Effective medicine is practiced in teams. This truth holds particularly in the surgical setting, where surgeons, anesthesiologists, internists and specialists work in tandem to plan and deliver the appropriate care to the patient. In discussions of the perioperative cycle, dialogue often diminishes when the patient has left the operating room. However, this post-operative time can be crucial in terms of the patient’s recovery and subsequent return to daily life. To address this need, hospitalists are essential practitioners for patients who have entered in-patient care following surgery. Moreover, anesthesiologists and hospitalists can collaborate in order to enhance perioperative care from intake to discharge.

Hospitalists are physicians who are dedicated to providing in-patient care for patients. To become a hospitalist, medical graduates must complete an internal medicine residency program. Specific residencies may include an emphasis on hospital medicine, by including hospitalist rotations or allowing residents to become involved with tailored research. Following residency, interested individuals can seek to complete a hospitalist fellowship¹. Fellowships vary in terms of clinical responsibilities, but many include a research component that focuses on a sub-topic such as patient safety, post-operative care, or quality. Due to this specific training, hospitalists convey a valuable trove of knowledge in the surgical setting.

Hospitalists and anesthesiologists often collaborate in the perioperative setting, thus allowing the surgeon to focus on the surgery². In many cases, the role of the anesthesiologist may overlap with that of the hospitalist. Particularly with the development of the Perioperative Surgical Home model, many anesthesiologists assume responsibility for pre-operative patient management and planning, as well as post-operative acute care. A subset of anesthesiologists have also completed training in intensive care or other fellowship training, hence these sub-specialists have the background to provide expert care to specific patient populations.

With this in mind, many hospitals have explored the option of anesthesiologists serving as hospitalists. A recent study from Loma Linda University School of Medicine introduced an intervention wherein anesthesiologists co-managed patients undergoing urologic surgery, selecting a cohort of anesthesiologists who previously completed additional training³. It was found that length of stay decreased from two to one day post-op. There was also a significant decrease in rates of complication as well as direct costs, when anesthesiologists led and participated in a hospitalist service. The study thus concluded that there were patient safety, clinical efficacy, and global cost benefits to the formal inclusion of anesthesiologists as part of the hospitalist care team. Following this study, other medical centers have concurred that anesthesiologists form a vital component of the post-operative period and are qualified to serve in a leadership role.

Progressive methods of delivering care will continue to explore how anesthesiologists can contribute to the perioperative cycle, in and out of the operating room. Post-operative care is essential to ensuring patient safety as well as the patient’s recovery to a healthy, full life.

Patients with cancer often require chemotherapeutic and/or radiation treatment. These patients, as well as those with chronic steroid use, immunomodulation therapy use for inflammatory disorders, and inborn or acquired immunodeficiencies are at higher risk of infection. Laboratory values suggestive of an immunosuppressed state include leukopenia and pancytopenia. Steroids can potentiate immunosuppression, even if relatively small amounts are injected into the epidural space. Systemic effects of corticosteroids may increase risk of infection or viral reactivation.

The risks of rare but serious infections must be weighed with the expected benefits of pain relief and functional improvement from epidural steroid injections. Case reports have emerged documenting infectious complications following epidural steroid injections. The root cause of a series of fungal infections following epidural steroid injection was traced to contaminated vial batches of methylprednisolone in the 2010’s [1]. Specific reports have been described for herpes zoster. One report describes herpes esophagitis following a cervical epidural steroid injection [2]. Another case describes cutaneous herpes zoster eruption following serial lumbar epidural steroid injections [3]. Finally numerous case reports describe epidural abscess formation even in the absence of known immunodeficiency [4]. As such, providers should seriously consider the higher risk of infection in the immunosuppressed patient population. Currently, antibiotic prophylaxis is not recommended for epidural steroid injections.

In addition to risks of infection, there are risks of cortisol excess when patients are taking other medications. Several cases describing iatrogenic Cushing’s syndrome, characterized by glucose intolerance, diffuse adipose deposition, and immune dysregulation, highlight the interaction between corticosteroids and ritonavir, a protease inhibitor used to treat Human Immunodeficiency Virus (HIV) [5, 6]. Cushing’s syndrome is the clinical manifestation of cortisol excess from endogenous or exogenous causes. Downstream complications of Cushing’s syndrome are serious: they range from myocardial infarction and stroke to bone loss, hypertension, type 2 diabetes, and depression. Thus, pain providers should perform a review of patient medications with particular attention to the coadministration of ritonavir in HIV-affected patients.

Pain physicians and anesthesia providers should be aware of the risks of epidural steroid injections when counseling patients. While epidural abscess formation is an appropriately often-cited complication, other effects related to administration of steroids should be discussed, including iatrogenic Cushing’s syndrome and immunosuppression.

References:

1. Moudgal V, et al. Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections. Open Forum Infect Dis. 2014 May 14;1(1)

2. Davis K, et al. A difficult case to swallow: herpes esophagitis after epidural steroid injection. Am J Ther. 2014;21(1):e9-14.

3. Parsons SJ, Hawboldt GS. Herpes zoster: a previously unrecognized complication of epidural steroids in the treatment of complex regional pain syndrome. J Pain Symptom Manage. 2003;25(3):198-9.

4. Kraeutler MJ, et al. Spinal subdural abscess following epidural steroid injection. J Neurosurg Spine. 2015; 22(1):90-3.

5. Maviki M, et al. Injecting epidural and intra-articular triamcinolone in HIV-positive patients on ritonavir: beware of iatrogenic Cushing’s syndrome. Skeletal Radiol. 2013; 42(2):313-5.

6. Albert NE, et al. Ritonavir and epidural triamcinolone as a cause of iatrogenic Cushing’s syndrome. Am J Med Sci. 2012;344(1):72-4.

Alongside clinical outcomes, patient satisfaction is at the core of delivering effective healthcare. An area of emphasis within this realm is the perioperative care spectrum, which refers to patient treatment before, during, and after surgery. At each of these stages, opportunities are present to enrich the patient’s experience, from reducing the patient’s wait-time to improving patient-physician communication, as well as to impact clinical outcomes to the patient, as well as viable cost savings to the hospital. Thusly, operational analytics are rising in prominence as an effective tool for measuring, addressing, and impacting patient experiences throughout the perioperative care cycle.

In this reference, operational analytics includes quantitative factors such as census, site of admission, and average length of stay, as well as qualitative variables, such as the evaluation of patient satisfaction at each stage of the perioperative cycle¹. At the hospital level, operational analytics can be leveraged to elucidate the trends in order to identify relationships between operational features and patient satisfaction. More specifically, operational analytics are useful for generating data on the patient’s journey throughout the perioperative care cycle, allowing for areas of intervention. Although specific operational factors are subject to variation by patient population, location, and healthcare system, there are several specific operational analytics that can be applied to most surgical settings.

Hospital census, or the number of patients at a given time, is a variable of interest for practice management². For anesthesiologists and surgeons, census is most applicable at the site of entry for surgical service, whether that refers to the patient entering pre-operative preparation or the anesthesia suite. By knowing exactly how many patients are present at each stage of the surgical algorithm, physicians and trainees can be allocated to service during high-volume times, and otherwise triaged to other services. Moreover, measuring census also has a benefit to the administrative side of the healthcare system, as it promotes the practice manager’s ability to efficiently admit patients to hospital beds. Without analytics, patients may be admitted haphazardly and beds in the surgical wing may be under- or over-utilized. However, by employing operational analytics to measure census, beds can be strategically distributed to accommodate the most emergent cases soonest, thus contributing to intelligent care delivery at the patient population level.

Operations research has largely improved the capacity of health systems to measure and address concerns within analytics variables such as census and bed management. Recently, researchers conducted a study across Hong Kong government hospitals that employed an intervention for hospital-wide master surgery schedules, optimizing for patient flow, capacity management, and resource allocation through the broad variable of measuring bed occupancy³. The researchers developed a simulation tool that integrated real-time information from multiple hospitals in order to predict each variable at different times of the day and year. Moreover, the data analytics collected were then applied to a decision-making tool for hospital practice managers, allowing for stakeholders to observe how the master surgery schedule changes over time and with patient flow. The intervention has the potential to influence clinical outcomes as well as economic outcomes over time. Such technological interventions that prioritize high-volume data collection for integration into analytics will continue to enter the dialogue on hospital operations management.

Operational analytics play a large role in optimizing the perioperative care spectrum, by increasing the data available on patient experience, while also identifying areas of improvement for the focus of physicians and practice managers — enhancing anesthesia management as well as operations of anesthesia services.

In the dialogue on healthcare in the United States, price transparency remains a major issue that has served as the impetus for debate. To understand accurate price transparency, it is essential to be knowledgeable on the difference between cost and charge. Particularly in the perioperative care and anesthesia services setting, this understanding is crucial for realizing how costs of care are computed and subsequently presented to patient populations.

Cost of care broadly refers to the specific expenses that a healthcare system utilizes in order to deliver comprehensive care. The cost of care can either be calculated from a top-down or bottom-up costing method¹. In this way, healthcare administrative managers essentially divide the total cost of, for example, an operation into the sum of its parts. Therefore, each subsection can be a resource by detailing the personnel and supplies that are necessary for each stage. In surgical services, this process must include all stages of the perioperative cycle, including pre-operative planning, sterilization and decontamination of needed surgical instruments, and preparation of the anesthesia necessary for the specific operation. Furthermore, the cost for housing a patient in the wards also factors into such calculations, including referencing relevant expenses for the floor space, accommodations, housekeeping, and meal service. The surgery itself is similarly composed of many costs, such as all required instruments, and the compensation of surgical staff, which may be fixed or variable depending on the scenario. Post-operative costs will reference the bed fee, as well as any dictated medications or physical therapy that is ordered by the physician. Each of these costs are thus summed into a global cost per procedure, which can further be separated into the total cost per minute in the OR.

Yet, this cost is very different from the charge. Most patients will only see the charge for their procedure, which is in many cases billed to the patient’s health insurer. However, this charge is not necessarily the same as the cost of the procedure. Rather, the charge has been calculated by the administration’s forecast averaging of all procedures over time, thus allowing for the hospital to remain viable whilst reimbursement processes ensue. Hence, charges may be greater than the detailed cost of a procedure, in relation to these factors.

In response to the complex distinction between cost and charge, patient coalitions have advocated for the ability to view charges prior to entering the hospital, in a public forum. The Centers for Medicare and Medicaid Services subsequently provided a solution. The 2019 Inpatient and Long-Term Care Hospital Prospective Payment System Rule expands previous requirements of the ACA, and requires hospitals to produce lists of standard charges for all operations and related drugs online in an easily accessible format². This list, known as the hospital’s charge master, was previously only accessible internally amongst healthcare administrators. The CMS rule will require administrative effort on the parts of hospitals, but will greatly expand price transparency between patients and their healthcare provider.

Policies will continue to refine the U.S. healthcare system, enhancing the ability of patients to understand the accurate cost of their healthcare. Recent changes have furthered this initiative, expanding transparency from hospital administration to patient population.

Health care reform has been a dominant topic since the 2017 presidential election. Numerous acts have been introduced to repeal or reform the Obama administration’s Affordable Care Act (ACA). The most notable among these acts was the American Health Care Act (AHCA), which was passed by the House of Representatives only to famously fail in the Senate after a dramatic thumbs-down vote by John McCain. Despite the flurry of political debate, news coverage, and legislative activity surrounding the ACA, it continues to remain in effect today, albeit with some important changes coming in 2019.

The most significant change introduced in January 2019 is the reduction of the individual mandate penalty to $0. As part of the tax reform bill signed into law in December 2017¹, this change is significant for several reasons. First, it eliminates the metaphorical stick used to goad the young and healthy into buying health insurance. The elimination of this incentive will likely lead many young people to forgo purchasing insurance, making the overall pool of insured Americans older and less healthy, thereby raising the cost of premiums. The impact on premiums will be compounded by the Trump administration’s decision to stop reimbursing insurers for cost sharing. Some experts project that premiums will increase an average of 2.8% (nearly $580 per year) in 2019, largely as a result of these policy changes². Even more significantly, in the case of Texas vs. Azar, twenty states challenged the ACA in federal court on the basis that the $0 individual mandate penalty no longer qualifies as a tax, making the law unconstitutional.³ A federal judge in Texas ruled in favor of the states, sending the case up to the Supreme Court for consideration, where a final ruling on behalf of the states could potentially toss out all of Obamacare.

The types of private insurance plans available to consumers and the ways in which they can be purchased are also scheduled to change in 2019. Short term plans in 2019 can be purchased for up to one year of coverage and can be renewed for up to three years—a significant change from the maximum three months of coverage allowed previously. Policies have also been revised to expand the availability of “association plans,” which are health insurance plans offered by trade, industry, and professional groups to their members. These plans are usually cheaper than insurance offered by employers, but in most cases fall short of the full suite of benefits required of ACA-compliant plans.⁴ Additionally, licensed online brokers will now be able to directly enroll customers into health insurance plans, where they were previously required to redirect customers to government-run exchanges for verification of eligibility criteria and enrollment. Now in 2019, customers can complete the entire enrollment process on third-party, private websites.⁴

One of the most notable developments for health insurance in 2019 is the emergence of greater variability in insurance plans across state lines. The Trump administration’s efforts to loosen ACA restrictions have led to a divergence between blue and red states as the former pass laws to reinforce Obamacare policies, while the latter passively embrace the federal pullback. In Minnesota, for example, silver plans are expected to be 11% cheaper in 2019 compared to 2018, while in Maryland silver plans are expected to be 36% more expensive.⁵

While these changes to private health insurance aren’t expected to have a special impact on anesthesia care, anesthesia providers will have to cope with the increased uncertainty presented by the current policy environment. Rising premiums and the elimination of the individual mandate penalty may lead to a reduction in the number of insured patients, which could reduce demand for some anesthesia services. The increased state-to-state variability may also complicate operations for anesthesia practices serving populations across state lines. Anesthesia service professionals should remain engaged in policy discussions happening in 2019 in order to stay ahead of any further changes on the horizon.

References:

1. Armour, Stephanie and Kristina Peterson. “Senate GOP Tax Plan to Include Repeal of Health Law Individual Mandate,” The Wall Street Journal (November 14, 2017). https://www.wsj.com/articles/senate-gop-tax-plan-to-include-repeal-of-health-law-individual-mandate-1510690807.
2. Gaba, Charles. “The Chart That Shows the Price Tag for Trump’s Obamacare Sabotage,” The New York Times (December 27, 2018). https://www.nytimes.com/2018/12/27/opinion/trump-obamacare-sabotage-chart-cost.html.
3. Keith, Katie. “Court Rules Individual Mandate, Entire ACA Unconstitutional,” Health Affairs 38, no. 2 (2019): 1-2. doi: 10.1377/hlthaff.2019.00024.
4. “7 Big Health Insurance (Obamacare/Trumpcare) Changes for 2019.” eHealth. Last modified October 2, 2018. https://www.ehealthinsurance.com/resources/individual-and-family/11282.
5. “Cost of Individual Health Insurance Depends More Than Ever on Where You Live.” Consumer Reports. Last modified August 30, 2018. https://www.consumerreports.org/health-insurance/cost-of-individual-health-insurance-depends-more-than-ever-on-where-you-live.