Atrial fibrillation (A Fib) is the most common sustained arrhythmia among adults. A Fib is characterized by disordered cardiac conduction within the atria, resulting in a classically irregularly irregular heart rhythm. The absence of P-waves represents disorganized atrial contraction and is a hallmark electrocardiographic (EKG) finding associated with A Fib. A Fib is concerning to perioperative providers because of its potentially fatal consequences, including cardiovascular collapse associated with tachyarrhythmias and thromboembolic events.

While chronic A Fib develops from several secondary causes, surgery is a common and discrete precipitant. One study found that 4% of adults develop A Fib after non-cardiac surgery.¹ A more recent database study revealed that, in descending order of risk, intrathoracic, vascular, and intra-abdominal surgeries were associated with clinically-important AFib.² In this study, age greater than 85 years was the strongest variable correlated with the development of A Fib.

Developing A Fib after cardiac surgery is more common than other surgeries, with the likelihood of developing A Fib ranging from 30-50% post-cardiac surgery.³ Among patients undergoing coronary artery bypass grafting (CABG), risk factors for postoperative A Fib include the following: age over 80 years, concurrent valvular surgery, off-pump procedures, withdrawal of beta blocker or angiotensin converting enzyme inhibitors, and prior history of A Fib or chronic obstructive pulmonary disease.⁴ Common prevention strategies include the use of perioperative beta blockers, amiodarone, and intracardiac atrial pacing.⁵ Despite having several models for risk stratification, no current standard exists for predicting whether a patient is at high or low risk for developing postoperative AFib.³ Thus, individualized assessments should be made by anesthesiologists, cardiothoracic surgeons, and cardiologists.

Initial assessment of new-onset (i.e., less than 48 hours since sinus rhythm) postoperative A Fib should focus on the stability of the patient. Patients with EKG findings of tachyarrhythmia (sustained heart rate >100 beats per minute) require immediate bedside attention. Patient complaints of newly developed lightheadedness, dizziness, chest pain, dyspnea, or diaphoresis should prompt providers to arrange for urgent direct current cardioversion (i.e., synchronized) at 100-200 joules. Administration of sedation or amnestic therapies (e.g., benzodiazepines) prior to cardioversion should be done at the anesthesiologist’s or cardiologist’s discretion. Stabilization of the arrhythmia may require multiple shocks and intravenous therapies.

Stable patients with new-onset A Fib and no associated symptoms should be medically managed prior to discharge from the recovery room. Standard laboratories should be obtained, with particular attention to values for hemoglobin, potassium, magnesium, and calcium levels. Intravenous beta-1 selective beta blockers (e.g., metoprolol, esmolol) are first-line therapies for A Fib. Second-line medications include intravenous non-dihydropyridine calcium channel blockers (e.g., diltiazem, verapamil). A Fib that is recalcitrant to the above therapies may respond to intravenous amiodarone. Caution should be exercised with the loading dose of amiodarone, as rapid administration may result in hypotension.

References:

1. Vaporciyan AA, et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg. 2004;127(3):779
2. Alonso-Coello P, et al. Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study. Anesth Analg. 2017;125(1):162-169
3. O’Brien B, et al. Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth. 2019 Jan;33(1):12-26.
4. Mathew JP, et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA. 2004;291(14):1720
5. Arsenault KA, et al. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev. 2013

The 2019 Medicare Physician Fee Schedule includes updates to many healthcare policies and programs, including the Quality Payment and Medicare Shared Savings Programs, the Laboratory Fee Schedule, and Physician Self-Referral, to name a few. Comments on the particulars of the final rule are due on December 31, 2018, and the official schedule will go into effect on January 1, 2019.¹ As an anesthesiologist, you may be wondering how this new physician fee schedule might affect you.

The national conversion factor for anesthesia services will undergo a slight change when the new schedule comes into effect. The conversion factor will increase under the new schedule from $22.1887 to $22.2730. ¹ The Medicare Access and Chip Reauthorization Act (MACRA) initially specified a 0.5 percent conversion factor update for anesthesia services. However, the Bipartisan Budget Act of 2018, which widely increased federal discretionary spending caps, further updated this ruling by including a provision for budget neutrality adjustments that outlined a lower, 0.25 percent updated conversion factor. This small increase in the national conversion factor ultimately allows anesthesiologists to charge higher fees for their services. Beyond anesthesia-specific practices, the more expansive final physician conversion factor will increase from $35.9996 to $36.0391. This physician conversion factor is still relevant to anesthesiologists who are billing for flat fee services. For example, “the use of ultrasound guidance in the placement of a nerve block.” would be considered a flat-fee service for which the physician conversion factor could be applied.²

Revisions made to the Quality Payment Program for 2019 take into account Merit-Based Incentive Payment System (MIPS) performances from 2017. If a clinician is MIPS eligible, their Medicare fee-for-service payments will be based on their MIPS performance from 2017, which will undergo a maximum two percent change after adjusting for budget neutrality.¹ MIPS performance is evaluated based on four factors: quality, promoting interoperability (use of information technology), improvement activities, and cost. ³ The MIPS program already includes certified registered nurse anesthetists and will be expanded to include additional clinician categories. Clinicians who are MIPS eligible can choose to be evaluated within certain categories based on activities that best reflect their practice. In addition, an expansion to the low-volume threshold criteria of the Quality Payment Program will enable clinicians to opt out of MIPS if they so choose. According to McDermott Consulting, “Per the 2019 LVT policy, to be excluded from MIPS, clinicians or groups will need to meet one of the following three criteria: have ≤ $90,000 in Part B allowed charges for covered professional services, provide care to ≤ 200 beneficiaries or provide ≤ 200 covered professional services under the PFS.”¹ Groups of healthcare professionals or individual practitioners will be able to opt into MIPS if they are not deemed exempt based on all three low-volume threshold criteria.

According to Seema Verma, the Centers for Medicare and Medicaid Services (CMS) administrator, new document requirements will be streamlined under the new fee schedule, allowing clinicians to “put patients over paperwork.”² These new documentation practices will make the paperwork process smoother by providing multiple options for healthcare practitioners when they approach billing patients. Overall, there are three important points to glean from the new physician fee schedule: first, the conversion factors relevant to anesthesiology practices are set to increase reimbursements, secondly, providers can expect more freedom to choose their level of involvement in the MIPS program, and lastly, regulations for filing claims and other paperwork will become more flexible and efficient.

References:

1. Madhani, Sheila, and Mara McDermott. “Top 10 Takeaways: 2019 Medicare Physician Fee Schedule.” McDermott+Consulting, 6 Nov. 2018, mcdermottplus.com/insights/top-10-takeaways-2019-medicare-physician-fee-schedule/.
2. Popa, Rachel. “What Anesthesia, Pain Management Providers Should Know about CMS’s 2019 Proposed Payment Rule: 6 Key Points.” Becker’s ASC Review, 23 July 2018, www.beckersasc.com/anesthesia/what-anesthesia-pain-management-providers-should-know-about-cms-s-2019-proposed-payment-rule-6-key-points.html.
3. Quality Payment Program, qpp.cms.gov/mips/overview

Residency is a critical step in one’s medical education journey. After attending medical school, participating in required clerkships and sub-clerkships, and completing an internship year, recent medical school graduates go on to become junior residents. The residency experience is one part clinical education, one part job experience. Residency is designed to not only prepare residents for their eventual specialty, but also to expose them to the rigors of the profession. All anesthesiologists must attend a three-year residency program, which includes clinical experience as a trainee, as well as educational programming such as grand rounds and clinical conferences.^[1] After successfully completing their residency programs and obtaining the proper certifications and state-specific licenses, many aspiring anesthesiologists will complete a sub-specialty fellowship. Sub-specialty fellowships allow residents to become experts in a certain sub-field within anesthesiology, such as critical care medicine or pediatric anesthesia. Each stage of residency training serves as a kind of trial period for the lifestyle of an anesthesiologist, which often requires long shifts, overnight and weekend calls, unpredictable hours, and any additional stressors associated with the surgical profession. In recent years, shift work policies have emerged as a topic of discussion in anesthesiology, as well as in the broader conversation in research. From residency to practice, shift work is now being closely examined as a necessary area for reform.

Historically, physician educators in anesthesiology, as well as many other disciplines, have insisted that residents work long hours to adequately prepare themselves for the life of a practicing physician. On average, the length of residency shifts in the United States has decreased incrementally over time. Before the 1980s, it was common for physicians to work 90-100 hour weeks, with shifts as long as 36 hours.^[2] The Bell Commission was established in response to cases of tragic patient outcomes that could have been attributed to resident physician sleep deprivation. The Commission sought to limit resident shifts to 80 hours per week in a four-week period, to restrict individual shifts to 24 consecutive hours, and to implement mandatory off-shifts.^[3] The Bell Commission was adopted by prominent hospitals in the New York area before it was taken up by other states in the U.S. Despite these changes, the debate continued over the benefits of instituting 16-hour vs. 24-hour individual shift limits.

In an attempt to shed some light on the matter, a Harvard research study led by sleep expert and physician Dr. Charles Czeisler examined how reducing residency shift times to 16 hours effects quality of sleep and attentional failures.^[4] Sleep times were monitored for interns and residents participating in the study, taking into account sleep interruptions due to clinical responsibility requests. The research team found a direct correlation between increased shift hours and frequency of attentional failures. These results provided the impetus to focus policy discussions and changes around shift regulations. The work was furthered by results from a recent study conducted by Johns Hopkins University and the University of Pennsylvania, which reported a strong relationship between reduced shift time and resident reporting on quality of life and training outcomes.^[5] Notably, the study found no significant difference in board examination results between the experimental and standard cohort. This finding suggests that the clinical education obtained by shift-limited residents is of the same quality as residents working standard, non-limited hours. Future research will explore innovative methods of building schedules aimed at enhancing work-life balance for residents that also maximize educational training, clinical training, and certification exam scores.

Anesthesiologists that graduate from residency and a possible fellowship may find themselves in a variety of settings: from academic medicine, to outpatient clinics, to private practice. It is clear that shift work policies will continue to be debated in all medical settings, By becoming vocal stakeholders in the conversation surrounding the issue of shift work, anesthesiologists can ensure that their important insights are taken into account.

References:

^[1] The American Board of Anesthesiology. Training/Residents. 2016. http://www.theaba.org/TRAINING-PROGRAMS/Resident-Options/ACCM-Fellowships

^[2] Patient Safety Primer. Duty Hours and Patient Safety. Aug 2018. The Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/primers/primer/19/Duty-Hours-and-Patient-Safety

^[3] Wallack MK, Chao L. Resident Work Hours: The Evolution of a Revolution. Arch Surg. 2001;136(12):1426–1432. doi:10.1001/archsurg.136.12.1426

^[4] Lockley SW et al. “Effect of reducing interns’ weekly work hours on sleep and attentional failures.” N Engl J Med. 2004 Oct 28;351(18):1829-37.

^[5] Hedin M. Johns Hopkins University HUB. “Study: Limiting shifts for medical trainees improves satisfaction without affecting educational outcomes.” Mar 2018. https://hub.jhu.edu/2018/03/20/limiting-medical-residents-shifts/

The emergence of shared decision making in health care has empowered patients to take a more active role in managing their own treatment. In contrast to former care paradigms in which patients largely deferred decision making to technocratic providers and physicians, shared decision making focuses on empowering patients to make their own treatment decisions through education that incorporates the patient’s values and preferences.¹ This shift places new importance on understanding what exactly drives decision making by patients.

The most obvious factors are those that would be considered by a “rational” patient in cost-benefit analyses: cost of treatment, indirect costs such as lost wages, likelihood of survival, probable complications, and quality of life, among others.  But for a host of reasons, patients do not usually carry out this sort of rational economic analysis when making health care decisions. For one, outcomes data are notoriously difficult to obtain, making many relevant statistics only available to very enterprising patients. Patients can also be easily overwhelmed by the gravity and complexity of the medical decisions they face. With the vast amount of literature available and potential analyses that could be done to determine the optimal treatment, many patients, feeling intimidated, may simply leave important health care decisions to their doctors.²

Perhaps the most important factors are psychological ones, which fall within the realm of behavioral economics. For example, a study compared the views of two groups of women: the first group was asked to estimate their lifetime risk of developing breast cancer (their mean estimate was 41%) then informed of their actual lifetime risk (13%), while the second group was informed of their 13% lifetime risk of developing breast cancer up front. The first group reported feeling relieved after learning about the 13% risk, which was considerably lower than their initial estimate, while the second group did not feel the same sense of relief and reported instead that the 13% figure was about what they had expected.³ This is a classic example of “hindsight bias”, a phenomenon with significant medical implications. Feeling relieved upon learning the lower percentage, the first group of women in the study may feel less inclined to receive mammograms.

For those in the anesthesia services industry, it is critical to account for both rational and behavioral economic factors when planning perioperative care. Rational factors are critical when considering best practices for the health and finances of patients, anesthesia practices, and society at large. However, rational planning is not effective until patient psychology and insights from behavioral economics are accounted for. Anesthesiology professionals are especially important actors in decision making because of their role in alleviating patient pain and discomfort during treatment. Pain is a powerful psychological influencer, and the anticipated pain associated with a course of action may have an outsized influence on a patient’s medical decision making. For this reason, anesthesia providers need to be engaged members in the movement toward shared decision making. Their expertise will be essential to creating interactive decision aids that can accurately guide patients and help plan more efficient anesthesia management. For example, anesthesia providers are often pressured to use lower-cost medications. However, drug expenses are small compared to human labor costs in most anesthesia practices.⁴ With their knowledge and experience, anesthesia professionals are better positioned to advocate for solutions such as better scheduling of anesthesia services and staff, that improve efficiency without sacrificing patient comfort or safety.

References:

1. Lee, Emily O. and Ezekiel J. Emanuel. 2013. “Shared Decision Making to Improve Care and Reduce Costs.” The New England Journal of Medicine 368, no. 1: 6-8.
2. Landro, Laura. 2017. “How to Get Patients to Take More Control of Their Medical Decisions.” The Wall Street Journal, February 28, 2017. https://www.wsj.com/articles/how-to-get-patients-to-take-more-control-of-their-medical-decisions-1488164941.
3. Ubel, Peter A. 2010. “Beyond Costs and Benefits: Understanding How Patients Make Health Care Decisions.” The Oncologist 15, suppl. 1: 5-10.
4. Watcha, Mehernoor F. and Paul F. White. 1997. “Economics of Anesthesia Practice.” Anesthesiology 86, no. 5: 1170-96.

In the United States healthcare system, the availability of digital medical data has created new opportunities for improving patient outcomes and quality of care. Healthcare systems have long collected data on patients undergoing surgery. However, pre-digitization, there was no method for compiling or storing a set of universal data. Historically, medical records were hand-written by the healthcare providers and placed in the patient’s file for storage. Policies dictated that these files were to be destroyed after a set amount of time. A valuable opportunity to identify trends in patient care and outcomes using consolidated data was lost to these practices. The internet, electronic medical records (EMRs), and quantitative clinical research have each played an important role in improving the delivery of healthcare. In the modern age of surgery and anesthesia care, data is a powerful tool to increase the efficacy of procedures and improve outcomes for all patients.

In clinics, private practices, and large-scale medical centers across the country, EMRs have become the routine method for registering patients into the healthcare system. Beyond utilization as a central resource for scheduling and patient care coordination, EMRs are also valuable as a repository for capturing patient data.^[1] Most EMR systems today can be tailored to align with the data capture priorities of specific health systems. When considering the surgical field, how do we determine which data among the near infinite options should be collected? A multi-disciplinary team of physician-researchers investigated this question through a commission that discussed and proposed a universal minimum data set for perioperative care^[2]. In the end, a consensus on 38 parameters for 74 operations was reached by researchers representing a range of medical institutions from Chicago, Illinois to Arusha, Tanzania. The hope is that if a significant proportion of medical centers performing a high volume of surgeries were to implement collection of these 38 parameters, the resulting data could be leveraged to examine macro-level trends for patient outcomes at the procedural and operative levels.  A universal minimum perioperative care dataset has the potential to generate significant results for research and practice.

Once a substantive amount of data has been collected systematically, the next step is to apply this data to address existing and future patient practices. This data has already been utilized to improve outcomes for patients with sepsis, a life-threatening condition caused by the body’s negative response to infection.^[3] Hospitals in the HCA Healthcare network have implemented a program called SPOT (Sepsis Prediction and Optimization of Therapy), which collects a number of data points from patients recovering from surgery, and then feeds the data into a machine learning algorithm capable of predicting whether or not the patient is susceptible to septic shock. On average, the algorithm is capable of predicting sepsis 18 hours before a physician would have diagnosed it in a patient. While this technology is still in development, preliminary results have been promising and the system can serve as an early model for effectively utilizing data to improve patient outcomes.

As healthcare technologies continue to advance, the use of patient data in clinical research should prove to be a highly productive tool for ensuring patient safety and optimized outcomes at every stage of the operative journey.

References:

^[1] Evans, R S. “Electronic Health Records: Then, Now, and in the Future.”Yearbook of Medical Informatics. Vol. Suppl 1,Suppl 1 S48-61. 20 May. 2016, doi:10.15265/IYS-2016-s006

^[2] Yerokun O et al. “10.15 Development of a Universal Minimum Data Set for Perioperative Care in the Global Setting”. Academic Surgical Congress. 2018. http://www.asc-abstracts.org/abs2018/10-15-development-of-a-universal-minimum-data-set-for-perioperative-care-in-the-global-setting/

^[3] “How HCA is Sniffing Out Sepsis Early.” HCA Today Blog. 10 September 2018. https://hcatodayblog.com/2018/09/10/spot-how-hca-is-sniffing-out-sepsis-early/