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Biomedical subjects

D A Lubarsky

Publications and source records attributed to D A Lubarsky.

At least 19 recordsLinked to original sources
PubMed2001

How much are patients willing to pay to avoid postoperative nausea and vomiting?

Postoperative nausea and vomiting (PONV) are unpleasant experiences. However, there is no drug that is completely effective in preventing PONV. Whereas cost effectiveness analyses rely on specific health outcomes (e.g., years of life saved), cost-benefit analyses assess the cost and benefit of medical therapy in terms of dollars. We hypothesized that patients were willing to pay for a hypothetical new drug that would eliminate PONV. Eighty elective day surgical patients using general anesthesia participated in the study. After their recovery in the postanesthetic care unit, they were asked to complete an interactive computer questionnaire on demographics, the value of avoiding PONV, and their willingness to pay for an antiemetic. Patients were willing to pay US$56 (US$26--US$97; median, 25%--75%) for an antiemetic that would completely prevent PONV. Patients who developed nausea (n = 21; 26%) and vomiting (n = 9; 11%) were willing to pay US$73 (US$44--US$110) and $100 (US$61--US$200; median, 25%--75%), respectively (P < 0.05). Seventy-six percent of patients considered avoiding postoperative nausea and 78% of patients considered avoiding vomiting as important (> or = 50 mm on a 0--100-mm visual analog scale). Nausea or vomiting in the postanesthetic care unit, greater patient income, previous history of PONV, more importance placed on avoiding nausea and vomiting, increasing age, and being married are independent covariates that increase the willingness to pay estimates. Patients associated a value with the avoidance of PONV and were willing to pay between US$56 and US$100 for a completely effective antiemetic.

Adult↗
PubMed2001

Cost identification analysis for succinylcholine.

UNLABELLED: The cost of a dose of succinylcholine from society's perspective equals the acquisition cost of the drug plus the cost of its adverse outcomes. We hypothesized that although the acquisition cost of succinylcholine is minimal, the true cost would be much larger. We reviewed the medical literature to identify the total cost of a dose of succinylcholine when administered for nonemergency purposes according to manufacturers' guidelines (i.e., to adults only). We found that 88% of the cost per dose of succinylcholine was for the chance of dying or sustaining permanent brain injury from anaphylactic or anaphylactoid reactions to succinylcholine. Consequently, the estimated cost per dose of succinylcholine was sensitive to the incidence of anaphylactic or anaphylactoid reactions to succinylcholine, the risk of severe injury from anaphylactic or anaphylactoid reactions, and the financial value of unforeseen instant death or permanent brain injury. The range for the cost per dose of succinylcholine was thus large, $9 to $93. Our best estimate of the cost per dose was $37. We conclude that the true cost per dose of succinylcholine from society's perspective is more than 20 times the acquisition cost. However, a precise costing requires better knowledge of the incidence and consequences of anaphylactic or anaphylactoid reactions to succinylcholine. IMPLICATIONS: The true cost of succinylcholine is more than 20 times the acquisition cost of the drug. The estimated cost is very sensitive to the risk and cost of patients dying or sustaining brain injury from anaphylactic or anaphylactoid reactions to succinylcholine.

Anaphylaxis↗
PubMed2000

The business of perioperative medicine.

Medical centers should insist that their top officials have a firm grasp of contemporary business principles, use that skill set, and run the medical business like any other. This business imperative does not exclude a conscious decision to measure success by the amount of articles published or charity care given rather than the amount of profits. Physician leaders should insist that while they care for patients, someone cares for the business.

Accounting↗
PubMed2000

Myocardial ischemia correlates with reduced fibrinolytic activity following peripheral vascular surgery.

STUDY OBJECTIVES: To evaluate the relationship between perioperative ischemia and serial concentrations of D-dimer, which is a sensitive and specific marker of fibrinolytic activity. Myocardial ischemia and infarction are well-recognized complications of peripheral vascular surgery. We hypothesized that patients at increased risk of perioperative myocardial ischemia might be identified preoperatively by abnormal hemostatic indices. DESIGN: Prospective clinical outcomes study. SETTING: A 1,124-bed tertiary care medical center. PATIENTS: 42 ASA physical status II, III, and IV patients undergoing peripheral vascular surgery. INTERVENTIONS: Serial D-dimer concentrations were measured preoperatively, and at 24 and 72 hours postoperatively. Continuous 12-lead ST-segment monitoring (Mortara Instrument, Inc., Milwaukee, WI) was performed with the acquisition of a 12-lead ECG every 20 seconds for 72 hours. MEASUREMENTS AND MAIN RESULTS: D-dimer measurements were performed in duplicate using the Dimer Gold assay (American Diagnostica, Greenwich CT). Ischemic episodes, as defined by continuous 12-lead ST-segment monitoring, occurred in 49% of patients. There were no demographic differences between ischemic and nonischemic groups. Although baseline D-dimer concentrations were not statistically significantly different between groups, patients experiencing perioperative myocardial ischemia generated significantly less D-dimer during the perioperative period (p = 0. 014). CONCLUSIONS: PATIENTS with an impaired fibrinolytic response, as defined by reduced generation of D-dimer, experienced an increased incidence of perioperative myocardial ischemia.

Aged↗
PubMed2000

Using Medicare multiples results in disproportionate reimbursement for anesthesiologists compared to other physicians.

Multispecialty groups and insurer fee schedules computed as a multiple of the Medicare reimbursement rate have resulted in a severely low reimbursement rate for anesthesia compared to other specialties. The authors suggest that anesthesiologists negotiate for a discount from the usual and customary fee equal to what the other specialties have been asked to bear.

Anesthesiology↗
PubMed2000

How much labor is in a labor epidural? Manpower cost and reimbursement for an obstetric analgesia service in a teaching institution.

BACKGROUND: Some anesthesiologists avoid provision of obstetric analgesia services (OAS) because of low reimbursement rates for the work involved. This study defines the manpower costs of operating an OAS in a tertiary referral center and examines reimbursement for this cost. METHODS: The time spent providing OAS in a total of 55 parturients was studied prospectively using a modification of classic time and motion studies. RESULTS: Mean duration of OAS in our population was 412 +/- 313 min. Mean bedside anesthesia staff time was 90 +/- 40 min, and mean number of visits to each patient's bedside was 6.3 +/- 2.0 visits. Assuming staffing on demand for service (intermittent staffing), a minimum of 2.5 full-time equivalent (FTE) attending anesthesiologists was required to meet demand. With intermittent staffing, labor cost was $325 per patient. Actual practice at Duke University Medical Center is around-the-clock (dedicated) staffing, which requires 4.4 FTEs at a cost of $728 per patient. Neither average indemnity reimbursement ($299) nor Medicaid reimbursement ($204) covered the cost per OAS patient. Breaking even is possible under indemnity reimbursement because operating room reimbursement subsidizes OAS costs. Breaking even cannot occur with Medicaid reimbursement under any circumstances. CONCLUSIONS: Obstetric analgesia services requires a minimum of 2.5 FTE attending anesthesiologists at Duke University Medical Center. With the current payer mix, positive-margin operating room activities associated with the obstetric service are not sufficient to compensate for the losses incurred by an OAS. Around-the-clock dedicated obstetric staffing (4.4 FTEs) cannot operate profitably under any reasonable circumstances at our institution.

Adult↗
PubMed2000

Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperidol, or placebo.

BACKGROUND: In an era of growing economic constraints on healthcare delivery, anesthesiologists are increasingly expected to understand cost analysis and evaluate clinical practices. Postoperative nausea and vomiting (PONV) are distressing for patients and may increase costs in an ambulatory surgical unit. The authors compared the cost-effectiveness of four prophylactic intravenous regimens for PONV: 4 mg ondansetron, 0.625 mg droperidol, 1.25 mg droperidol, and placebo. METHODS: Adult surgical outpatients at high risk for PONV were studied. Study drugs were administered intravenously within 20 min of induction of nitrous oxide-isoflurane or enflurane anesthesia. A decision-tree analysis was used to group patients into 12 mutually exclusive subgroups based on treatment and outcome. Costs were calculated for the prevention and treatment of PONV. Cost-effectiveness analysis was performed for each group. RESULTS: Two thousand sixty-one patients were enrolled. Efficacy data for study drugs have been previously reported, and the database from that study was used for pharmacoeconomic analysis. The mean-median total cost per patient who received prophylactic treatment with 4 mg ondansetron, 0.625 mg droperidol, 1.25 mg droperidol, and placebo were $112 or $16.44, $109 or $0.63, $104 or $0.51, and $164 or $51.20, respectively (P = 0.001, active treatment groups vs. placebo). The use of a prophylactic antiemetic agent significantly increased patient satisfaction (P < 0.05). Personnel costs in managing PONV and unexpected hospital admission constitute major cost components in our analysis. Exclusion of nursing labor costs from the calculation did not alter the overall conclusions regarding the relative costs of antiemetic therapy. CONCLUSION: The use of prophylactic antiemetic therapy in high-risk ambulatory surgical patients was more effective in preventing PONV and achieved greater patient satisfaction at a lower cost compared with placebo. The use of 1.25 mg droperidol intravenously was associated with greater effectiveness, lower costs, and similar patient satisfaction compared with 0.625 mg droperidol intravenously and 4 mg ondansetron intravenously.

Adolescent↗
PubMed1999

Relying solely on historical surgical times to estimate accurately future surgical times is unlikely to reduce the average length of time cases finish late.

STUDY OBJECTIVE: To determine whether using only previous cases' surgical times for predicting accurately surgical times of future cases is likely to reduce the average length of time cases finish late (after their scheduled finish times). DESIGN: Computer simulation. MEASUREMENTS AND MAIN RESULTS: Data from an operating room (OR) information system for two surgical suites were analyzed. For each case performed in fiscal year 1996, we searched backward for 1 year and counted the number of previous cases that were the same type of procedure performed by the same surgeon. Then, for each suite, surgical times were fitted to a statistical model estimating the effect of the type of procedure and who the surgeon was on surgical time. The estimated "variance components" were used in Monte-Carlo computer simulations to evaluate whether a hypothetical increase in the number of previous cases available to estimate the next case's surgical time would improve scheduling accuracy. Predictions of how long newly scheduled cases should take were impaired because 36.5% +/- 0.4% (mean +/- SE) of cases at a tertiary surgical suite and 28.6% +/- 0.7% of cases at an ambulatory surgery center did not have any cases in the previous year with the same procedure type and surgeon. Computer simulation was used to generate additional hypothetical cases. Using this data, even having many previous cases on which to base predictions of future surgical times would only decrease the average length of time that cases finish late by a few minutes. CONCLUSION: An OR manager considering using only historical surgical times to estimate future surgical times should first investigate, using data from their own surgical suite, what percentage of cases do not have historical data. Even if there are sufficient historical data to estimate future surgical times accurately, relying solely on historical times is probably an ineffective strategy to have future cases finish on time.

Ambulatory Surgical Procedures↗
PubMed1999

Computer simulation to determine how rapid anesthetic recovery protocols to decrease the time for emergence or increase the phase I postanesthesia care unit bypass rate affect staffing of an ambulatory surgery center.

UNLABELLED: Ambulatory surgery centers (ASC) are implementing new anesthetic techniques and rapid recovery protocols in the postanesthesia care unit (PACU) to achieve earlier discharge after general anesthesia. Using computer simulation, we addressed two questions. First, what is the decrease in an ASC's operating room (OR) staff if the time from which the surgery is finished to the time the patient leaves the OR is decreased? Second, what is the decrease in PACU nursing staffing if patients bypass phase I PACU (i.e., proceed from the OR directly to the phase II PACU)? The decrease in labor costs from rapid emergence or fast-tracking depends on how staff are compensated, how many ORs routinely run concurrently, and what percentage of patients undergo general anesthesia. The results show potential decreases in ASCs' labor costs ($7.39 per case) from technologies (e.g., new anesthetics or Bispectral Index [Aspect Medical Systems, Natick, MA] monitoring) to decrease emergence times or increase the phase I bypass rates. IMPLICATIONS: Decreases in operating room and postanesthesia care unit labor costs resulting from faster emergence and phase I postanesthesia care unit bypass vary depending on the amount of routine overtime, how the staff are compensated, and how many patients are routinely anesthetized each day.

Ambulatory Surgical Procedures↗
PubMed1999

An operating room scheduling strategy to maximize the use of operating room block time: computer simulation of patient scheduling and survey of patients' preferences for surgical waiting time.

UNLABELLED: Determining the appropriate amount of block time to allocate to surgeons and selecting the days on which to schedule elective cases can maximize operating room (OR) use. We used computer simulation to model OR scheduling. Inputs in the computer model included different methods to determine when a patient will have surgery (on-line bin-packing algorithms), case durations, lengths of time patients wait for surgery (2 wk is the median longest length of time that the outpatients [n = 367] surveyed considered acceptable), hours of block time each day, and number of blocks each week. For block time to be allocated to maximize OR utilization, two parameters must be specified: the method used to decide on what day a patient will have surgery and the average length of time patients wait to have surgery. OR utilization depends greatly on, and increases as, the average length of time patients wait for surgery increases. IMPLICATIONS: Operating room utilization can be maximized by allocating block time for the elective cases based on expected total hours of elective cases, scheduling patients into the first available date provided open block time is available within 4 wk, and otherwise scheduling patients in "overflow" time outside of the block time.

Anesthesia↗
PubMed1999

Statistical method to evaluate management strategies to decrease variability in operating room utilization: application of linear statistical modeling and Monte Carlo simulation to operating room management.

BACKGROUND: Operating room (OR) managers seeking to maximize labor productivity in their OR suite may attempt to reduce day-today variability in hours of OR time for which there are staff but for which there are no cases ("underutilized time"). The authors developed a method to analyze data from surgical services information systems to evaluate which management interventions can most effectively decrease variability in underutilized time. METHODS: The method uses seven summary statistics of daily workload in a surgical suite: daily allocated hours of OR time, estimated hours of elective cases, actual hours of elective cases, estimated hours of add-on cases, actual hours of add-on cases, hours of turnover time, and hours of underutilized time. Simultaneous linear statistical equations (a structural equation model) specify the relationship among these variables. Estimated coefficients are used in Monte Carlo simulations. RESULTS: The authors applied the analysis they developed to two OR suites: a tertiary care hospital's suite and an ambulatory surgery center. At both suites, the most effective strategy to decrease variability in underutilized OR time was to choose optimally the day on which to do each elective case so as to best fill the allocated hours. Eliminating all (1) errors in predicting how long elective or add-on cases would last, (2) variability in turnover or delays between cases, or (3) day-to-day variation in hours of add-on cases would have a small effect. CONCLUSIONS: This method can be used for decision support to determine how to decrease variability in underutilized OR time.

Humans↗
PubMed1998

Use of an automated anesthesia information system to determine reference limits for vital signs during cesarean section.

INTRODUCTION: We evaluated whether automated anesthesia information systems can be used to calculate reference limits (population-based "normal values") for vital signs. We considered four populations of women undergoing cesarean section: healthy under spinal anesthesia, healthy under general anesthesia, pre-eclamptic/eclamptic under spinal anesthesia, and pre-eclamptic/eclamptic under general anesthesia. METHODS: Reference limits were calculated for each of the study populations by determination of percentiles for: minimum heart rate, maximum heart rate, minimum arterial oxyhemoglobin saturation (SaO2), minimum mean arterial pressure (MAP), maximum MAP, decrease in MAP, and increase in MAP. RESULTS: There was one adverse anesthetic outcome among the 1,300 women in the study; the woman sustained a post-dural puncture headache. The 5th percentiles of SaO2 were at least 95% saturation under spinal versus 90% under general. Under spinal anesthesia, 95th percentiles for decreases in MAP from baseline were 63 mmHg for healthy and 75 mmHg for pre-eclamptic/eclamptic women. Under general anesthesia, the 95th percentiles for maximum MAP were 161 and 177 mmHg, respectively. Two women of the 1,300 patients experienced simultaneously a minimum SaO2 < 92% and minimum MAP < 50 mmHg. DISCUSSION: Automated anesthesia information systems can be used to determine reference limits for vital signs during anesthesia. Reference limits may play a role in malpractice cases when an expert claims that care by an anesthesiologist was sub-standard as shown by vital signs that were not maintained within the normal range during the critical portions of an anesthetic. Automated anesthesia information systems may enhance expert witnesses' clinical judgment.

Adult↗
PubMed1998

Valuing the work performed by anesthesiology residents and the financial impact on teaching hospitals in the United States of a reduced anesthesia residency program size.

UNLABELLED: We performed a financial analysis at a large university tertiary care hospital to determine the incremental cost of replacing its anesthesiology residents with alternative dependent providers (i.e., certified registered nurse anesthetists in the operating room, advanced practice nurses and physician assistants outside the operating room). The annual average net cost of an anesthesiology resident during a 3-yr residency is approximately $38,000, and residents performed an average of $89,000 of essential clinical work annually based on replacement costs. The incremental cost (replacement labor cost minus net resident cost) to replace all essential clinical duties performed by an anesthesiology resident at Duke University Medical Center and affiliated hospitals is approximately $153,000 throughout 3 yr of clinical anesthesiology training. If this approach were applied nationwide, incremental costs of substitution would range from $36,000,000 to $93,000,000 per year. We conclude that maintaining clinical service in the face of anesthesiology residency reductions can have a marked impact on the overall cost of providing anesthesiology services in teaching hospitals. Simply replacing residents with alternate nonphysician providers is a very expensive option. IMPLICATIONS: We sought to calculate the financial burden resulting from a decreased number of anesthesiology residents. Replacing each resident's essential clinical work with similarly skilled healthcare providers would cost hospitals approximately $153,000 over the course of a 3-yr residency. Varying projections yield future nationwide costs of $36,000,000 to $93,000,000 per year. Simply replacing residents with alternate nonphysician providers is a very expensive option.

Anesthesiology↗
PubMed1998

A method to compare costs of drugs and supplies among anesthesia providers: a simple statistical method to reduce variations in cost due to variations in casemix.

BACKGROUND: Comparison of costs among anesthesia providers using "cost per case" does not adjust for variations in casemix (such as the type of procedure and patient condition). The authors propose an alternative method for comparing costs using the American Society of Anesthesiologists' Relative Value Scale (ASARVS) system, which incorporates basic units (for the procedure), modifier units (for the patient's physical condition), "other" units (such as for the placement of invasive monitors), and time units (proportional to the case duration). METHODS: Data were obtained from a series of 3,340 anesthetics performed at a tertiary hospital. Administered and discarded drug, supply, and fluid costs were used. RESULTS: Costs expressed as dollars per ASARVS unit had 54% less variability than costs expressed as dollars per case (P < 0.0001). Pearson correlations between demographic variables and cost per ASARVS unit ranged from -0.10 to 0.13. Total (e.g., quarterly) costs for simulated sets of cases were predicted within 0.0 +/- 2.3% by multiplying (1) their sum of units and (2) a like set of case's sum of costs divided by sum of units. CONCLUSIONS: Costs of anesthetic supplies and drugs of a case were more accurately reported as "cost per unit" than as "cost per case." This method of calculating the cost of anesthetic drugs and supplies has several applications, including (1) comparison of costs among anesthesia providers and (2) benchmarking costs among hospitals and anesthesia groups. By design, anesthesia providers' time is quantified by their ASARVS units. Together anesthesia costs (personnel, supplies, and drugs) are better reported as "cost per unit" than as "cost per case."

Adult↗