The association between epidural labor analgesia and maternal fever remains somewhat controversial despite being supported by evidence in randomized controlled trials, observation and retrospective studies. Perhaps this is because maternal fever during labor itself is a complex and multi-factorial phenomenon, and many criticisms of the studies demonstrating the above association include selection bias, bias in obstetric practice, and faulty study design. Anesthesiologists are often tasked to explain the potential complications of epidural analgesia, and it behooves us to better acquaint ourselves with this often overlooked topic.

Randomized controlled trials comparing intravenous opioid or unmedicated labor to epidural analgesia show that the epidural arm is more likely to experience hyperthermia and overt clinical fever. The increase in temperature is gradual, with women who receive epidural analgesia earlier in labor experiencing greater increases. There is some degree of selection bias in observational studies, as those women who are more at risk for fever (e.g. longer labor, longer duration of ruptured membranes, more frequent cervical examinations) are also more likely to elect for epidural analgesia. However, the randomized controlled trials give stronger support to a causal relationship.

The mechanism is incompletely understood, as not all women who receive an epidural exhibit an increase in core body temperature – only about 20% do. The most consistently supported mechanism is that of noninfectious inflammation mediated by pro-inflammatory cytokines. Less popular theories include altered thermoregulation and avoidance of opioids, which may suppress fever.

The maternal consequences of fever during labor include elevation of heart rate, cardiac output, oxygen consumption and catecholamine production. Shivering and antibiotic exposure are more common in febrile women. Frequently obstetric management is altered, with a higher associated incidence of operative vaginal and cesarean delivery. It is unclear whether the labor pattern is altered by the fever, or it simply influences obstetric decision making in respect to fears of maternal or fetal complications of delaying delivery.

Maternal fever also has fetal effects as well, including fetal hyperthermia. This in turn may be associated with low fetal tone, lower Apgar scores, advanced airway management, cardiopulmonary resuscitation, and neonatal seizure.

Treatment of maternal fever, whether or not associated with epidural analgesia, is therefore important. However, treatment options are limited given the unclear etiology of the fever. Acetaminophen is not effective in suppressing epidural-related maternal fever. High dose methylprednisolone, is effective, however it is impractical given the risk of increased neonatal bacteremia. Therapeutic effects of systemic opioids have also been weak, and carry the complication of possible neonatal respiratory depression.

There is a need for further research into the etiology, prevention and treatment of epidural related maternal fever. In the meantime, anesthesia providers can provide patients with what is known on the topic to help them make an informed decision.

References

Arendt KW, Segal BS. The association between epidural labor analgesia and maternal fever. Clin Perinatol. 2013 Sep;40(3):385-98. doi: 10.1016/j.clp.2013.06.002. Epub 2013 Jul 19.

Segal, S. Labor epidural analgesia and maternal fever. Anesth Analg. 2010 Dec;111(6):1467-75. doi: 10.1213/ANE.0b013e3181f713d4. Epub 2010 Sep 22.

The Centers for Medicare and Medicaid Services (CMS) has released two rule updates that will heavily impact anesthesiology providers in 2018. As previously discussed, CMS is a government agency that administers governmental health programs, providing guidelines for pricing and reimbursement at the state level for Medicare Centers of Excellence and other Medicare/Medicaid-serving providers. Anesthesiology providers, including anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) are subject to such guidelines. Furthermore, CMS as an agency is trending towards providing more specific diagnosis and reimbursement codes for surgical procedures, highlighting the specific anesthesia procedures. The most recent round of Rule Updates supports the trend.

As of Jan 1, 2018, CMS has pronounced that anesthesia for endoscopies are to be affected by a new reimbursement scheme. The decision was driven by a meeting of key stakeholders, that included the Medicare Payment Advisory Commission, the American Society of Anesthesiologists (ASA), and the American Medical Association.

In sum, the rule changes will change services rendered as follows:
1. Endoscopic retrograde cholangio-pancreatography (ECRP) is now a unique code. As such, ECRPs will be reimbursed at a greater base unit as compared to prior to this ruling, at a rate of 6 units versus 5 units. For reference, one unit is roughly 8 minutes to 22 minutes of provider time.
2. Colonoscopies and screening for colonoscopies has been reduced. These procedures will now receive 3-4 units per procedure.

The American Society of Anesthesiologists is particularly active in the CMS space and has advocated heavily for appropriate and equal reimbursement of anesthesiology services. In response to the above Rule Updates, the ASA has released a public statement criticizing the undervaluation of endoscopies. The ASA, after conducting market research among its membership, is assured that these procedures should achieve at least 4 units. While the difference in one unit may seem negligible, in terms of reimbursement it can have grave implications. Sum reimbursement is dependent on the CMS-determined conversion factor; for 2018, CMS has concluded that the anesthesia conversion factor will be 22.1887 USD (a rise from 2017’s 22.0454 USD value), in comparison to an overall resource-based conversion factor of 35.9996 USD. Therefore, to conduct a simple thought exercise, one could imagine 1000 endoscopy procedures occurring per year in an endoscopy suite. At a rate of 5 units per procedure, the net annual reimbursement would equate to 1000 procedures * 5 units per procedure * 22.1887 conversion factor = 110,943.50 USD. However, at the updated CMS rate, this net annual reimbursement would change to 1000 procedures * 3 units per procedure * 22.1887 conversion factor = 66, 566.10 USD, a dramatic decrease. In combination with the fact that many physicians will continue to devote the same amount of time to the procedure, the decreased unit allocation could lead to a severe undervaluing of the physician’s time. Conversely, if the physician or physician’s office aims to achieve reimbursement parity, they must require that physicians minimize the number of minutes they spend per procedure per patient, which can lead to medical error and lapses in safety. From the perspective of the ASA, rule changes which decrease unit allocation for routine procedures is dangerous for the provider, the patient, and the healthcare system as a whole.

The anesthesia space will continue to be impacted by rapid changes in CMS governance. Anesthesiologists, CRNAs, and healthcare administrators must be kept knowledgeable of such changes to keep pace with the rapid innovation present in the American healthcare system.

Sources:
https://www.asahq.org/advocacy/fda-and-washington-alerts/washington-alerts/2017/11/cms-releases-final-rule-for-2018-medicare-physician-fee-schedule
https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html

There is considerable flexibility in decisions made by healthcare facilities concerning anesthesia services, specifically with respect to the employment of physician anesthesiologists and the use of non-physician anesthesia providers. While there are a variety of providers involved with the delivery of anesthesia care, as well as diversity among anesthesia delivery models, anesthesiologists and certified registered nurse anesthetists (CRNAs) are the primary anesthesia provider types. Non-physician providers are increasingly being utilized in today’s anesthesia workforce, and there is a growing influx of women and younger providers into the workforce. Concerns about a provider shortage are also escalating, and regional differences exist throughout the workforce. Understanding these recent trends necessitates examining changes in demography and today’s healthcare sector, specifically in the aging population, the rise of value-based care, and new provider models.

Current demographic changes are influencing the anesthesia workforce and causing shifts in demand, as the growing number of baby boomers retiring as well as an aging U.S. population are causing an increase in the demand for healthcare services, including anesthesia and perioperative care. Additionally, many older, predominantly male anesthesiologists are retiring. There is an influx of younger anesthesiologists, including an increasing number of women, into the field. This trend is expected to continue as older providers retire [1]. The overall number of anesthesia providers continues to shrink, however. These demographic trends, including the  retiring physician population, may increase the shortage of anesthesia providers. Studies on the anesthesia labor market in the U.S. have predicted that the shortage will continue to grow through at least 2025 [2]. This trend is not unique to the U.S., however, as there is currently a global shortage in the surgical and anesthesia workforce leaving five billion people around the world without access to safe, affordable anesthesia and surgical care, according to a WFSA global workforce survey [3].

As concerns about the cost of health care and the physician shortage persist, restructuring the anesthesia workforce to reduce the total personnel costs for anesthesia care is another continuing trend. Restructuring the anesthesia workforce in favor of utilizing more CRNAs has been found to be cost efficient. Increasing the number of anesthetics delivered by CRNAs or the proportion of cases performed under a care team model are two potential cost saving strategies [4]. The use of non-physician anesthesia providers is growing, as are team-based anesthesia delivery models. This shift towards collaborative anesthesia models is in part the result of the current trend in today’s healthcare system of bundled and value-based care. As the team-based approach and CRNA-only services continue to expand, and as more women and younger providers enter the workforce, it is important to understand these recent trends and their potential impact on future workforce dynamics.

SOURCES

The intersection between medicine and technology is a complex, growing, and evolving space that continues to push the boundaries of feasibility. A long-standing product of this intersection is telehealth, which, per the WHO, “involves the use of telecommunications and virtual technology to deliver health care outside of traditional health-care facilities”.[1] Today, telehealth lies at the forefront of medical care delivery in rural America.

Innovations in telehealth have a great potential to minimize the differential between urban and rural areas by increasing people’s access to necessary medical services. These innovations allow for medical service delivery over long distances while facilitating knowledge-sharing and the distribution of medical decision-making across various, remote providers. However, evidence suggests that since the early 20^th century, most innovations in telehealth have never been implemented beyond the pilot stage, despite their viability.[2]

For more specialized services such as anesthesia, the concept of using telehealth is still not entirely new. Reports of preadmission anesthesia or critical care consultations date back to the early 2000s. An example is a 2004 Canadian pilot study showing successful administration of preadmission anesthesia using telehealth technology. In the study, both patients and anesthesiologists were highly satisfied with the consultation experience. Specifically, the use of airway cameras allowed anesthesiologists to asses cardiac and pulmonary health in a similar manner to that of a conventional consultation, but with superior visualization due to illumination. However, there were also notable hindrances, including privacy concerns associated with electronic correspondence and the lack of physical contact between physicians and their patients. [3]

Since then, in 2009, the U.S. government enacted the Health Information technology for Economic and Clinical Health (HITECH) Act to promote and expand the adoption of health IT and the telehealth services. A major component of HITECH was to provide funding to implement telehealth networks for patients in rural and remote areas. [4]

Today, advances in health and communication technologies have allowed anesthesiologists to extend perioperative consultation services to geographically remote areas. Due to the increasing economic pressures on healthcare delivery and the decreased costs and comparable outcomes of telemedicine, the adoption of telehealth services is an increasingly attractive option.[5] It is well-founded to anticipate that the U.S. healthcare system’s quest for equality and efficiency of care will be defined by emerging telehealth technologies.

References

[1] Telehealth. (n.d.). Retrieved February 14, 2018, from http://www.who.int/sustainable-development/health-sector/strategies/telehealth/en/

[2] Alverson, D. C., Shannon, S., Sullivan, E., Prill, A., Effertz, G., Helitzer, D., … & Preston, A. (2004). Telehealth in the trenches: reporting back from the frontlines in rural America. Telemedicine Journal & e-Health, 10(Supplement 2), S-95.

[3] Wong, D. T., Kamming, D., Salenieks, M. E., Go, K., Kohm, C., & Chung, F. (2004). Preadmission anesthesia consultation using telemedicine technology: a pilot study. The Journal of the American Society of Anesthesiologists, 100(6), 1605-1607.

[4] Doarn, C. R., Pruitt, S., Jacobs, J., Harris, Y., Bott, D. M., Riley, W., … & Oliver, A. L. (2014). Federal efforts to define and advance telehealth—a work in progress. Telemedicine and e-Health, 20(5), 409-418.

[5] Galvez, J. A., & Rehman, M. A. (2011). Telemedicine in anesthesia: an update. Current Opinion in Anesthesiology, 24(4), 459-462.

This post is part of a series exploring the issues of ethics in anesthesiology practice.

A well-defined and dutifully upheld code of ethics is a core component of professionalism for most medical specialties. Anesthesiology is no exception and, in fact, deals in uniquely complex ways with ethical issues surrounding medical practice. Anesthesiologists are at the bedside when patients are in their most extreme moments of vulnerability. Pain management and surgical safety are essential to the entire spectrum of illness and treatment. As such, an anesthesiologist is almost always involved when difficult and novel ethical questions arise in medical care. This is one reason that anesthesiologists work under such intense pressure, but also why their work can be so meaningful.

Most patients would agree that, when judging the caliber of their healthcare provider, an ethical approach to medicine is a top priority. The specifications of ethical protocol are laid out by a range of medical associations through careful consensus among top experts. However, the approach to the ethics of care is not always so formalized in medicine. The history of ethics in healthcare is long and multifaceted, but some of the driving forces in furthering the conversation on these challenging topics have come out of the field of anesthesiology practice.

Anesthesiology ethics are not merely an adaption of a broader ethical code in medicine, but rather a movement unto itself that has often set standards for other specialties to follow. To trace its origins, we would begin at the unlikely starting point of Filicudi, Italy, in 1917.

It was then and there that John Bonica was born, the forefather of contemporary anesthesiology practice. Bonica took an unconventional path to his profession. After immigrating to the United States at about ten years of age, Bonica took up wrestling in high school. He then became a professional wrestler as a young adult under the name “The Masked Marvel” and financed his medical education and the launch of his profession. Then, over the course of his career as a military anesthesiologist, he confronted extreme suffering that moved him deeply and inspired a lasting interest in pain management.

In 1953, John Bonica published his seminal work The Management of Pain. The book offered a novel investigation of pain management as a distinct area of study—it is the first textbook of its kind. Following its publication, Bonica continued to work on these themes over his career. In the 60s, he established the first multidisciplinary pain clinic. By 1970, Bonica led the launch of the International Symposium on Pain, which in turn gave rise to the International Association for the Study of Pain (IASP).

Perhaps most importantly, Bonica spoke publicly of pain relief being a human right. His framing of pain management as not only an important discipline of its own right, but also one where human rights were concerned, presents the spirit of ethical anesthesiology that continues to this day. The central mission is to prevent and alleviate pain threads throughout the principles and practice of every anesthesiologist. While Bonica’s leadership in the field helped to foment ethical practice as a central tenant of anesthesiology, you can find similar motivations in the work of contemporaneous anesthesiologists. Because of anesthesiologists’ uniquely proximal role to the experience of pain, it naturally follows that this profession would be leaders in the ethical implications that arise.

Anesthesiology is complex technically, clinically and ethically. As the specialty has grown in numbers, scope of practice, and scientific complexity, so too have the ethical issues that are prompted by these advances. Anesthesiologists will likely continue to face these developments as the field progresses, and in the spirit of Bonica, center their efforts around the ethical treatment of pain.

References:

https://www.iasp-pain.org/AboutIASP/Content.aspx?ItemNumber=1129

http://journalofethics.ama-assn.org/2015/03/fred1-1503.html

http://journalofethics.ama-assn.org.ezp-prod1.hul.harvard.edu/2015/03/pdf/mhst1-1503.pdf