximum spatial gradient magnetic field of 720 Gauss/cm or less Important Note: This product displays magnetic field interactions in the MRI environment. However, during the intended use of this product, it is fixed in place using adhesive tape. The appropriate fixation of this product is required to prevent possible issues in the MRI environment because it will effectively prevent this object from being moved due to magnetic field interactions.

re echogenic needles really all that? Evidently so, according to French researchers led by Xavier Capdevila, MD, PhD. Their study of 252 test punctures found that the ultrasound-specific instruments were significantly more efficient than conventional needles, offering greater visibility and ease of use, particularly when the angle of insertion exceeded 30 degrees. The researchers reported their findings at the 2011 annuual meeting of the American Society of Anesthesiologists (abstract 1744). The study used conventional Nanoline (blue) and echogenic Sonoplex (red) needles from Pajunk. Phantom procedure 0°-30° Shaft visibility 9 8 7 6 5 4 3 2 1 0

Image quality

Physician comfort

Environment sharpness

Percentage of time visibility during procedure

Needle sharpness

Turkey leg procedure 0°-30° Shaft visibility 9 8 7 6 5 4 3 2 1 0

MRI-related Heating … the MRI-related heating experiments for the LMA ProSeal™ at 3-Tesla … indicated that the greatest amount of heating that occurred in association with these specific conditions was equal to or less than +1.6°C.

Tip visibility

Image quality

Tip visibility

Physician comfort

Environment sharpness

Artifact Information MRI quality may be compromised if the area of interest is in the exact same area or relatively close to the position of the LMA ProSeal™.

Percentage of time visibility during procedure

Phantom procedure 30°-45° Shaft visibility 9 8 7 6 5 4 3 2 1 0

Image quality

help them understand MRI terminology and knowledge of their institution’s specific MRI conditions,” Dr. Galgon said. In the meantime, many anesthesiologists are opting to intubate patients and risk the adverse events associated with neuromuscular blocking drugs and intubation, Dr. Galgon said. Lorraine Foley, MD, staff anesthesiologist at Winchester Hospital in Winchester, Mass., who was not involved in the study, said she uses an LMA Classic, Unique or Supreme for patients not at risk for aspiration, despite her familiarity with MRI-compatibility terminology. “That the ProSeal and Flexible manuals state they were nonclinically tested under certain conditions and require more clinical testing makes me wary of using them,” said Dr. Foley, who is also clinical assistant professor of anesthesia at Tufts School of Medicine, in Boston. Given that the ProSeal and Flexible LMA are metal-reinforced and can cause artifacts during the MRI, particularly during head or neck scans, she eschews their use altogether. In contrast, said Dr. Foley, LMAs and other supraglottic devices that are not reinforced can be used as alternatives to the ProSeal and Flexible without worry about movement, heating and artifact. —David Wild

Needle sharpness

Tip visibility

Physician comfort

Environment sharpness

Percentage of time visibility during procedure

Needle sharpness

Turkey leg procedure 30°-45° Shaft visibility 9 8 7 6 5 4 3 2 1 0

Image quality

Tip visibility

Physician comfort

Environment sharpness

Percentage of time visibility during procedure

Needle sharpness

Turkey leg procedure >45°

Image quality

Physician comfort

Percentage of time visibility during procedure

Shaft visibility 9 8 7 6 5 4 3 2 1 0

Tip visibility

Environment sharpness

Needle sharpness

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Anesthesiology Board Review, Second Edition

Kerri Robertson; David J. Lubarsky; Sudharma Ranasinghe McGraw-Hill, August 30, 2005 This guide is presented in a rigorous question-and-answer format consisting of short clinical questions with concise answers. Emphasis is on distilling key facts and clinical pearls that are essential for exam success. Only the right answer is provided so there’s no chance of an incorrect answer staying in your mind.

Anesthesiology Oral Board Flash Cards

Jeff Gadsden; Dean Jones McGraw-Hill, August 25, 2011

ORdER ONlINE For pricing, a more complete review and easy ordering with a credit card, go to McMahonMedicalBooks.com. We can supply any medical book in print, so if you don’t find the book you want, email your request with billing information to RMcMahon@McMahonMed.com. If you are an author and would like your medical book featured in this book section, contact Ray McMahon, Publisher, at RMcMahon@McMahonMed.com.

These cards are the perfect way for residents to prepare for any random question that an examiner may ask on the anesthesia oral boards. The cards are designed to impart best patient care for a specific disease, condition or surgical procedure and teach residents how to think through an unexpected operating scenario.

Atlas of Airway Management: Techniques and Tools

Steven Orebaugh Lippincott Williams & Wilkins, October 10, 2011 This edition includes new sections on pediatric applications, bronchoscopy, special airway considerations in the emergency room and the ICU, and post-intubation care issues.

Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine

James Rathmell Lippincott Williams & Wilkins, November 7, 2011 This atlas is a practical guide for practitioners who perform interventional procedures with radiographic guidance to alleviate acute or chronic pain. The author provides an overview of each technique, with detailed, fullcolor illustrations of the relevant anatomy, technical aspects of each treatment and a description of potential complications. Indications for each technique, as well as medical evidence on the technique’s applicability, is included.

Gout and Other Crystal Arthropathies

Robert Terkeltaub Elsevier/Saunders, September 23, 2011 This book presents the state-of-the-art, clinically focused coverage you need to manage these increasingly prevalent diseases. Diagnose the full range of crystal arthropathies and treat your patients effectively with discussions of recently approved drugs and those currently under review. This comprehensive resource is ideal for any physician who diagnoses, treats and manages gout and crystal-induced arthropathies.

Information Technology Applied to Anesthesiology, An Issue of Anesthesiology Clinics

Kevin K. Tremper Elsevier/Saunders, September 23, 2011 This issue covers topics in perioperative clinical information systems (IS), including the anatomy of an anesthesia information management system; vendor and market landscape; impact of lexicons on adoption of an IS; clinical research using an IS, real-time alerts and reminders using an IS; shortcomings and challenges of IS adoption; and more.

Neuroscientific Foundations of Anesthesiology

George Mashour Oxford University Press, October 5, 2011 This book thoroughly examines the anesthetic modulation of the central, peripheral and autonomic nervous systems and will help redefine anesthesiology as a fundamentally neuroscientific field. The book is organized by sections, with each focusing on a different part of the nervous system.

Obstetric Anesthesia

Craig M. Palmer; Robert D’Angelo; Michael J. Paech Oxford University Press, April 13, 2011 With this new handbook, anesthesiologists have easy access to stepby-step information on how to manage patients in specific situations. Every aspect of obstetric anesthesia practice is covered. Distilled, synthesized text is complemented by a generous number of tables, charts, figures and flow diagrams, all presented in accessible handbook format. AN1111

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Free Virtual Simulator Raises Bronchoscopic Expertise

free online bronchoscopy simulator significantly improves anesthesiologists’ knowledge of the bronchial anatomy, based on findings from about 2,000 residents, fellows and staff who performed the Web-based procedure. Participants were quizzed before and after they performed the virtual bronchoscopy; scores after increased by an average of approximately 30%. However, average scores remained low, at 56%. The developers of the simulator presented the findings at the 2011 annual meeting of the Society for Airway Management (abstract 6). “This is a glass half-full, glass half-empty kind of study,” said Jerome Klafta, MD, professor and vice chair for education and academic affairs in the Department of Anesthesia and Critical Care at the University of Chicago Pritzker School of Medicine.

Figure. Training with the Web-based simulator increased knowledge of bronchial anatomy, but average scores still hovered in the F range.

“The poor scores are puzzling, said Dr. Klafta, who has no vested interest in the simulator but uses it regularly as an educational resource. “It’s striking to me that, even with this educational intervention, scores were this low.” David Wong, MD, and Peter Slinger, MD, of the Department of Anesthesia at the University of Toronto, Canada, along with two colleagues developed the online bronchoscopy simulator after noticing that anesthesiologists and trainees who did not regularly perform thoracic anesthesia were unfamiliar with bronchial anatomy. The simulator program includes a lung diagram, an endoscopic view of the lungs and electronic controls for navigating a virtual bronchoscope through the bronchotracheal anatomy (Figure). As part of the ongoing study, Dr. Wong asks participants before and after the simulation to answer a 15-question quiz based on video and images. Participants identify segments of the tracheobronchial anatomy and evaluate placement of a double-lumen tube and bronchial blockers. Dr. Wong presented data from 542 junior anesthesia residents, 326 senior residents, 155 fellows and 905 staff anesthesiologists who have performed the simulation and completed the pre- and post-simulation quizzes. The average scores increased from 5.6 (±3) to 7.9 (±3.4) among junior residents, 6.4 (±2.9) to 8.5 (±3.3) among senior residents, 6.7 (±3.1) to 8.6 (±3.2) among fellows and 6.6 (±3.1) to 8.4 (±3.2) among staff anesthesiologists. All pre- and post-simulator differences were statistically significant (P<0.05). Dr. Wong also found that a single simulated bronchoscopy heightened the participants’ confidence in

‘This is a glass half-full, glass half-empty kind of study.’ —Jerome Klafta, MD performing a real-life procedure. Specifically, 80% of respondents said they were “more confident” in their ability to provide lung isolation after performing the simulation. The low quiz scores before simulator training confirmed Dr. Wong’s suspicions that many anesthesiologists have insufficient knowledge of bronchial anatomy. Like Dr. Klafta, Dr. Wong said that although performing a simulated bronchoscopy can significantly improve understanding of the anatomy, “there is still room to achieve better scores. “This is one element of what needs to be a multifaceted approach to increasing knowledge of this anatomy and improving lung isolation management skills,” Dr. Wong told Anesthesiology News. “Didactic teaching, bedside teaching and real-time simulation elements are also necessary.” The next step will be to determine the impact of the simulator in a hands-on environment. In the meantime, he said, the Web-based simulator is a nocost tool that is particularly useful to those in health care settings who do not have access to a simulation laboratory or practical training with a clinical expert to refresh their knowledge of bronchial anatomy. The bronchoscopy simulator is available online at www.thoracic-anesthesia.com.

ClipChart Hollywood, CA: The death in 2009 of pop star Michael Jackson vaulted propofol into the public spotlight. Now, a pair of anesthesiologists are getting a star turn—but not quite the way either likely imagined. teven S. Shafer, MD, and Paul F. White, PhD, MD, have S signed on to testify in the trial of Conrad Murray, MD, Jackson’s private physician, who is accused of administering the overdose of the sedative that killed the singer. Dr. Murray has pleaded not guilty. wkward fact: Drs. Shafer and White, both leading experts in A anesthetic pharmacology, find themselves on different sides of the Los Angeles courtroom where Dr. Murray is facing a charge of involuntary manslaughter. Dr. Shafer, editor of Anesthesia & Analgesia, is a witness for the prosecution and has been sharply critical of Dr. Murray for allegedly allowing Jackson to use propofol as a sleep aid. We are in pharmacological Never-Never Land,” Dr. Shafer told “ jurors at one point in his testimony, in an apparent reference to Jackson’s former ranch, Neverland. Using propofol for insomnia is “something that’s only been done to Michael Jackson and to no one else in history to the best of my knowledge. So any dose, any dose of propofol is a potentially dangerous dose.”

r. Murray’s lawyers initially intended to argue that Jackson D may have ingested enough propofol to kill himself, but they abandoned that theory during the trial. Instead, Dr. White tried to cast doubt on the prosecution’s assertion that Jackson must have received a lethal infusion of propofol. In the process, he testified that the singer may have given himself an injection of the drug, a scenario Dr. White said better fit the medical and physical evidence of the death. rs. Shafer and White know each other well, but the trial has D not helped their relationship. The two men overlapped briefly on the Stanford University faculty in the late 1980s; both are active in the International Society for Anaesthetic Pharmacology; and Dr. White edits a section of Dr. Shafer’s journal. ccording to news reports, Dr. Shafer testified that he was A “disappointed” in Dr. White for endorsing the discarded defense theory that Jackson might have ingested a fatal dose of propofol. Dr. White reportedly referred to Dr. Shafer (or perhaps the prosecutor) using a term that was non-medical and unprintable. The profanity, uttered to reporters in the courtroom, led Judge Michael Pastor to schedule a Nov. 16 hearing to determine if Dr. White should be held in contempt of court.

—David Wild

33 I AnesthesiologyNews.com

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Earplugs Help ICU Patients Get Some Peace and Quiet

cheap and simple solution—earplugs—could help patients sleep better in the intensive care unit. In a study at the Medical University of Vienna, in Austria, cardiac surgery patients rated their comfort after one night in the ICU. The researchers found that patients who used earplugs reported not only better-quality sleep, but also greater comfort. The results, presented at the 2011 annual meeting of the International Anesthesia Research Society (IARS; abstract S-89), were based on data from 59 extubated patient volunteers, 24 of whom wore earplugs from 10 p.m. to 6 a.m. The control group comprised 35 patients who received no earplugs. The following morning, a standardized questionnaire was used to evaluate patient comfort. The two groups were identical for demographics, type of surgery, time to extubation (mean, 4.5 hours) and time of admission to the ICU. Patients who used earplugs reported less delay in sleep onset compared with controls (21% vs. 35%). Patients with earplugs also reported less nocturnal wakening (71% vs. 79%). Pain scores, assessed with a visual analog scale, were 4.0±2.0 in the earplug group and 4.7±2.8 in the controls. There was no difference in the dosages of opioids or adjuvant pain medication patients received.

On a scale of 1 (best) to 5 (worst), patients with earplugs rated their quality of sleep as 2.8±1.1, compared with 3.4±1.2 in the controls. Patient comfort, evaluated using the same scale, also was better in patients who wore earplugs (1.7±0.8 vs. 2.3±1.2; P<0.05 for all). Sleep disruption by noise is a problem for most ICU patients who are not anesthetized or sedated, said lead author Martin Dworschak, MD, associate professor of anesthesiology at the Vienna institution. “As compared to patients in whom the tracheal tube is left in place, exposure time is markedly longer in patients who are extubated early after surgery,” he said, “since sedatives are usually stopped and opioids reduced in order to not compromise spontaneous ventilation after extubation.” This lack of sleep can have severe consequences. “Sleep deprivation increases stress hormone levels and negatively impacts immune response, mood, task performance, alertness, respiratory muscle function and sensitivity to carbon dioxide of the respiratory center that may result in prolonged weaning from the respirator,” Dr. Dworschak said. Fragmented sleep also has been associated with postoperative delirium and memory impairment, he said. Jarring noises such as alarms from monitoring devices, ringing phones and operation of equipment typically found in the ICU

setting are responsible for disrupting patients’ sleep. Robert Thiele, MD, critical care anesthesia fellow at Duke University School of Medicine, in Durham, N.C., also has done research relating to earplugs in the perioperative setting. The ICU “is noisy. Monitors are ubiquitous and alarming constantly,” Dr. Thiele said. “There are a lot of people taking care of sick patients and they are communicating verbally in a small space—interacting 24 hours a day. We don’t stop working at night.” Although Dr. Thiele’s study, which he presented at last year’s IARS meeting (abstract S-229) looked at the impact of earplugs on the probability of awareness under general anesthesia (using bispectral index scores as a surrogate), he said that the use of earplugs to improve patient comfort in the ICU is an area well worth investigating. “It’s certainly possible that disrupting the sleep cycle would negatively impact outcomes,” Dr. Thiele said. “Patients who experience delirium clearly have worse outcomes than those who don’t, and it’s possible that this could be caused, in part, by disruption of the sleep cycle.” —Jennifer Hanawald

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New Society To Focus on Health Economics, Clinical Outcomes Anesthesiologists instrumental in founding group

he Society for Health Economics, Education & Research, or SHEER, is now accepting members. The group is dedicated to making clinical outcomes a focus of education and research in health economics. Another key goal of the organization is to inform health care professionals about economic comparative effectiveness and health technology assessment. Physicians, health care executives, industry, payers and the academic community may benefit. SHEER was formed to link individuals and organizations with an interest in clinically relevant health economics. Half of the society’s officers are anesthesiologists or otherwise affiliated with the specialty. Anesthesiologist David Lubarsky, MD, MBA, president of the UHealth Physician Practice in the University of Miami Health System, is the first president of SHEER. “We wanted to create a forum for all those interested in practical health economic analyses to find collaborators on new projects,” said Dr. Lubarsky, who is also a professor in the Department of Management at the University of Miami School of Business. “We hope to learn from each other.” The founders expect membership to include clinicians, physician executives and academic faculty in all arenas, from public health to industry. Dr. Lubarsky said everyone from business school faculty to epidemiologists have expressed interest in joining the group. “There is no corporate participation at the moment,” he said, although companies have expressed interest. Dr. Lubarsky said that SHEER would use membership dues to fund relevant research, and that ultimately, the organization hopes the research will impact health policy and clinical practice. SHEER is the only organization of its kind focusing on health economics, according to Dr. Lubarsky. Alex Macario, MD, MBA, professor of anesthesiology at Stanford University School of Medicine, in Stanford, Calif., is the secretary of SHEER. “We hope to facilitate research and analyses that help doctors, departments, hospitals and health systems make better operational and financial decisions,” said Dr. Macario, a member of the Anesthesiology News editorial board.

Link to Anesthesiology Although anesthesiologists form the backbone of the organization’s leadership, Dr. Macario said the goals of the society would have both broad and specific impacts. “The aim is to bring people together who know about economic assessment of devices and drugs to help society— including hospitals and companies— know what interventions provide the most value to patients,” he said. “However, because the surgical suite, anesthesia and surgical procedures are a high resource-intensive environment, even small gains in efficiency will lead to meaningful economy in the perioperative setting.” Dr. Lubarsky noted that shortly after anesthesiologists made other health care professionals aware of the fledgling society, it was generally agreed that the concept needed to be expanded. “Anesthesiology has been at the forefront of accepting a rigorous academic approach to management and economic decision making,” he said. “Few journals are like Anesthesia & Analgesia, which dedicates an entire section to this study. It was natural to start this in our specialty.” Timely Birth Dr. Macario said the need for a

group like SHEER reflects the increasing importance of managing costs. “Even though economic assessment of drugs has been required for launching in the United States and Europe for a long time, in contrast devices have been virtually exempt,” Dr. Macario said. “With accountable care organizations, one lump sum payment will be made that will cover all fees. Also, the federal government has funded an institute to perform comparative effectiveness studies [through the Department of Health and Human Services], so SHEER is right in step with those initiatives.” “As health care imperatives to expand access and improve safety become law and drivers of payment, there are many unknowns as to how to do this effectively,” Dr. Lubarsky added. “What new processes and equipment will allow us to provide this care in the best manner?” Lee A. Fleisher, MD, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, in Philadelphia, will be SHEER’s first vice president. “Drugs and devices are usually evaluated in a simplistic manner, in which all the potential health outcomes and costs are not taken into consideration,” said Dr. Fleisher, who is also a member

of the Anesthesiology News editorial board. “Part of the goal of SHEER is through research and education to ensure that all components of a technology are evaluated for their risks, benefits and associated costs. This information should then be communicated to decision makers so that the most informed decision can be made.” Although the medical industry is creating products that merit study, there is little academic attention focused on such studies, according to Dr. Lubarsky. He warned that direct funding of such studies has the potential to cast suspicion on the validity of the results. “It was time to find a new way to provide the answers that so many administrators want to know,” he said. “Should we use our old technology or new?” Regarding potential conflicts of interest, Dr. Macario noted that “SHEER does not represent any different concerns from any other professional society.” Despite the broad-ranging and potentially myriad goals of the organization, Dr. Lubarsky stressed that the aim was simple. “The average clinician can expect to gain practical knowledge to guide cost-effective actions,” he said. —George Volansky

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