J Med Syst (2015) 39: 48 DOI 10.1007/s10916-015-0226-2
SYSTEMS-LEVEL QUALITY IMPROVEMENT
An Anesthesia Medication Cost Scorecard – Concepts for Individualized Feedback Raymond J. Malapero & Rodney A. Gabriel & Robert Gimlich & Jesse M. Ehrenfeld & Beverly K. Philip & David W. Bates & Richard D. Urman
Received: 29 December 2014 / Accepted: 3 February 2015 / Published online: 3 March 2015 # Springer Science+Business Media New York 2015
Abstract There is a growing emphasis on both cost containment and better quality health care. The creation of better methods for alerting providers and their departments to the costs associated with patient care is one tool for improving efficiency. Since anesthetic medications used in the OR setting are one easily monitored factor contributing to OR costs, anesthetic cost report cards can be used to assess the cost and, potentially the quality of care provided by each practitioner. An ongoing challenge is the identification of the most effective strategies to control costs, promote cost awareness and at the same time maximize quality. To test the scorecard concept, we utilized existing informatics systems to gather and analyze drug costs for anesthesia providers in the OR. Drug costs were analyzed by medication class for each provider. Individual anesthesiologist’s anesthetic costs were collected and compared to the average costs of the overall group and individual trends over time were noted. We presented drug usage data in an electronic report card format. Real-time individual reports
can be provided to anesthesiologists to allow for anesthetic cost feedback. Data provided can include number of cases, average case time, total anesthetic medication costs, and average anesthetic cost per case. Also included can be subcategories of pre-medication, antibiotics, hypnotics, local anesthetics, neuromuscular blocking drugs, analgesics, vasopressors, beta-blockers, anti-emetics, volatile anesthetics, and reversal agents. The concept of anesthetic cost report card should be further developed for individual feedback, and could include many other dimensions. Such a report card can be utilized to encourage lower anesthetic costs, quality improvement among anesthesia providers, and for cost containment in the operating room. Keywords Operating room . Management . Costs . Performance improvement . Report card . Anesthesia . Drugs
Introduction This work attributed to: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston MA This article is part of the Topical Collection on Systems-Level Quality Improvement R. J. Malapero : R. A. Gabriel : R. Gimlich : B. K. Philip : R. D. Urman (*) Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] J. M. Ehrenfeld Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA D. W. Bates Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, USA
The efficiency and cost management of the operating room (OR) is highly integral to hospital finances [1]. The OR represents an expensive part of the hospital, and when it is managed well it can play a key role in creating positive margins for hospitals [2, 3]. Since anesthetic medication costs are one major component of OR expenses, active monitoring of this cost metric is, therefore, invaluable. Minimization of the costs associated with anesthetic medications while keeping medication errors to a minimum is a continuous challenge for health care [4]. Under health care reform, the central notion is to reduce system costs, while at the same time improving quality and safety. Over the years, a small number of studies have explored the drug errors made by anesthesiologists in the OR [4–6], and they have shown that these drugs carry important risk. With fee-for-service reimbursement, however, the main
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issue was that there was little down side to delivering expensive care. Analysis and reporting of anesthetic costs takes a multidisciplinary team of anesthesiologists and pharmacists, working in close collaboration with OR and hospital administrators. Linking pharmacy records with data from anesthesia records allows for both data collection on anesthetic cost, and also increases compliance and documentation accuracy. Both allow for safer patient care and more accurate documentation practices [7, 8]. Proper and accurate clinical documentation is necessary for cost containment and continuous quality improvement. The ability to report anesthetic costs to providers gives them and OR managers the opportunity to analyze and review their anesthetic technique, medication selection, and medication administration. Having the ability to provide feedback is beneficial to providers and their leadership. The term Bfeedback^ is defined as the act of providing knowledge of the results of a behavior or performance to an individual or group. The education and performance of healthcare providers and improvement of the health care system is contingent on having feedback on their practice [9]. The key aspects of effective feedback are trust in the quality of data, verbal and/or graphic feedback delivery, timeliness, confidentiality and educational implementation, and presentation of feedback close to the time of decision-making [10–14]. Whereas passive feedback provides information without a mechanism for requiring subsequent action, active feedback occurs when clinician interest is stimulated and engaged concurrently [15]. Effective use of feedback incorporates an action or response to the feedback to close the identified gap. The implementation of immediate, formal feedback with goal-oriented behavior in the OR setting is optimal [16]. The development of reporting systems in OR management, using informatics systems to gather and analyze anesthetic costs, is essential to the future of anesthesiology practice. The information provided by these data reports will be important not only to individual anesthesiologists, but also to OR managers, pharmacists, and hospital administrators. Prior to this report card, we have published concept papers on utilizing an anesthesia report card covering various aspects of anesthesiology practice such as compliance and credentialing requirements, academic achievements, clinical performance, and OR metrics such as number of canceled cases, average case time, case hours, compliance with timeouts/checklists, surgical antibiotics, and anesthesia record signing [17, 18]. However, this is the first report card focused primarily on anesthetic costs while having the ability to look at specific medication classes and individual medication administration patterns. We hypothesize that this report card will provide useful content on anesthetic costs and provide an effective means for cost containment in the operating room. Additionally, it will allow real-time data and comparison between individual providers.
J Med Syst (2015) 39: 48
Methods In this proof of concept study, we designed a mechanism to report real-time costs of pharmacological agents utilized by individual anesthetic providers during a specific time period. The data analysis was exempted by the Institutional Review Board. The purpose was to provide individual feedback in an effort to raise cost-awareness and decrease anesthetic costs at a large academic center. Aggregate data from the overall group will also be provided so that the providers can compare their performance to that of their colleagues. Ultimately, the facility can effectively track and evaluate the group and the anesthesiologist’s contributions to OR-related costs. The data points included in this cost report were provided by members of the OR leadership management and OR pharmacy leaders. The selected categories were chosen based on pharmacy item and cost tracking and by experts in OR management. As this is a dynamic score card, current cost items could be changed or removed, and new metrics can be added as more items related to anesthetic cost are tracked on a patient-by-patient basis. Other dimensions beyond pharmaceutical costs could also be added. Metrics within the scorecard focus on the costs of commonly used pharmacologic agents during the administration of anesthesia. All costs are reported in US dollars based on our institutional costs. Reports contain data for individual providers and aggregate values. The data reported can be viewed from all surgical cases performed or filtered by specific surgical subdivisions (i.e., neurosurgery). Individual metrics can also be compared to all anesthetic providers using the same filters. For each provider, data was provided both monthly and quarterly. Reporting was adjusted for type of case, length of case, ASA physical status classification, BMI, and patient age. Basic summary data was provided including number of cases, total case time, and average case time from OR management. The report card then provided a total anesthetic medication cost and average anesthetic cost per case. Anesthetic medication costs were provided through the OR pharmacy database. To further analyze medications costs, medication usage was subcategorized into antibiotics, volatile anesthetics, hypnotics, neuromuscular blocking drugs, analgesics, vasopressors, and anti-emetics. Each of these categories can be further categorized by individual medication cost and usage. We chose medication and doses commonly distributed at our institution. Each of these metrics were calculated for an individual, and compared to the overall total group, based on surgical subspecialty for peer-comparison.
Results Individual and group anesthetic costs were provided via our proposed report card. This report card provides the individual
J Med Syst (2015) 39: 48
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cost breakdown by provider. Figure 1 displays the format of the report card. Each report card allows the anesthesiologist to monitor their costs on both a monthly and quarterly basis. Anesthetic providers at our institution can access the report card at any time, and comparison data was provided and compared to their peers. Figure 2 provides an example of a report card with real data. Total cost data was displayed along with number of cases, total case time, average case time, and average cost per anesthetic. Clinicians have full access to updated report cards allowing frequent feedback to clinicians for their costs over the past month and quarter. The reports were broken down based on
surgical service (i.e., orthopedics, cardiac, neurosurgery, general) as different OR subspecialty cases can incur different anesthetic costs and to allow peer comparison. These real-time reports were also available to management and supervisors allowing them to monitor and intervene where anesthetic costs were not on par with other subspecialty anesthetic costs.
Fig. 1 Anesthetic Pharmacologic Cost Report Card. This figure demonstrates the general structure of the report card. a. Total case values are listed and allow for adjustment against peer group. b. Costs by category
for the individual and the group are listed in each column. Monthly and quarterly averages are presented in a color-coordinated chart
Discussion Anesthetic costs represent a significant contributor to operating room costs, which are in turn a major factor in hospital
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J Med Syst (2015) 39: 48
Fig. 2 Sample data from an anesthesia provider. a. This displays the potential summative data that can be reported to a provider, and their monthly and quarterly cost comparison to the group based on cases performed in the ambulatory suite. Additionally, comparison data for cost adjustment is included. Darker colored boxes indicate values
increased in comparison to the group monthly or quarterly average. b. Costs data is presented as a break down by medication class and individual medication. Darker colored boxes indicate values increased in comparison to the group monthly or quarterly average
revenue. To improve their performance, anesthetic providers need tools to identify areas where excess expenses are created. Ideally, these tools will allow identification of variation across a range of domains and enable peer comparisons and include both cost and quality data. The proposed prototype begins to address these needs and furthermore offers a way to provide this information quickly and efficiently to both front-line providers and administrators. Routine analysis and group comparison allows providers to see how they compare with each other, and allows for the evaluation and correction of inefficiencies. As healthcare institutions continue to be faced with decreasing revenues and the pressure to cut costs, the ability to analyze anesthetic costs individually, by group, across the
department, and by classes and individual medications becomes a powerful tool to reel in costs. The ability to have an automated system with accurate data gives the opportunity for frequent review and evaluation of cost saving protocol implementation by leadership. This innovative report card also allows the pharmacy to compare charted anesthetic records with pharmacy records to encourage consistency in documentation and pharmacy reconciliation. Having these capabilities creates a better environment for improved patient care and quality. Additionally, using the electronic anesthesia record, medication transfer compliance can be easily reviewed. Tighter monitoring of controlled substances and medication reconciliation can be
J Med Syst (2015) 39: 48
easily realized, and more importantly this encourages better patient care as documentation accuracies and compliance will be reported. Anesthesia as a specialty is rapidly embracing a culture of constant feedback in relation to our practice and patient care. Taking that feedback and utilizing it in a way to improve the care we provide our patients is key to the competency of medicine, and it is often cited in our ethical and professional responsibilities. Providers should review and actively improve their practice based on the feedback they received from their report cards. Additionally, the OR management should also make providers accountable for their costs. This is especially true when medication costs are subtracted from the main OR, rather than anesthesia department budget, placing the onus on the hospital leadership to encourage cost-effective practices. Creating an environment of routine feedback encourages buyin from all participants [17]. Unfortunately, feedback can also create negative feelings in the forms of constructive feedback and comparison to peers [19]. The report card needs to be encouraged by leadership and presented as a positive addition to the clinical environment. Feedback should be part of a physician’s lifelong learning, and is being ingrained in physicians from their earliest level of training. Resident feedback in real-time in comparison to their co-residents is well received and often desired by trainees so they can compare their performance to their peers on quality metrics [20]. Establishing a culture of physician improvement should be department wide and across the scope of patient care. It is a leading factor in physician improvement [17]. Feedback is most successful when it is both real-time and ongoing, thus giving the opportunity to detect cost issues early and prevent future issues in anesthetic costs. Our report card provides the anesthesiologist a chance to review their individual costs per anesthetic, average costs per case, costs by medication class, and by individual medication. Real-time data collection for reporting will make constant feedback and the ability for management and self-evaluation possible at any time. This reflects the constantly changing dynamic of the OR and health system. The report card is a template to provide timely and useful feedback to decrease anesthetic costs at the individual and group level. The ultimate goal of patient care is safety, and it should be kept in mind that cost containment should always be practiced with a priority for patient safety. Quantitative and graphical comparison with peers allows clinicians to share among their colleagues their use of medications in a safe yet cost efficient manner. The use of regular reporting also can increase patient care and decrease anesthetic costs by way of the so-called Hawthorne Effect. This famous industrial experiment highlighted how the effect of increased supervision from superiors or colleagues can cause an intentional or unintentional improvement in human behaviors or performance [21]. This effect has been seen in the healthcare setting where
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improvement in hand hygiene is demonstrated when employees think they are being monitored, and can even create a lasting effect after monitoring is removed [22]. This unintended consequence of the report card can create a shift towards improvement in costs and care as anesthesiologists know their superiors are reviewing their report cards. Even with all the benefits this report card provides, this tool does have specific limitations. Some anesthesiologists may have a majority of their caseloads in a particular subspecialty area, such as cardiac, orthopedic, or neurological surgery. Their cases may dictate a higher level acuity of patients or particular anesthetic technique, as mentioned above. Some anesthesiologists also have a higher number of shorter cases with a higher ratio of induction, reversal, and anti-emetic medication use than providers in longer cases. Anesthetics requiring multiple modes of anesthesia may also have increased costs, for example patients undergoing a regional technique with sedation. The cost of antibiotics is also usually out of the anesthesiologist’s control as they are dictated by type of surgery and hospital antibiotic guidelines. Our report card allows for more comparable peer groups by providing subspecialtyspecific comparison of costs and adjusting for patient age, BMI, and ASA physical status classification. During normal practice, anesthesiologists may experience a period of time where they have higher acuity patients or more challenging, complicated cases with higher preoperative complication risks. These anesthetics may be inherently more expensive requiring more medications for management, or requiring specific techniques such as total intravenous anesthetics of bariatric protocols. The use of timeaveraged cost reporting and comparisons helps to average out these cases over the general caseload of an individual anesthesiologist. This will also hopefully allow for reasonable comparisons with the peer group. We suggest that different health care entities try to work within their medical record systems to obtain data to produce their own valuable reporting. However, we recognize that not all entities have electronic medical records, and some may be unable to utilize their system for such reports. This creates a challenge to creating a system for reporting across a multitude of platforms. This may pose an IT challenge to some health care sites, but sites that have efficient data collection systems will find this tool highly valuable. This concept study has several limitations. The number of domains addressed was limited, and could be extended to many other areas beyond medications. It will be helpful to link such information to quality and even outcome information in the future. Furthermore, getting providers and administrators to utilize such tools—even if they are developed—is not easy, and this may be best accomplished if providers in particular receive some training in continuous quality improvement. It will also become possible in the future to use some of the techniques being developed to analyze Bbig data,^
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which allow consideration of multiple data streams simultaneously. Another large limitation is the ability to quantify volatile anesthetic costs as they are the most highly utilized general anesthetic agent and contribute significantly to anesthetic cost. Utilizing electronic anesthesia records, cost can be calculated utilizing the fresh gas flow, volatile concentration, and time, but these calculations are estimates and may not be accurate or have anesthetic records that can input this information. Newer anesthesia delivery systems utilize calculations within the machine that let the provider know their volatile cost. These systems would allow for more accurate volatile cost, and may even be able to be included in these reports. Finally, intermittent national drug shortages may affect practice patterns among providers. In summary, we believe continuous, effective review and feedback will be integral to reducing anesthesia costs while improving the standard of patient care. The OR continues to be one of the largest contributors to the financial success of the hospital; however, it can also be the most expensive unit in the hospital for patient care. For hospitals in particular financial success can be greatly impacted by reining in OR costs. Continued introduction and development of anesthesia information management systems for daily anesthesia practice will enable further research into anesthetic cost determinants and the impact of cost savings on patient care. Continuous, effective review and feedback will continue to become integral to valued-based anesthesia care. Financial Support None Meetings at which work has been previously presented: none
References 1. Krupka, D. C., and Sandberg, W. S., Operating room design and its impact on operating room economics. Curr Opin Anaesthesiol 19(2): 185–91, 2006. 2. Cima, R. R., Brown, M. J., Hebl, J. R., Moore, R., Rogers, J. C., Kollengode, A., et al., Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg 213(1):83–92, 2011. discussion 3–4. 3. Kodali, B. S., Kim, D., Bleday, R., Flanagan, H., and Urman, R. D., Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center. J Surg Res 187(2): 403–11, 2014. 4. Webster, C. S., Merry, A. F., Larsson, L., McGrath, K. A., and Weller, J., The frequency and nature of drug adminstration error during anaesthesia. Anaesthesia and Intensive Care 29(5):494–500, 2001. 5. Fasting, F., and Gisvold, S. E., Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anaesth 47(11):1060– 1067, 2000.
J Med Syst (2015) 39: 48 6. Orser, B. A., Chen, R. J. B., and Yee, D. A., Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anaesth 48(2):139–146, 2001. 7. Gottlieb, O., Anesthesia information management systems in the ambulatory setting: benefits and challenges. Anesthesiol Clin 32(2): 559–576, 2014. 8. Avidan, A., Dotan, K., Weissman, C., Cohen, M. J., and Levin, P. D., Accuracy of manual entry of drug administration data into an anesthesia information management system. Can J Anaesth 61(11):979– 985, 2014. 9. Willig, J. H., Krawitz, M., Panjamapirom, A., Ray, M. N., Nevin, C. R., English, T. M., et al., Closing the feedback loop: an interactive voice response system to provide follow-up and feedback in primary care settings. Journal of medical systems 37(2):9905, 2013. 10. van der Veer, S. N., de Keizer, N. F., Ravelli, A. C., Tenkink, S., and Jager, K. J., Improving quality of care. A systematic review on how medical registries provide information feedback to health care providers. Int J Med Inform. 79(5):305–23, 2010. 11. de Vos, M., Graafmans, W., Kooistra, M., Meijboom, B., Van Der Voort, P., and Westert, G., Using quality indicators to improve hospital care: a review of the literature. Int J Qual Health Care 21(2):119– 29, 2009. 12. Hysong, S. J., Meta-analysis: audit and feedback features impact effectiveness on care quality. Med Care 47(3):356–63, 2009. 13. Jamtvedt, G., Young, J. M., Kristoffersen, D. T., O’Brien, M. A., and Oxman, A. D., Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care 15(6):433–6, 2006. 14. Veloski, J., Boex, J. R., Grasberger, M. J., Evans, A., and Wolfson, D. B., Systematic review of the literature on assessment, feedback and physicians’ clinical performance: BEME Guide No. 7. Med Teach 28(2):117–28, 2006. 15. Mugford, M., Banfield, P., and O’Hanlon, M., Effects of feedback of information on clinical practice: a review. BMJ 303(6799):398–402, 1991. 16. Kaye, A. D., Okanlawon, O. J., and Urman, R. D., Clinical performance feedback and quality improvement opportunities for perioperative physicians. Adv Med Educ Pract. 5:115–23, 2014. 17. Peccora, C. D., Gimlich, R., Cornell, R. P., Vacanti, C. A., Ehrenfeld, J. M., and Urman, R. D., Anesthesia report card - a customizable tool for performance improvement. Journal of medical systems 38(9):105, 2014. 18. Gabriel, R. A., Gimlich, R., Ehrenfeld, J. M., and Urman, R. D., Operating room metrics score card-creating a prototype for individualized feedback. J Med Syst 38(11):144, 2014. 19. Heidegger, T., Husemann, Y., Nuebling, M., Morf, D., Sieber, T., Huth, A., et al., Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria. British Journal of Anaesthesia 89(6):863–72, 2002. 20. Ehrenfeld, J. M., McEvoy, M. D., Furman, W. R., Snyder, D., and Sandberg, W. S., Automated near-real-time clinical performance feedback for anesthesiology residents: one piece of the milestones puzzle. Anesthesiology 120(1):172–84, 2014. 21. Hindle, T. Idea: The Hawthorne effect. The Economist: Guide to Management Ideas and Gurus: 2008, 322. 22. Srigley, J. A., Gardam, M., Fernie, G., Lightfood, D., Lebovic, G., and Muller, M. P., Hand hygiene monitoring technology: a systematic review of efficacy. Journal of Hospital Infection 89(1):51–60, 2015.
SYSTEMS-LEVEL QUALITY IMPROVEMENT
An Anesthesia Medication Cost Scorecard – Concepts for Individualized Feedback Raymond J. Malapero & Rodney A. Gabriel & Robert Gimlich & Jesse M. Ehrenfeld & Beverly K. Philip & David W. Bates & Richard D. Urman
Received: 29 December 2014 / Accepted: 3 February 2015 / Published online: 3 March 2015 # Springer Science+Business Media New York 2015
Abstract There is a growing emphasis on both cost containment and better quality health care. The creation of better methods for alerting providers and their departments to the costs associated with patient care is one tool for improving efficiency. Since anesthetic medications used in the OR setting are one easily monitored factor contributing to OR costs, anesthetic cost report cards can be used to assess the cost and, potentially the quality of care provided by each practitioner. An ongoing challenge is the identification of the most effective strategies to control costs, promote cost awareness and at the same time maximize quality. To test the scorecard concept, we utilized existing informatics systems to gather and analyze drug costs for anesthesia providers in the OR. Drug costs were analyzed by medication class for each provider. Individual anesthesiologist’s anesthetic costs were collected and compared to the average costs of the overall group and individual trends over time were noted. We presented drug usage data in an electronic report card format. Real-time individual reports
can be provided to anesthesiologists to allow for anesthetic cost feedback. Data provided can include number of cases, average case time, total anesthetic medication costs, and average anesthetic cost per case. Also included can be subcategories of pre-medication, antibiotics, hypnotics, local anesthetics, neuromuscular blocking drugs, analgesics, vasopressors, beta-blockers, anti-emetics, volatile anesthetics, and reversal agents. The concept of anesthetic cost report card should be further developed for individual feedback, and could include many other dimensions. Such a report card can be utilized to encourage lower anesthetic costs, quality improvement among anesthesia providers, and for cost containment in the operating room. Keywords Operating room . Management . Costs . Performance improvement . Report card . Anesthesia . Drugs
Introduction This work attributed to: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston MA This article is part of the Topical Collection on Systems-Level Quality Improvement R. J. Malapero : R. A. Gabriel : R. Gimlich : B. K. Philip : R. D. Urman (*) Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] J. M. Ehrenfeld Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA D. W. Bates Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, USA
The efficiency and cost management of the operating room (OR) is highly integral to hospital finances [1]. The OR represents an expensive part of the hospital, and when it is managed well it can play a key role in creating positive margins for hospitals [2, 3]. Since anesthetic medication costs are one major component of OR expenses, active monitoring of this cost metric is, therefore, invaluable. Minimization of the costs associated with anesthetic medications while keeping medication errors to a minimum is a continuous challenge for health care [4]. Under health care reform, the central notion is to reduce system costs, while at the same time improving quality and safety. Over the years, a small number of studies have explored the drug errors made by anesthesiologists in the OR [4–6], and they have shown that these drugs carry important risk. With fee-for-service reimbursement, however, the main
48 Page 2 of 6
issue was that there was little down side to delivering expensive care. Analysis and reporting of anesthetic costs takes a multidisciplinary team of anesthesiologists and pharmacists, working in close collaboration with OR and hospital administrators. Linking pharmacy records with data from anesthesia records allows for both data collection on anesthetic cost, and also increases compliance and documentation accuracy. Both allow for safer patient care and more accurate documentation practices [7, 8]. Proper and accurate clinical documentation is necessary for cost containment and continuous quality improvement. The ability to report anesthetic costs to providers gives them and OR managers the opportunity to analyze and review their anesthetic technique, medication selection, and medication administration. Having the ability to provide feedback is beneficial to providers and their leadership. The term Bfeedback^ is defined as the act of providing knowledge of the results of a behavior or performance to an individual or group. The education and performance of healthcare providers and improvement of the health care system is contingent on having feedback on their practice [9]. The key aspects of effective feedback are trust in the quality of data, verbal and/or graphic feedback delivery, timeliness, confidentiality and educational implementation, and presentation of feedback close to the time of decision-making [10–14]. Whereas passive feedback provides information without a mechanism for requiring subsequent action, active feedback occurs when clinician interest is stimulated and engaged concurrently [15]. Effective use of feedback incorporates an action or response to the feedback to close the identified gap. The implementation of immediate, formal feedback with goal-oriented behavior in the OR setting is optimal [16]. The development of reporting systems in OR management, using informatics systems to gather and analyze anesthetic costs, is essential to the future of anesthesiology practice. The information provided by these data reports will be important not only to individual anesthesiologists, but also to OR managers, pharmacists, and hospital administrators. Prior to this report card, we have published concept papers on utilizing an anesthesia report card covering various aspects of anesthesiology practice such as compliance and credentialing requirements, academic achievements, clinical performance, and OR metrics such as number of canceled cases, average case time, case hours, compliance with timeouts/checklists, surgical antibiotics, and anesthesia record signing [17, 18]. However, this is the first report card focused primarily on anesthetic costs while having the ability to look at specific medication classes and individual medication administration patterns. We hypothesize that this report card will provide useful content on anesthetic costs and provide an effective means for cost containment in the operating room. Additionally, it will allow real-time data and comparison between individual providers.
J Med Syst (2015) 39: 48
Methods In this proof of concept study, we designed a mechanism to report real-time costs of pharmacological agents utilized by individual anesthetic providers during a specific time period. The data analysis was exempted by the Institutional Review Board. The purpose was to provide individual feedback in an effort to raise cost-awareness and decrease anesthetic costs at a large academic center. Aggregate data from the overall group will also be provided so that the providers can compare their performance to that of their colleagues. Ultimately, the facility can effectively track and evaluate the group and the anesthesiologist’s contributions to OR-related costs. The data points included in this cost report were provided by members of the OR leadership management and OR pharmacy leaders. The selected categories were chosen based on pharmacy item and cost tracking and by experts in OR management. As this is a dynamic score card, current cost items could be changed or removed, and new metrics can be added as more items related to anesthetic cost are tracked on a patient-by-patient basis. Other dimensions beyond pharmaceutical costs could also be added. Metrics within the scorecard focus on the costs of commonly used pharmacologic agents during the administration of anesthesia. All costs are reported in US dollars based on our institutional costs. Reports contain data for individual providers and aggregate values. The data reported can be viewed from all surgical cases performed or filtered by specific surgical subdivisions (i.e., neurosurgery). Individual metrics can also be compared to all anesthetic providers using the same filters. For each provider, data was provided both monthly and quarterly. Reporting was adjusted for type of case, length of case, ASA physical status classification, BMI, and patient age. Basic summary data was provided including number of cases, total case time, and average case time from OR management. The report card then provided a total anesthetic medication cost and average anesthetic cost per case. Anesthetic medication costs were provided through the OR pharmacy database. To further analyze medications costs, medication usage was subcategorized into antibiotics, volatile anesthetics, hypnotics, neuromuscular blocking drugs, analgesics, vasopressors, and anti-emetics. Each of these categories can be further categorized by individual medication cost and usage. We chose medication and doses commonly distributed at our institution. Each of these metrics were calculated for an individual, and compared to the overall total group, based on surgical subspecialty for peer-comparison.
Results Individual and group anesthetic costs were provided via our proposed report card. This report card provides the individual
J Med Syst (2015) 39: 48
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cost breakdown by provider. Figure 1 displays the format of the report card. Each report card allows the anesthesiologist to monitor their costs on both a monthly and quarterly basis. Anesthetic providers at our institution can access the report card at any time, and comparison data was provided and compared to their peers. Figure 2 provides an example of a report card with real data. Total cost data was displayed along with number of cases, total case time, average case time, and average cost per anesthetic. Clinicians have full access to updated report cards allowing frequent feedback to clinicians for their costs over the past month and quarter. The reports were broken down based on
surgical service (i.e., orthopedics, cardiac, neurosurgery, general) as different OR subspecialty cases can incur different anesthetic costs and to allow peer comparison. These real-time reports were also available to management and supervisors allowing them to monitor and intervene where anesthetic costs were not on par with other subspecialty anesthetic costs.
Fig. 1 Anesthetic Pharmacologic Cost Report Card. This figure demonstrates the general structure of the report card. a. Total case values are listed and allow for adjustment against peer group. b. Costs by category
for the individual and the group are listed in each column. Monthly and quarterly averages are presented in a color-coordinated chart
Discussion Anesthetic costs represent a significant contributor to operating room costs, which are in turn a major factor in hospital
48 Page 4 of 6
J Med Syst (2015) 39: 48
Fig. 2 Sample data from an anesthesia provider. a. This displays the potential summative data that can be reported to a provider, and their monthly and quarterly cost comparison to the group based on cases performed in the ambulatory suite. Additionally, comparison data for cost adjustment is included. Darker colored boxes indicate values
increased in comparison to the group monthly or quarterly average. b. Costs data is presented as a break down by medication class and individual medication. Darker colored boxes indicate values increased in comparison to the group monthly or quarterly average
revenue. To improve their performance, anesthetic providers need tools to identify areas where excess expenses are created. Ideally, these tools will allow identification of variation across a range of domains and enable peer comparisons and include both cost and quality data. The proposed prototype begins to address these needs and furthermore offers a way to provide this information quickly and efficiently to both front-line providers and administrators. Routine analysis and group comparison allows providers to see how they compare with each other, and allows for the evaluation and correction of inefficiencies. As healthcare institutions continue to be faced with decreasing revenues and the pressure to cut costs, the ability to analyze anesthetic costs individually, by group, across the
department, and by classes and individual medications becomes a powerful tool to reel in costs. The ability to have an automated system with accurate data gives the opportunity for frequent review and evaluation of cost saving protocol implementation by leadership. This innovative report card also allows the pharmacy to compare charted anesthetic records with pharmacy records to encourage consistency in documentation and pharmacy reconciliation. Having these capabilities creates a better environment for improved patient care and quality. Additionally, using the electronic anesthesia record, medication transfer compliance can be easily reviewed. Tighter monitoring of controlled substances and medication reconciliation can be
J Med Syst (2015) 39: 48
easily realized, and more importantly this encourages better patient care as documentation accuracies and compliance will be reported. Anesthesia as a specialty is rapidly embracing a culture of constant feedback in relation to our practice and patient care. Taking that feedback and utilizing it in a way to improve the care we provide our patients is key to the competency of medicine, and it is often cited in our ethical and professional responsibilities. Providers should review and actively improve their practice based on the feedback they received from their report cards. Additionally, the OR management should also make providers accountable for their costs. This is especially true when medication costs are subtracted from the main OR, rather than anesthesia department budget, placing the onus on the hospital leadership to encourage cost-effective practices. Creating an environment of routine feedback encourages buyin from all participants [17]. Unfortunately, feedback can also create negative feelings in the forms of constructive feedback and comparison to peers [19]. The report card needs to be encouraged by leadership and presented as a positive addition to the clinical environment. Feedback should be part of a physician’s lifelong learning, and is being ingrained in physicians from their earliest level of training. Resident feedback in real-time in comparison to their co-residents is well received and often desired by trainees so they can compare their performance to their peers on quality metrics [20]. Establishing a culture of physician improvement should be department wide and across the scope of patient care. It is a leading factor in physician improvement [17]. Feedback is most successful when it is both real-time and ongoing, thus giving the opportunity to detect cost issues early and prevent future issues in anesthetic costs. Our report card provides the anesthesiologist a chance to review their individual costs per anesthetic, average costs per case, costs by medication class, and by individual medication. Real-time data collection for reporting will make constant feedback and the ability for management and self-evaluation possible at any time. This reflects the constantly changing dynamic of the OR and health system. The report card is a template to provide timely and useful feedback to decrease anesthetic costs at the individual and group level. The ultimate goal of patient care is safety, and it should be kept in mind that cost containment should always be practiced with a priority for patient safety. Quantitative and graphical comparison with peers allows clinicians to share among their colleagues their use of medications in a safe yet cost efficient manner. The use of regular reporting also can increase patient care and decrease anesthetic costs by way of the so-called Hawthorne Effect. This famous industrial experiment highlighted how the effect of increased supervision from superiors or colleagues can cause an intentional or unintentional improvement in human behaviors or performance [21]. This effect has been seen in the healthcare setting where
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improvement in hand hygiene is demonstrated when employees think they are being monitored, and can even create a lasting effect after monitoring is removed [22]. This unintended consequence of the report card can create a shift towards improvement in costs and care as anesthesiologists know their superiors are reviewing their report cards. Even with all the benefits this report card provides, this tool does have specific limitations. Some anesthesiologists may have a majority of their caseloads in a particular subspecialty area, such as cardiac, orthopedic, or neurological surgery. Their cases may dictate a higher level acuity of patients or particular anesthetic technique, as mentioned above. Some anesthesiologists also have a higher number of shorter cases with a higher ratio of induction, reversal, and anti-emetic medication use than providers in longer cases. Anesthetics requiring multiple modes of anesthesia may also have increased costs, for example patients undergoing a regional technique with sedation. The cost of antibiotics is also usually out of the anesthesiologist’s control as they are dictated by type of surgery and hospital antibiotic guidelines. Our report card allows for more comparable peer groups by providing subspecialtyspecific comparison of costs and adjusting for patient age, BMI, and ASA physical status classification. During normal practice, anesthesiologists may experience a period of time where they have higher acuity patients or more challenging, complicated cases with higher preoperative complication risks. These anesthetics may be inherently more expensive requiring more medications for management, or requiring specific techniques such as total intravenous anesthetics of bariatric protocols. The use of timeaveraged cost reporting and comparisons helps to average out these cases over the general caseload of an individual anesthesiologist. This will also hopefully allow for reasonable comparisons with the peer group. We suggest that different health care entities try to work within their medical record systems to obtain data to produce their own valuable reporting. However, we recognize that not all entities have electronic medical records, and some may be unable to utilize their system for such reports. This creates a challenge to creating a system for reporting across a multitude of platforms. This may pose an IT challenge to some health care sites, but sites that have efficient data collection systems will find this tool highly valuable. This concept study has several limitations. The number of domains addressed was limited, and could be extended to many other areas beyond medications. It will be helpful to link such information to quality and even outcome information in the future. Furthermore, getting providers and administrators to utilize such tools—even if they are developed—is not easy, and this may be best accomplished if providers in particular receive some training in continuous quality improvement. It will also become possible in the future to use some of the techniques being developed to analyze Bbig data,^
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which allow consideration of multiple data streams simultaneously. Another large limitation is the ability to quantify volatile anesthetic costs as they are the most highly utilized general anesthetic agent and contribute significantly to anesthetic cost. Utilizing electronic anesthesia records, cost can be calculated utilizing the fresh gas flow, volatile concentration, and time, but these calculations are estimates and may not be accurate or have anesthetic records that can input this information. Newer anesthesia delivery systems utilize calculations within the machine that let the provider know their volatile cost. These systems would allow for more accurate volatile cost, and may even be able to be included in these reports. Finally, intermittent national drug shortages may affect practice patterns among providers. In summary, we believe continuous, effective review and feedback will be integral to reducing anesthesia costs while improving the standard of patient care. The OR continues to be one of the largest contributors to the financial success of the hospital; however, it can also be the most expensive unit in the hospital for patient care. For hospitals in particular financial success can be greatly impacted by reining in OR costs. Continued introduction and development of anesthesia information management systems for daily anesthesia practice will enable further research into anesthetic cost determinants and the impact of cost savings on patient care. Continuous, effective review and feedback will continue to become integral to valued-based anesthesia care. Financial Support None Meetings at which work has been previously presented: none
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