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Biomedical subjects

Alex Macario

Publications and source records attributed to Alex Macario.

At least 19 recordsLinked to original sources
PubMed2006

Anesthesiologists' practice patterns for treatment of postoperative nausea and vomiting in the ambulatory Post Anesthesia Care Unit.

BACKGROUND: When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV). Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1) If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU)?; 2) Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3) If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment? METHODS: A questionnaire with five short hypothetical clinical vignettes was mailed to 300 randomly selected USA anesthesiologists. The types of pharmacological and nonpharmacological interventions for PONV treatment were analyzed. RESULTS: The questionnaire was completed by 106 anesthesiologists (38% response rate), who reported that on average 52% of their practice was ambulatory. If a patient develops PONV and received no prophylaxis, 67% (95% CI, 62%-79%) of anesthesiologists reported they would administer a 5-HT3-antagonist as first choice for treatment, with metoclopramide and dexamethasone being the next two most common choices. 65% (95% CI, 55%-74%) of anesthesiologists reported they would also use non-pharmacologic interventions to treat PONV in the PACU, with an i.v. fluid bolus or nasal cannula oxygen being the most common. When PONV prophylaxis was given during the anesthetic, the preferred PONV treatment choice changed. Whereas 3%-7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% (95% confidence intervals, 18%-36%) of practitioners would re-dose the 5-HT3-antagonist for PONV treatment. CONCLUSION: 5-HT3-antagonists are the most common choice for treatment of established PONV for outpatients when no prophylaxis is used, and also following prophylactic regimens that include a 5HT3 antagonist, regardless of the number of prophylactic antiemetics given. Whereas 3%-7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.

Journal Article↗
PubMed2006

A Markov computer simulation model of the economics of neuromuscular blockade in patients with acute respiratory distress syndrome.

BACKGROUND: Management of acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) is clinically challenging and costly. Neuromuscular blocking agents may facilitate mechanical ventilation and improve oxygenation, but may result in prolonged recovery of neuromuscular function and acute quadriplegic myopathy syndrome (AQMS). The goal of this study was to address a hypothetical question via computer modeling: Would a reduction in intubation time of 6 hours and/or a reduction in the incidence of AQMS from 25% to 21%, provide enough benefit to justify a drug with an additional expenditure of $267 (the difference in acquisition cost between a generic and brand name neuromuscular blocker)? METHODS: The base case was a 55 year-old man in the ICU with ARDS who receives neuromuscular blockade for 3.5 days. A Markov model was designed with hypothetical patients in 1 of 6 mutually exclusive health states: ICU-intubated, ICU-extubated, hospital ward, long-term care, home, or death, over a period of 6 months. The net monetary benefit was computed. RESULTS: Our computer simulation modeling predicted the mean cost for ARDS patients receiving standard care for 6 months to be $62,238 (5%-95% percentiles $42,259-$83,766), with an overall 6-month mortality of 39%. Assuming a ceiling ratio of $35,000, even if a drug (that cost $267 more) hypothetically reduced AQMS from 25% to 21% and decreased intubation time by 6 hours, the net monetary benefit would only equal $137. CONCLUSION: ARDS patients receiving a neuromuscular blocker have a high mortality, and unpredictable outcome, which results in large variability in costs per case. If a patient dies, there is no benefit to any drug that reduces ventilation time or AQMS incidence. A prospective, randomized pharmacoeconomic study of neuromuscular blockers in the ICU to asses AQMS or intubation times is impractical because of the highly variable clinical course of patients with ARDS.

Computer Simulation↗
PubMed2006

Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology.

HYPOTHESIS: A handheld wand-scanning device (1.5 lb, battery powered, 10 x 10 x 1.5 in) has been developed to detect commonly used surgical gauze sponges, which have been tagged with a radiofrequency identification (RFID) chip. We tested the hypothesis that this wand device has a successful detection rate of 100%, with 100% specificity and 100% sensitivity. DESIGN: Prospective, blinded, experimental clinical trial. SETTING: Stanford University Medical Center, Stanford, Calif. PATIENTS: Eight patients undergoing abdominal or pelvic surgery. INTERVENTIONS: Eight untagged sponges (1 control per patient) and 28 RFID sponges were placed in the patients. Just before closure, the first surgeon placed 1 RFID sponge (adult laparotomy tape; 18 x 18 in, 4-ply) in the surgical site, while the second surgeon looked away so as to be blinded to sponge placement. The edges of the wound were pulled together so that the inside of the cavity was not exposed during the detection experiments. The second (blinded) surgeon used the wand-scanning device to try to detect the RFID sponge. MAIN OUTCOME MEASURES: A successful detection was defined as detection of an RFID sponge within 1 minute. We also administered a questionnaire to the surgeon and nurse involved in the detections to assess ease of use. RESULTS: The RFID wand device detected all sponges correctly, in less than 3 seconds on average. There were no false-positive or false-negative results. CONCLUSIONS: We found a detection accuracy of 100% for the RFID wand device. Despite this engineering success, the possibility of human error and retained sponges remains because handheld scanning can be performed incorrectly.

Abdomen↗
PubMed2006

Factors affecting supply and demand of anesthesiologists in Western Europe.

PURPOSE OF REVIEW: Current demographic and macroeconomic trends indicate that, in Western Europe, the demand for anesthesia services will continue to increase. It is, however, questionable whether there will be sufficient supply. RECENT FINDINGS: In Western Europe, admission to medical schools is typically restricted. The European Working Time Directive has decreased the clinical exposure of residents. Also, increasing feminization of the physician workforce and the aging of current practitioners may change the available workforce. Current healthcare reforms that include demand-lowering elements may also negatively affect supply and demand for anesthesiologists. SUMMARY: Steps must be taken to augment the number of practitioners to ensure a sufficient number of anesthesiologists. Employers will have to offer flexible working practices and adequate compensation to attract new anesthesiologists. Alternatively, more responsibilities and tasks may be allocated to well-trained anesthesia assistants (e.g. nurses). National anesthesia associations must improve and coordinate resident training, which may alleviate the recruitment problem. A European training standard in anesthesia might adjust the regional disequilibrium of supply and demand, as might salary competition. In the long run, the undersupply of anesthesiologists may be offset by factors such as more procedures being performed non-invasively and further demand-lowering healthcare policies.

Anesthesiology↗
PubMed2006

The drive for operating room efficiency will increase quality of patient care.

PURPOSE OF REVIEW: The public is demanding that medicine both increase its efficiency and lower its costs. 'Watchdog' groups are scrutinizing our performance, publicizing our results, and forcing us to compete. They want doctors first to use evidence-based medicine to identify truly beneficial healthcare interventions and then to use continuous quality improvement to perform those beneficial interventions consistently at lower costs. RECENT FINDINGS: A renaissance is underway in our thinking about quality and efficiency in the operating room. 'Work process redesign' and 'the systems approach' are starting to be more than slogans, as researchers redesign the physical environment of the operating room, along with its 'workflow' and methods of communication. SUMMARY: Soon physicians and hospitals will be receiving 'pay-for-performance', whereby our income will depend on our ability to demonstrate both good patient care processes and good outcomes. Medicine is starting to act like a competitive industry, and this tendency will be good for quality and efficiency in the operating room. Community and academic practitioners need to understand and participate in this transformation in order to be able to influence its evolution and to survive financially.

Appointments and Schedules↗
PubMed2006

Staffing and case scheduling for anesthesia in geographically dispersed locations outside of operating rooms.

PURPOSE OF REVIEW: Scheduling and staffing for anesthetics outside of the operating room that are geographically dispersed is different than for operating room cases. Whereas methods to predict how long such cases take were published recently, this article reviews staffing and case scheduling. RECENT FINDINGS: Methods have been developed based on the assumption that physicians doing procedures requiring anesthesia are provided open access to anesthesia time within a reasonable number of days (e.g., 2 weeks) or on any future workday. The latter is commonly used in operating rooms. Outside of operating rooms, the former is more practical economically. Statistical forecasting of anesthesia staffing months ahead is conducted by using billing data with the objective of maximizing the efficiency of use of anesthesia time. Calculations assume that anesthesia time that would otherwise be underutilized is released for use by services that would otherwise work in overutilized anesthesia time. Forecasting is different for services with many patients hospitalized preoperatively (e.g., electroconvulsive therapy). Implementation encourages longer-term changes benefiting the anesthesia group (e.g., services choose to work longer hours for fewer days of the week). SUMMARY: Plan staffing based on providing open access to anesthesia time within a reasonable number of days (e.g., 2 weeks). Schedule cases and release allocated time based on reducing overutilized anesthesia time.

Anesthesia↗
PubMed2006

Systematic literature review of spinal decompression via motorized traction for chronic discogenic low back pain.

OBJECTIVE: The objective of this study was to systematically review the literature to assess the efficacy of nonsurgical spinal decompression achieved with motorized traction for chronic discogenic lumbosacral back pain. DESIGN: Computer-aided systematic literature search of MEDLINE and the Cochrane collaboration for prospective clinical trials on adults with low back pain in the English literature from 1975 to October 2005. Methodologic quality for each study was assessed. Studies were included if the intervention group received motorized spinal decompression and the comparison group received sham or another type of nonsurgical treatment. RESULTS: Data from 10 studies were fully analyzed. Seven studies were randomized controlled trials using various apparatus types. Because of this low number, we also analyzed three nonrandomized case series studies of spinal decompression systems. As the overall quality of studies was low and the patient groups heterogeneous, a meta-analysis was not appropriate and a qualitative review was undertaken. Sample sizes averaged 121 patients (range 27-292), with six of the seven randomized studies reporting no difference with motorized spinal decompression and one study reporting reduced pain but not disability. The three unrandomized studies (no control group) of motorized spinal decompression found a 77% to 86% reduction in pain. CONCLUSIONS: These data suggest that the efficacy of spinal decompression achieved with motorized traction for chronic discogenic low back pain remains unproved. This may be, in part, due to heterogeneous patient groups and the difficulties involved in properly blinding patients to the mechanical pulling mechanism. Scientifically more rigorous studies with better randomization, control groups, and standardized outcome measures are needed to overcome the limitations of past studies.

Chronic Disease↗
PubMed2006

Scheduling elective pediatric procedures that require anesthesia: the perspective of parents.

Daily variability in volume of elective pediatric procedures that require anesthesia may lead to an imbalance between available operating room resources and case load. Longer intervals between scheduling and the surgical date generally result in higher operating room utilization. In this study, we sought to determine which factors influence when parents schedule their children for procedures. We also aimed to identify parents' ideal and longest acceptable waiting intervals and determine whether type of procedure, for example, affects scheduling. From a convenience sample of 250 randomly selected parents of children presenting for elective surgery, 236 completed surveys were analyzed. The remaining 14 surveys were not returned. Overall, parents scheduled their child's procedure a median of 4.3 wk (interquartile range 2.0-8.6) in advance and reported an ideal waiting interval of 3 wk (interquartile range 2-4), and longest acceptable interval of 6 wk (interquartile range 4-10). Parents were willing to wait longer to schedule cardiac (4 wk, P = 0.004) and plastic (3.5 wk, P = 0.024) surgery when compared with general surgical procedures. Overall, parents ranked severity of the child's illness, earliest available time, and surgeon's suggested date as the three most important factors influencing when their child's surgery is scheduled. The timetable for scheduling procedures was highly correlated with both mother and father having available time off work (tau(b) = 0.72, P < 0.0001). Surprisingly, parents did not show a preference for scheduling cases during vacation or summer months.

Anesthesia↗
PubMed2005

Meta-analysis of trials comparing postoperative recovery after anesthesia with sevoflurane or desflurane.

PURPOSE: Results of published, randomized controlled trials comparing sevoflurane and desflurane were pooled to measure differences in times until patients obeyed commands, were extubated, were oriented, were discharged from the postanesthesia care unit (PACU), and were ready to be discharged to home, as well as the occurrence of postoperative nausea and vomiting (PONV). METHODS: We reviewed all randomized clinical trials in MEDLINE through December 18, 2003, with a title or abstract containing the words sevoflurane and desflurane. Two reviewers independently extracted study data from papers that met inclusion criteria. Endpoints were pooled using random-effects meta-analysis. RESULTS: Twenty-two reports of 25 studies (3 reports each described 2 studies) met our inclusion criteria. A total of 746 patients received sevoflurane, and 752 received desflurane. Patients receiving desflurane recovered 1-2 minutes quicker in the operating room than patients receiving sevoflurane. They obeyed commands 1.7 minutes sooner (p < 0.001; 95% confidence interval [CI], 0.7-2.7 minutes), were extubated 1.3 minutes sooner (p = 0.003; 95% CI, 0.4-2.2 minutes), and were oriented 1.8 minutes sooner (p < 0.001; 95% CI, 0.7-2.9 minutes). No significant differences were detected in the phase I or II PACU recovery times or in the rate of PONV. CONCLUSION: Meta-analysis of studies in which the duration of anesthesia was up to 3.1 hours indicated that patients receiving either desflurane or sevoflurane did not have significant differences in PACU time or PONV frequency. Patients receiving desflurane followed commands, were extubated, and were oriented 1.0-1.2 minutes earlier than patients receiving sevoflurane.

Adult↗
PubMed2005

Validity and usefulness of a method to monitor surgical services' average bias in scheduled case durations.

PURPOSE: Unbiased prediction of case durations is an integral part of matching operating room (OR) staffing to workload. Monitoring systematic bias in surgeons' scheduled case durations can identify those services with estimates sufficiently inaccurate that statistical analysis of historical data may be useful in preference to the surgeons' estimates. We describe a method to monitor surgical services' average bias in scheduled case durations. METHODS: Actual case duration, predicted (scheduled) case duration, and service were obtained for all 58,291 cases during 39 four-week periods at an academic hospital. For each four-week period, a ratio was computed for each service. The numerator for each service equalled the sum of the differences in minutes between actual case duration and scheduled case duration. The denominator equalled the sum in hours of the actual durations of all of the service's cases. The ratio was multiplied by eight hours to yield the number of minutes of underestimated case duration per eight hours of OR time during the four-week period. RESULTS: The ratios followed a normal distribution for each service. Using the Student's t distribution, the 95% lower confidence bounds for the average underestimate of case duration ranged from three to 65 min per eight hours of used OR time. CONCLUSIONS: To reduce over-utilized OR time, we recommend monitoring each service's 95% lower confidence bound of the bias in scheduled case durations. For services consistently underestimating their case durations, schedule their cases using statistical estimates of case durations based on their historical data, and disregard their own estimates.

Academic Medical Centers↗
PubMed2005

Quantifying effect of a hospital's caseload for a surgical specialty on that of another hospital using multi-attribute market segments.

Inpatient and outpatient data were used to create market segments consisting of hierarchical combinations of surgical procedure, then type of payer, and then location of patients' residences. The competitive effect of one hospital's caseload for a given surgical specialty on the caseload of another hospital was determined from the numbers of patients in each segment. Earlier methods for estimating surgical competition that ignored market segments over-estimated the competitive effects of one hospital on another. Thus, results differed from those obtained previously for all types of hospital admissions. When actual market segments with homogeneous groups of patients are used, competitive effects of hospitals in the same market area are far less than expected.

Catchment Area, Health↗
PubMed2005

Patient preferences for anesthesia outcomes associated with cesarean delivery.

UNLABELLED: When deciding on neuraxial medication (e.g., spinal opioids) for cesarean delivery (CS) under regional anesthesia, anesthesiologists make treatment decisions that "trade off" relieving pain with the potential for increased risk of side effects. No previous studies have examined obstetric patients' anesthesia preferences. Researchers administered 100 written surveys to pregnant women attending our institutions' expectant parent class. We determined patients' preferences for importance of specific intraoperative and postoperative anesthesia outcomes using priority ranking and relative value scales. We also explored patients' fears, concerns, and tolerance regarding CS and analgesics. Eighty-two of 100 surveys were returned and analyzed. Pain during and after CS was the greatest concern followed by vomiting, nausea, cramping, pruritus, and shivering. Ranking and relative value scores were closely correlated (R2 = 0.7). Patients would tolerate a visual analog pain score (0-100 mm) of 56 +/- 22 before exposing their baby to the potential effects of analgesics they receive. In contrast to previous general surgical population surveys that found nausea and vomiting as primary concerns, we found pain during and after CS as parturients' most important concern. Common side effects such as pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, e.g., inclusion of spinal opioids given in adequate doses. IMPLICATIONS: Medical care can be improved by incorporating patients' preferences into medical decision making. We surveyed obstetric patients to determine their preferences regarding potential cesarean delivery anesthesia outcomes. Unlike general surgical patients who rate nausea and vomiting highest, parturients considered pain during and after cesarean delivery the most important concern.

Adult↗
PubMed2004

When to release allocated operating room time to increase operating room efficiency.

UNLABELLED: We studied when allocated, but unfilled, operating room (OR) time of surgical services should be released to maximize OR efficiency. OR time was allocated for two surgical suites based on OR efficiency. Then, we analyzed real OR schedules. We added new hypothetical cases lasting 1, 2, or 3 h into OR time of the service that had the largest difference between allocated and scheduled cases (i.e., the most unfilled OR time) 5 days before the day of surgery. The process was repeated using the updated OR schedule available the day before surgery. The pair-wise difference in resulting overutilized OR time was calculated for n = 754 days of data from each of the two surgical suites. We found that postponing the decision of which service gets the new case until early the day before surgery reduces overutilized OR time by <15 min per OR per day as compared to releasing the allocated OR time 5 days before surgery. These results show that when OR time is released has a negligible effect on OR efficiency. This is especially true for ambulatory surgery centers with brief cases or large surgical suites with specialty-specific OR teams. What matters much more is having the correct OR allocations and, if OR time needs to be released, making that decision based on the scheduled workload. IMPLICATIONS: Provided operating room (OR) time is allocated and cases are scheduled based on maximizing OR efficiency, then whether OR time is released five days or one day before the day of surgery has a negligible effect on OR efficiency.

Ambulatory Surgical Procedures↗
PubMed2003

What questions do patients undergoing lower extremity joint replacement surgery have?

BACKGROUND: The value of the Internet to deliver preoperative education would increase if there was variability in questions patients want answered. This study's goal was to have patients consulting an orthopedic surgeon about undergoing either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA) rate the importance of different questions concerning their care. METHODS: We assembled questions patients might have about joint replacement surgery by analyzing the literature and querying a pilot group of patients and surgeons. Twenty-nine patients considering undergoing THA and 19 patients considering TKR completed a written survey asking them to rate 30 different questions, with a 5 point Likert scale from 1 (least important)--5 (most important). RESULTS: For patients considering THA or TKR, the 4 highest rated questions were: Will the surgery affect my abilities to care for myself?, Am I going to need physical therapy?, How mobile will I be after my surgery?, When will I be able to walk normally again? The mean percentage disagreement was 42% for questions answered by TKR patients and 47% for the THA group. Some patients gave a high rating to questions lowly rated by the rest of the group. CONCLUSIONS: Although there was enough agreement to define a core set of questions that should be addressed with most patients considering THA or TKA, some of the remaining questions were also highly important to some patients. The Web may offer a flexible medium for accommodating this large variety of information needs.

Adult↗
PubMed2003

Physicians' perceptions of minimum time that should be saved to move a surgical case from one operating room to another: internet-based survey of the membership of the Association of Anesthesia Clinical Directors (AACD).

STUDY OBJECTIVE: Moving the last case of the day from one operating room (OR) to another OR can increase OR efficiency. However, there is a penalty cost for moving a case. The goal of the study was to measure perceptions of the minimum time that needs to be saved for it to be worthwhile to move a case from a late-running OR to another OR. DESIGN: Internet-based survey of the Association of Anesthesia Clinical Directors (AACD) and/or attendees at one of its courses. As subjects completed the computer-assisted survey, answers to test questions were checked immediately to ensure respondents understood the relevant concepts. MEASUREMENTS: Respondents were asked to complete the statement: "I would move the case if I would expect to save ____ hours of overutilized OR time." MAIN RESULTS: 234 E-mail invitations to complete the survey were transmitted. Of that number, 87 completed surveys were returned. Respondents were physicians, mostly from the United States. The 25th, 50th, and 75th percentiles of the penalty cost were 1.0 hour of overutilized OR time. The 95% confidence intervals were 0.5 to 1.0 hour for the 25th percentile, 1.0 to 1.0 hour for the 50th percentile, and 1.0 to 2.0 hours for the 75th percentile. There was no significant correlation between the penalty cost and the number of ORs at the respondent's facility, number of times the survey was submitted until it was completed correctly, or total number of errors in responses. CONCLUSIONS: Members of the AACD perceive the penalty cost for moving a case to be 1 hour.

Anesthesia Department, Hospital↗