Category: Articles
The Current and Future State of Anesthesiology
Hypoglossal Nerve Stimulators for OSA
UpToDate: Hypoglossal nerve stimulation for adult patients with obstructive sleep apnea. April 2024
StatPearls: Hypoglossal Stimulation Device. July 2023
Things that worked for me:
- ETT, sux (no lingering paralysis secondary to upcoming nerve stimulation)
- Propofol gtt with 12 mcg Precedex in 50cc syringe
- Fentanyl for pain
- HOB 180 degrees away
Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: A Superior Technique and Easy to Implement – PMC
Farapulse for Afib
Cardiac Clearance for Surgery
Are you healthy enough for surgery?
Calculators:
MDCalc: Revised Cardiac Risk Index for Pre-Operative Risk
2018 Prevention Guidelines Tool CV Risk Calculator
The Big Papers:
UpToDate: Evaluation of cardiac risk prior to noncardiac surgery. March 2024.
StatPearls: Cardiac Risk Stratification. May 2023.
Preoperative Cardiac Risk Assessment. Am Fam Physician. 2002;66(10):1889-1897.
Infographics:
How Wealthy Investors Got Rich Looting America’s Needy Hospitals
Compensation for Services
The Full Guide to Physician On-call Pay | Physicians Thrive
Physician Call Compensation Rates: 11 Determining Factors (beckershospitalreview.com)
Anesthesia Stipend Analysis (anesthesiaexperts.com)
Managing Compensation for Anesthesiologists, CRNAs and AAs (beckersasc.com)
28 Statistics on Highest Emergency On-Call Coverage Per Diem Payments (beckershospitalreview.com) –> 2012 data 
Hospital Call Stipends : r/anesthesiology (reddit.com)
Anesthesia Management: MGMA: No guarantees for physician on-call pay | Anesthesia Experts –> 2014 post
Locum tenens compensation trends by specialty | 2023 report (locumstory.com)
Understanding Call Pay Compensation Methods – Coker (cokergroup.com)
Developing an Anesthesia Compensation Model That Makes Sense | Change Healthcare
Cardioversions with APN
A policy has been passed by our hospital that would allow APNs ability to perform elective cardioversions in our EP department.
Two studies from the United Kingdom demonstrated safe and effective performance of CVs when directed by nurses with advanced training 5, 6. In a study by Boodhoo et al. (5) in 2004, nurses who performed CVs had at least 1 year of coronary care unit experience, were Advanced Cardiac Life Support (ALS) certified, and had performed a minimum of 20 supervised CVs. In their hospital, the nurses administered the sedation without an anesthesiologist present. Although, as the authors suggest, this sedation approach reduces costs, a cardiac registered nurse in the United States would not be granted hospital privileges to independently provide moderate sedation. In the study by Currie (6), an anesthesiologist rather than a nurse administered sedation, but unlike the present study, patients who were considered high risk due to advanced heart disease, presence of a pacemaker, or severe obesity, were excluded from the nurse-directed CV approach.
The only published study based on U.S. experience with nurse-led CVs is a retrospective study by Norton et al. (7) that compared the outcomes of CVs performed by physicians alone, those by physicians with a nurse practitioner, and those of nurse practitioners independently. They found comparable success rates in each group, with a success rate of 93% in the nurse practitioner group, and there were no complications in any of the CV groups. Unlike the present study, however, the nurse practitioner was certified in ICD interrogation and reprogramming, performed the CV completely independently, and billed for the procedures. The APP who performed the CVs in the present study is a salaried employee of the hospital where the procedures were performed and did not bill independently for procedures.
In addition, the findings of the present study are only applicable to practices where sedation for CVs is administered by an anesthesiologist.
Outcomes Associated With Electrical Cardioversion for Atrial Fibrillation When Performed Autonomously by an Advanced Practice Provider. JACC: Clinical Electrophysiology, Volume 3, Issue 12, 2017, Pages 1447-1452.
Thoughts
In these studies, they looked specifically at having anesthesiologists be present as well as removing potentially complex cardioversion cases.
It seems all of these studies are done in an academic practice or NHS type hospital environment. Are there studies where it shows cost effectiveness for private practice groups?
How much of the safety burden is placed on anesthesiologists for managing instability for the procedure?
3 Trends Impacting Anesthesia Compensation – ECG Management Consultants
Where do we see anesthesia going as well as reimbursements?
Medicare’s geographic adjustment for a particular physician payment locality is determined using three geographic practice cost indices (GPCI) that correspond to the three components of a Medicare fee–physician work, practice expense, and malpractice expense.
Physician work–the financial value of physicians’ time, skill, and effort that are associated with providing the service.
Practice expense–the costs incurred by physicians in employing office staff, renting office space, and buying supplies and equipment.
Malpractice expense–the premiums paid by physicians for professional liability insurance. Each RVU measures the relative costliness of providing a particular service.
These GPCIs adjust physician fees for variations in physicians’ costs of providing care in different payment localities. Specifically, they raise or lower Medicare fees depending on whether a payment locality’s average cost of operating a physician practice is above or below the national average. CMS is required to review the GPCIs at least every 3 years and, at that time, may update them using more recent data. The major data source used in calculating the GPCIs, the decennial census, provides new data once every 10 years. The GPCIs were last updated in 2005 and CMS is scheduled to review and, if necessary, update them again in 2008. Concerns have been raised in Congress and among stakeholders, including state medical associations, that the geographic boundaries of some payment localities do not accurately address variations in the costs of operating a private medical practice. If they do not, beneficiaries could potentially experience problems accessing physician services.
From https://www.govinfo.gov/content/pkg/GAOREPORTS-GAO-07-466/html/GAOREPORTS-GAO-07-466.htm
More than half of the current physician payment localities had at least one county within them with a large payment difference–that is, there was a payment difference of 5 percent or more between physicians’ costs and Medicare’s geographic adjustment for an area. Overall, there were 447 counties with large payment differences–representing 14 percent of all counties. These counties were located across the United States, but a disproportionate number were located in five states. Specifically, 60 percent of counties with large payment differences were located in California, Georgia, Minnesota, Ohio, and Virginia. Large payment differences occur because many payment localities combine counties with very different costs, which may be attributed to several factors. For example, although substantial population growth has occurred in certain geographic areas, potentially leading to increased costs, CMS has not revised the payment localities to reflect these changes.
From https://www.govinfo.gov/content/pkg/GAOREPORTS-GAO-07-466/html/GAOREPORTS-GAO-07-466.htm
Perhaps insurance company data could be used to help discover discrepancies in cost and apply new findings to these geographic areas.
CMS Physician Fee Schedule — Anesthesia specific
ASA: Anesthesia Payments –> The 33% Problem — AnesthesiaExperts:33% Rule
AnesthesiaExperts: Q&A on the 33% problem
AnesthesiaLLC.com: The Low, Low Anesthesia Conversion Factor
Lawmakers Ask HHS to Review Medicare Rates for Anesthesia Services, Sept 2010
Anesthesia Subsidies from a Hospital’s Perspective
ECG Management Consultants:
AnesthesiaLLC.com: Today’s Anesthesia Economics Coping with New Realities.
Sleepy Time 