Bio

Bio


Alex Macario grew up the first decade of his life in Europe as his parents are scientists and held different positions in Sweden, Italy, and France. He finished high school in Albany NY and went to the University of Rochester on a Joseph C. Wilson Scholarship .

Dr. Macario completed his undergraduate, medical school and business school education at the University of Rochester. He then trained in the anesthesiology residency at Stanford University, went on to serve as Chief Resident, and completed a postgraduate fellowship in health services research.

Dr. Macario is Professor in the Department of Anesthesiology, Perioperative and Pain Medicine and, by courtesy, also in the Department of Health Research and Policy at the Stanford University School of Medicine.

Dr. Macario is Vice-Chair for Education and Program Director for the Anesthesia Residency which has more than 80 housestaff. He has led the building of several new and innovative education initiatives including: 1) the Stanford Fellowship in Anesthesia Research and Medicine Program (http://med.stanford.edu/anesthesia/education/residentresearch.html) which is a research intensive track within the main residency, and 2) the Stanford Anesthesia Teaching Scholars Program (http://med.stanford.edu/anesthesia/education/teaching_scholars.html) to improve pedagogical training of faculty.

Dr. Macario's research career has been dedicated to the economics of health care, in particular the tradeoffs between costs and outcomes for patients having surgery and anesthesia. Dr. Macario has completed internationally recognized studies on the management of the operating room suite, as well as pioneering work on the cost-effectiveness of drugs and devices.

He is founder (in 1996) and director of the Management Fellowship, a postgraduate program which trains several physicians each year in areas such as leadership, informatics, entrepreneurship, quality, and management science with special attention to the delivery of surgical and anesthesia care.

Dr. Macario has also authored "A Sabbatical in Madrid: A Diary of Spain," an award winning travel memoir. Dr. Macario has two children in college and lives with his wife in their home on the Stanford Campus. In his free time Dr. Macario enjoys rooting for Stanford sports, biking up the local hills, and hitting tennis balls.

Clinical Focus


  • Anesthesia
  • multispecialty division including anesthesia for orthopedics, urology, neurosurgery, and general surgery

Academic Appointments


Administrative Appointments


  • Program Director, Combined internal medicine anesthesiology residency (2013 - Present)
  • Director, CME Grand Rounds Program, Department of Anesthesiology (2010 - Present)
  • Associate Program Director, Combined Pediatrics and Anesthesia Residency (2010 - Present)
  • Director, Faculty Teaching Scholars Program, Department of Anesthesiology (2007 - Present)
  • Vice-Chairman for Education, Department of Anesthesia (2006 - Present)
  • Program Director, Anesthesiology Residency (2006 - Present)
  • Program Director, Management of Perioperative Services Fellowship (1996 - Present)
  • Executive Committee, Faculty Senate, Stanford University School of Medicine (2007 - 2012)
  • Editorial Board, Anesthesiology Research and Practice (2007 - Present)
  • Editorial Board, Anesthesiology News (1999 - Present)
  • Editor, Stanford Anesthesia News (Alumni Publication) (2001 - 2006)

Honors & Awards


  • First place, “best article”, Journal of Medical Internet Research: 4th World Congress on Social Media & Web 2.0 Health & Medicine (2012)
  • Education Advisory Board, Association of University Anesthesiologists (2012)
  • Charter member, Education Academy, Foundation for Anesthesia Education & Research (2012)
  • Ellis N. Cohen Achievement Award (Department of Anesthesiology highest honor), Stanford University (2009)
  • Keynote speaker, American Association of Clinical Directors Annual Meeting (2007)
  • 1st place, Literature Prize, American Society of Anesthesiology Annual Meeting (2004)
  • Annual Resident Research Prize, 3rd Place, American Society of Anesthesiologists (1995)
  • Valdes - Dapena Research Prize, The Graduate Hospital, University of Pennsylvania (1991)
  • Phi Beta Kappa, University of Rochester (1986)
  • Graduation Speaker, College of Arts & Sciences, University of Rochester (1986)
  • Rigby - Wile Prize in Biology, University of Rochester (1985)
  • Joseph C. Wilson Scholar, University of Rochester (1982)

Boards, Advisory Committees, Professional Organizations


  • Examiner, American Board of Anesthesiology (2011 - Present)
  • Editorial Board, http://www.medscape.com/anesthesiology (2010 - Present)
  • Committee on Professional Diversity, American Society of Anesthesiology, Mentor Program (2010 - Present)
  • Editorial Board, Anesthesiology Research and Practice (2007 - Present)
  • Editorial Board, Cochrane Collaboration: Pain, Palliative and Supportive Care Group (2004 - Present)
  • Member, Association of University Anesthesiologists (honorific society) (2000 - Present)

Professional Education


  • Board Certification: Anesthesia, American Board of Anesthesiology (1995)
  • Fellowship:Stanford University Medical Center (1995) CA
  • Chief Resident, Stanford University, Anesthesiology (1994)
  • Residency:Stanford University School of Medicine (1994) CA
  • Internship:Graduate Hospital (1991) PA
  • Medical Education:University of Rochester (1990) NY
  • MBA, University of Rochester, Health Economics (1988)
  • BA, University of Rochester, Sociology (1986)

Community and International Work


  • Zimbabwe Global Health elective for anesthesia residency

    Topic

    Anesthesiology

    Partnering Organization(s)

    University of Zimbabwe College of Health Sciences, Department of Anesthesiology

    Populations Served

    Housestaff

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

  • Postgraduate Fellowship in Global Health

    Topic

    Faculty

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

  • Global Health Trip 1994, Vietnam

    Topic

    Anesthesia for cleft lip and palate surgery on children

    Partnering Organization(s)

    Interplast

    Populations Served

    Pediatrics

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

Research & Scholarship

Current Research and Scholarly Interests


Dr. Macario is interested in the economics of health care, in particular the tradeoffs between costs and outcomes for patients having surgery and anesthesia. Dr. Macario has completed internationally recognized studies on the management of the operating room suite, as well as pioneering work on the cost-effectiveness of drugs and devices. He is Founder and Director of a Postgraduate Fellowship for physicians interested in applying quantitative tools to solve health services research questions.

Dr. Macario's research team has several ongoing projects including:
1. Economics of Fiberscope Use for Tracheal Intubation
2. Waste in the operating room: can we do better?
3. Anesthesia resident education: Web 2.0
4. Anesthesia Information Management Systems
5. Translating what is known to work in medicine to actual care being delivered to patients: what are the barriers?
6. Complex Event Processing (CEP) for the detection of Sepsis
7. Anesthesia Complications Incidence Report from 500,000 Anesthetics
8. Mobile Applications for Health Care
9. Data analytics in health care and surgery and anesthesia
10. Analysis of Online Physician-Review Sites

Clinical Trials


  • A Randomized Controlled Study of Rolapitant for the Prevention of Nausea and Vomiting Following Surgery (Study P04937AM1)(COMPLETED) Not Recruiting

    This is a multicenter, randomized, controlled study in women who are having elective open abdominal surgery with general anesthesia and who are expected to need patient-controlled analgesia (PCA) after surgery. The primary objective is to assess the effect of rolapitant in the prevention of postoperative nausea and vomiting as measured by the prevention of vomiting in the first 24 hours after surgery. Participation in the study may last up to 3 months. The total duration of the study will be approximately 36 weeks.

    Stanford is currently not accepting patients for this trial. For more information, please contact David Drover, (650) 725 - 0364.

    View full details

Teaching

2013-14 Courses


Postdoctoral Advisees


Graduate and Fellowship Programs


Publications

Journal Articles


  • A Cost Analysis of Neuraxial Anesthesia to Facilitate External Cephalic Version for Breech Fetal Presentation ANESTHESIA AND ANALGESIA Carvalho, B., Tan, J. M., Macario, A., El-Sayed, Y. Y., Sultan, P. 2013; 117 (1): 155-159

    Abstract

    BACKGROUND:In this study, we sought to determine whether neuraxial anesthesia to facilitate external cephalic version (ECV) increased delivery costs for breech fetal presentation.METHODS:Using a computer cost model, which considers possible outcomes and probability uncertainties at the same time, we estimated total expected delivery costs for breech presentation managed by a trial of ECV with and without neuraxial anesthesia.RESULTS:From published studies, the average probability of successful ECV with neuraxial anesthesia was 60% (with individual studies ranging from 44% to 87%) compared with 38% (with individual studies ranging from 31% to 58%) without neuraxial anesthesia. The mean expected total delivery costs, including the cost of attempting/performing ECV with anesthesia, equaled $8931 (2.5th-97.5th percentile prediction interval $8541-$9252). The cost was $9207 (2.5th-97.5th percentile prediction interval $8896-$9419) if ECV was attempted/performed without anesthesia. The expected mean incremental difference between the total cost of delivery that includes ECV with anesthesia and ECV without anesthesia was $-276 (2.5th-97.5th percentile prediction interval $-720 to $112).CONCLUSION:The total cost of delivery in women with breech presentation may be decreased (up to $720) or increased (up to $112) if ECV is attempted/performed with neuraxial anesthesia compared with ECV without neuraxial anesthesia. Increased ECV success with neuraxial anesthesia and the subsequent reduction in breech cesarean delivery rate offset the costs of providing anesthesia to facilitate ECV.

    View details for DOI 10.1213/ANE.0b013e31828e5bc7

    View details for Web of Science ID 000326512300025

  • Use of Tablet (iPad (R)) as a Tool for Teaching Anesthesiology in an Orthopedic Rotation REVISTA BRASILEIRA DE ANESTESIOLOGIA Tanaka, P. P., Hawrylyshyn, K. A., Macario, A. 2012; 62 (2): 214-222

    Abstract

    The goal of this study was to compare scores on house staff evaluations of "overall teaching quality" during a rotation in anesthesia for orthopedics in the first six months (n=11 residents were provided with curriculum in a printed binder) and in the final six months (n=9 residents were provided with the same curriculum in a tablet computer (iPad, Apple®, Inc, Cupertino, Ca)).At the beginning of the two-week rotation, the resident was given an iPad containing: a syllabus with daily reading assignments, rotation objectives according to the ACGME core competencies, and journal articles. Prior to the study, these curriculum materials had been distributed in a printed binder. The iPad also provided peer reviewed internet sites and direct access to online textbooks, but was not linked to the electronic medical record. At the end of the rotation, residents anonymously answered questions to evaluate the rotation on an ordinal scale from 1 (unsatisfactory) to 5 (outstanding). All residents were unaware that the data would be analyzed retrospectively for this study.The mean global rating of the rotation as assessed by "overall teaching quality of this rotation" increased from 4.09 (N=11 evaluations before intervention, SD 0.83, median 4, range 3-5) to 4.89 (N=9 evaluations after intervention, SD 0.33, median 5, range 4-5) p=0.04.Residents responded favorably to the introduction of an innovative iPad based curriculum for the orthopedic anesthesia rotation. More studies are needed to show how such mobile computing technologies can enhance learning, especially since residents work at multiple locations, have duty hour limits, and the need to document resident learning in six ACGME core competencies.

    View details for Web of Science ID 000301768500007

    View details for PubMedID 22440376

  • Anesthesia Information Management Systems: Past, Present, and Future of Anesthesia Records MOUNT SINAI JOURNAL OF MEDICINE Kadry, B., Feaster, W. W., Macario, A., Ehrenfeld, J. M. 2012; 79 (1): 154-165

    Abstract

    Documenting a patient's anesthetic in the medical record is quite different from summarizing an office visit, writing a surgical procedure note, or recording other clinical encounters. Some of the biggest differences are the frequent sampling of physiologic data, volume of data, and diversity of data collected. The goal of the anesthesia record is to accurately and comprehensively capture a patient's anesthetic experience in a succinct format. Having ready access to physiologic trends is essential to allowing anesthesiologists to make proper diagnoses and treatment decisions. Although the value provided by anesthesia information management systems and their functions may be different than other electronic health records, the real benefits of an anesthesia information management system depend on having it fully integrated with the other health information technologies. An anesthesia information management system is built around the electronic anesthesia record and incorporates anesthesia-relevant data pulled from disparate systems such as laboratory, billing, imaging, communication, pharmacy, and scheduling. The ability of an anesthesia information management system to collect data automatically enables anesthesiologists to reliably create an accurate record at all times, regardless of other concurrent demands. These systems also have the potential to convert large volumes of data into actionable information for outcomes research and quality-improvement initiatives. Developing a system to validate the data is crucial in conducting outcomes research using large datasets. Technology innovations outside of healthcare, such as multitouch interfaces, near-instant software response times, powerful but simple search capabilities, and intuitive designs, have raised the bar for users' expectations of health information technology.

    View details for DOI 10.1002/msj.21281

    View details for Web of Science ID 000299033500016

    View details for PubMedID 22238048

  • Analysis of 4999 Online Physician Ratings Indicates That Most Patients Give Physicians a Favorable Rating JOURNAL OF MEDICAL INTERNET RESEARCH Kadry, B., Chu, L. F., Kadry, B., Gammas, D., Macario, A. 2011; 13 (4)

    Abstract

    Many online physician-rating sites provide patients with information about physicians and allow patients to rate physicians. Understanding what information is available is important given that patients may use this information to choose a physician.The goals of this study were to (1) determine the most frequently visited physician-rating websites with user-generated content, (2) evaluate the available information on these websites, and (3) analyze 4999 individual online ratings of physicians.On October 1, 2010, using Google Trends we identified the 10 most frequently visited online physician-rating sites with user-generated content. We then studied each site to evaluate the available information (eg, board certification, years in practice), the types of rating scales (eg, 1-5, 1-4, 1-100), and dimensions of care (eg, recommend to a friend, waiting room time) used to rate physicians. We analyzed data from 4999 selected physician ratings without identifiers to assess how physicians are rated online.The 10 most commonly visited websites with user-generated content were HealthGrades.com, Vitals.com, Yelp.com, YP.com, RevolutionHealth.com, RateMD.com, Angieslist.com, Checkbook.org, Kudzu.com, and ZocDoc.com. A total of 35 different dimensions of care were rated by patients in the websites, with a median of 4.5 (mean 4.9, SD 2.8, range 1-9) questions per site. Depending on the scale used for each physician-rating website, the average rating was 77 out of 100 for sites using a 100-point scale (SD 11, median 76, range 33-100), 3.84 out of 5 (77%) for sites using a 5-point scale (SD 0.98, median 4, range 1-5), and 3.1 out of 4 (78%) for sites using a 4-point scale (SD 0.72, median 3, range 1-4). The percentage of reviews rated ?75 on a 100-point scale was 61.5% (246/400), ?4 on a 5-point scale was 57.74% (2078/3599), and ?3 on a 4-point scale was 74.0% (740/1000). The patient's single overall rating of the physician correlated with the other dimensions of care that were rated by patients for the same physician (Pearson correlation, r = .73, P < .001).Most patients give physicians a favorable rating on online physician-rating sites. A single overall rating to evaluate physicians may be sufficient to assess a patient's opinion of the physician. The optimal content and rating method that is useful to patients when visiting online physician-rating sites deserves further study. Conducting a qualitative analysis to compare the quantitative ratings would help validate the rating instruments used to evaluate physicians.

    View details for DOI 10.2196/jmir.1960

    View details for Web of Science ID 000299313300040

    View details for PubMedID 22088924

  • TITRATION OF SEVOFLURANE IN ELDERLY PATIENTS: BLINDED, RANDOMIZED CLINICAL TRIAL, IN NON-CARDIAC SURGERY AFTER BETA-ADRENERGIC BLOCKADE JOURNAL OF CLINICAL MONITORING AND COMPUTING Drover, D. R., Schmiesing, C., Buchin, A. F., Ortega, H. R., Tanner, J. W., Atkins, J. H., Macario, A. 2011; 25 (3): 175-181

    Abstract

    Monitoring depth of anesthesia via the processed electroencephalogram (EEG) has been found useful in reducing the amount of anesthetic drugs, optimizing wake-up times, and, in some studies, reducing awareness. Our goal was to determine if titrating sevoflurane as the maintenance anesthetic to a depth of anesthesia monitor (SEDLine™, Masimo, CA) would shorten time to extubation in elderly patients undergoing non-cardiac surgery while on beta-adrenergic blockade. This patient population was selected because the usual cardiovascular signs of inadequate general anesthesia may be masked by beta-blocker therapy.Surgical patients older than 65 years of age receiving beta-adrenergic blockers for a minimum of 24 h preoperatively were randomized to two groups: a group whose titration of sevoflurane was based on SEDLine™ data (SEDLine™ group) and a group whose titration was based on usual clinical criteria (control group) where SEDLine™ data were concealed. The primary endpoint was time from skin closure to time to extubation. Aldrete score, White Fast Track score and QoR-40 were also assessed.There was no significant difference in time to extubation [12.5 (SD 7.4) min in the control group versus 13.0 (SD 5.9) min for the treatment group]. The control group used more fentanyl [339 mcg (SD 205)] than did the treatment group [238 mcg (SD 123)] (P<0.02). There was no difference in sevoflurane utilization, Aldrete, White Fast Track scores, time to PACU discharge, or QoR-40 assessments between the groups.Use of the SEDLine™ monitor's data to titrate sevoflurane did not improve the time to extubation or change short-term outcome of geriatric surgical patients receiving beta-adrenergic blockers. (ClinicalTrials.gov number, NCT00938782).

    View details for DOI 10.1007/s10877-011-9293-1

    View details for Web of Science ID 000298814400004

    View details for PubMedID 21830049

  • A Literature Review of Randomized Clinical Trials of Intravenous Acetaminophen (Paracetamol) for Acute Postoperative Pain PAIN PRACTICE Macario, A., Royal, M. A. 2011; 11 (3): 290-296

    Abstract

    This study's objective was to systematically review the literature to assess analgesic outcomes of intravenous (IV) acetaminophen for acute postoperative pain in adults.We searched Medline and the Cochrane library (January 1, 2000 to January 17, 2010, date of last search) for prospective, randomized, controlled trials (RCTs) of IV acetaminophen vs. either an active comparator or placebo.Sixteen articles from 9 countries published between 2005 and 2010 met inclusion criteria and had a total of 1,464 patients. Median sample size=54 patients (range 25 to 165) and median follow-up=1 day (range 1 hour to 7 days). Four of the 16 articles had 3 arms in the study. One article had 4 arms. As a result, 22 study comparisons were analyzed: IV acetaminophen to an active comparator (n=8 studies) and IV acetaminophen to placebo (n=14 studies). The RCTs were of high methodological quality with Jadad median score=5. In 7 of 8 active comparator studies (IV parecoxib [n=3 studies], IV metamizol [n=4], oral ibuprofen [n=1]), IV acetaminophen had similar analgesic outcomes as the active comparator. Twelve of the 14 placebo studies found that IV acetaminophen patients had improved analgesia. Ten of those 14 studies reported less opioid consumption, a lower percentage of patients rescuing, or a longer time to first rescue with IV acetaminophen. Formal meta-analysis pooling was not performed because the studies had different primary end points, and the IV acetaminophen dosing regimens varied in dose, and duration and timing.In aggregate, these data indicate that IV acetaminophen is an effective analgesic across a variety of surgical procedures.

    View details for DOI 10.1111/j.1533-2500.2010.00426.x

    View details for Web of Science ID 000296466700011

    View details for PubMedID 21114616

  • Self-Reported Information Needs of Anesthesia Residency Applicants and Analysis of Applicant-Related Web Sites Resources at 131 United States Training Programs ANESTHESIA AND ANALGESIA Chu, L. F., Young, C. A., Zamora, A. K., Lowe, D., Hoang, D. B., Pearl, R. G., Macario, A. 2011; 112 (2): 430-439

    Abstract

    Despite the use of web-based information resources by both anesthesia departments and applicants, little research has been done to assess these resources and determine whether they are meeting applicant needs. Evidence is needed to guide anesthesia informatics research in developing high-quality anesthesia residency program Web sites (ARPWs).We used an anonymous web-based program (SurveyMonkey, Portland, OR) to distribute a survey investigating the information needs and perceived usefulness of ARPWs to all 572 Stanford anesthesia residency program applicants. A quantitative scoring system was then created to assess the quality of ARPWs in meeting the information needs of these applicants. Two researchers independently analyzed all 131 ARPWs in the United States to determine whether the ARPWs met the needs of applicants based on the scoring system. Finally, a qualitative assessment of the overall user experience of ARPWs was developed to account for the subjective elements of the Web site's presentation.Ninety-eight percent of respondents reported having used ARPWs during the application process. Fifty-six percent reported first visiting the Stanford ARPW when deciding whether to apply to Stanford's anesthesia residency program. Multimedia and Web 2.0 technologies were "very" or "most" useful in "learning intangible aspects of a program, like how happy people are" (42% multimedia and Web 2.0 versus 14% text and photos). ARPWs, on average, contained only 46% of the content items identified as important by applicants. The average (SD) quality scores among all ARPWs was 2.06 (0.59) of 4.0 maximum points. The mean overall qualitative score for all 131 ARPWs was 4.97 (1.92) of 10 points. Only 2% of applicants indicated that the majority (75%-100%) of Web sites they visited provided a complete experience.Anesthesia residency applicants rely heavily on ARPWs to research programs, prepare for interviews, and formulate a rank list. Anesthesia departments can improve their ARPWs by including information such as total hours worked and work hours by rotation (missing in 96% and 97% of ARPWs) and providing a valid web address on the Fellowship and Residency Electronic Interactive Database Access System (FREIDA) (missing in 28% of ARPWs).

    View details for DOI 10.1213/ANE.0b013e3182027a94

    View details for Web of Science ID 000286576000023

    View details for PubMedID 21081766

  • Can an Acute Pain Service Be Cost-Effective? ANESTHESIA AND ANALGESIA Sun, E., Dexter, F., Macario, A. 2010; 111 (4): 841-844

    View details for DOI 10.1213/ANE.0b013e3181f33533

    View details for Web of Science ID 000282310200005

    View details for PubMedID 20870982

  • Learning management systems and lecture capture in the medical academic environment. International anesthesiology clinics Chu, L. F., Young, C. A., Ngai, L. K., Cun, T., Pearl, R. G., Macario, A. 2010; 48 (3): 27-51

    Abstract

    As residents work disparate schedules at multiple locations and because of workweek hour limits mandated by the ACGME, residents may be unable to attend lectures, seminars, or other activities that would enhance their skills. Further, the ACGME requires that residency programs document resident learning in six stated core competencies and provide proof of completion for various other requirements. LMS/LC is a promising technology to provide a means by which residency programs may overcome these obstacles. More studies are needed to show under what conditions an LMS/LC program actually enhances learning, and which elements are most useful to the new generation of learners comfortable with Web 2.0 technologies.

    View details for DOI 10.1097/AIA.0b013e3181e5c1d5

    View details for PubMedID 20616636

  • The role of social networking applications in the medical academic environment. International anesthesiology clinics Chu, L. F., Zamora, A. K., Young, C. A., Kurup, V., Macario, A. 2010; 48 (3): 61-82

    View details for DOI 10.1097/AIA.0b013e3181e6e7d8

    View details for PubMedID 20616638

  • The limitations of using operating room utilisation to allocate surgeons more or less surgical block time in the USA ANAESTHESIA Macario, A. 2010; 65 (6): 548-552
  • What does one minute of operating room time cost? JOURNAL OF CLINICAL ANESTHESIA Macario, A. 2010; 22 (4): 233-236
  • Preoperative evaluation clinics CURRENT OPINION IN ANESTHESIOLOGY Yen, C., Tsai, M., Macario, A. 2010; 23 (2): 167-172

    Abstract

    The ever-increasing demand for productivity has forced anesthesiology departments to implement a safe, efficient, and structured approach to the preoperative evaluation of surgical patients. The goal of the present article is to discuss the evolution, benefits, and the future of preoperative clinics including a telephone-based system.Outpatient preoperative evaluation clinics are common, but the optimal model is unknown and may depend on a hospital's characteristics such as the types of specialty care provided, geographic and socioeconomic differences of the population served by the hospital, the expectations of patients, and whether the facility is private versus academic practice where house staff education is necessary. The advantages of a telephone-based screening and assessment system include that patients need not make a separate visit to the hospital that typically would require taking time off from work.It is difficult to compare the efficacy of different preoperative evaluation systems with regard to properly educating the patient, minimizing complications, and maximizing surgical suite functioning. Several authors have pointed out that quality improvement of the preoperative clinic should be guided by obtaining patient feedback.

    View details for DOI 10.1097/ACO.0b013e328336f4b9

    View details for Web of Science ID 000275817300008

    View details for PubMedID 20124896

  • Challenges that limit meaningful use of health information technology CURRENT OPINION IN ANESTHESIOLOGY Kadry, B., Sanderson, I. C., Macario, A. 2010; 23 (2): 184-192

    Abstract

    Health information technology (HIT) is perceived as an essential component for addressing inefficiencies in healthcare. Without understanding the challenges that limit meaningful use of HIT, there is a high chance that institutions will convert complex paper-based systems to expensive digital chaos.Clinical information systems do not communicate with each other automatically because integration of existing data standards is lacking. Data standards for medical specialties need further development. Database architectures are often designed to support single clinical applications and are not easily modified to meet the enterprise-wide needs desired by all end-users. Despite the improvements in charge capture and better access to health information the realized savings and impact on patient throughput is not enough to cover the cost of the technology, maintenance, and support. HIT is necessary for improved quality of care but it increases the cost of doing business. Poor user interface and system design hinders clinical workflow and can result in wasted time, poor data collection, misleading data analysis, and potentially negative clinical outcomes. Healthcare organizations have little recourse if a vendor fails to deliver as intended once the vendor's system becomes embedded into the organization. Decisions on technology acquisitions and implementations are often made by individuals or groups that lack clinical informatics expertise.Government incentives to increase HIT will likely result in a more computerized clinical environment. Understanding the challenges can help avoid costly mistakes. The future looks promising but caution is warranted, as achievement of full benefits of HIT requires addressing significant challenges.

    View details for DOI 10.1097/ACO.0b013e328336ea0e

    View details for Web of Science ID 000275817300011

    View details for PubMedID 20084001

  • Anesthesia 2.0: Internet-based information resources and Web 2.0 applications in anesthesia education CURRENT OPINION IN ANESTHESIOLOGY Chu, L. F., Young, C., Zamora, A., Kurup, V., Macario, A. 2010; 23 (2): 218-227

    Abstract

    Informatics is a broad field encompassing artificial intelligence, cognitive science, computer science, information science, and social science. The goal of this review is to illustrate how Web 2.0 information technologies could be used to improve anesthesia education.Educators in all specialties of medicine are increasingly studying Web 2.0 technologies to maximize postgraduate medical education of housestaff. These technologies include microblogging, blogs, really simple syndication (RSS) feeds, podcasts, wikis, and social bookmarking and networking. 'Anesthesia 2.0' reflects our expectation that these technologies will foster innovation and interactivity in anesthesia-related web resources which embraces the principles of openness, sharing, and interconnectedness that represent the Web 2.0 movement. Although several recent studies have shown benefits of implementing these systems into medical education, much more investigation is needed.Although direct practice and observation in the operating room are essential, Web 2.0 technologies hold great promise to innovate anesthesia education and clinical practice such that the resident learner need not be in a classroom for a didactic talk, or even in the operating room to see how an arterial line is properly placed. Thoughtful research to maximize implementation of these technologies should be a priority for development by academic anesthesiology departments. Web 2.0 and advanced informatics resources will be part of physician lifelong learning and clinical practice.

    View details for DOI 10.1097/ACO.0b013e328337339c

    View details for Web of Science ID 000275817300015

    View details for PubMedID 20090518

  • Prevalence of anaesthesia information management systems in university-affiliated hospitals in Europe EUROPEAN JOURNAL OF ANAESTHESIOLOGY Balust, J., Halbeis, C. B., Macario, A. 2010; 27 (2): 202-208

    Abstract

    An increasing number of studies suggest that anaesthesia information management systems (AIMS) improve clinical care. The purpose of this web survey study was to assess the prevalence of AIMS in European university-affiliated anaesthesia departments and to identify the motivations for and barriers to AIMS adoption.A survey was e-mailed to 252 academic anaesthesia chairs of 294 university-affiliated hospitals in 22 European countries, with 41 e-mails returned as undeliverable, leaving the final sample equal to 211. Responders provided information on demographics, the other information technology systems available in their hospitals, and current implementation status of AIMS. Adopters were asked about motivations for installing AIMS, whereas nonadopters were asked about barriers to AIMS adoption.Eighty-six (29%) of 294 hospitals responded. Forty-four of the 86 departments (51%) were considered AIMS adopters because they were already using (n = 15), implementing (n = 13) or selecting an AIMS (n = 16). The 42 remaining departments (49%) were considered nonadopters as they were not expecting to install an AIMS owing to lack of funds (n = 27), other reasons (n = 13) such as lack of support from the information technology department, or simply did not have a plan (n = 2). The top ranked motivators for adopting AIMS were improved clinical documentation, improvement in patient care and safety, and convenience for anaesthesiologists. AIMS adopters were more likely than nonadopters to already have other information technology systems deployed throughout the hospital.At least 44 (or 15%) of the 294 university-affiliated departments surveyed in this study have already implemented, are implementing, or are currently selecting an AIMS. The main barrier identified by AIMS nonadopters is lack of funds.

    View details for DOI 10.1097/EJA.0b013e3283313fc2

    View details for Web of Science ID 000274176900013

    View details for PubMedID 19918183

  • Improving safety in the operating room: a systematic literature review of retained surgical sponges CURRENT OPINION IN ANESTHESIOLOGY Wan, W., Le, T., Riskin, L., Macario, A. 2009; 22 (2): 207-214

    Abstract

    Gossypibomas are surgical sponges that are unintentionally left inside a patient during a surgical procedure. To improve this patient safety indicator, anesthesiologists will need to work with operating room personnel. This study's goal was to systematically review the literature on retained sponges to identify body location, time to discovery, methods for detection, and risk factors.Two hundred and fifty-four gossypiboma cases (147 reports from the period 1963-2008) were identified via the National Library of Medicine's Medline and the Cochrane Library. Gossypibomas (mean patient age 49 years, range 6-92 years) were most commonly found in the abdomen (56%), pelvis (18%), and thorax (11%). Average discovery time equaled 6.9 years (SD 10.2 years) with a median (quartiles) of 2.2 years (0.3-8.4 years). The most common detection methods were computed tomography (61%), radiography (35%), and ultrasound (34%). Pain/irritation (42%), palpable mass (27%), and fever (12%) were the leading signs and symptoms, but 6% of cases were asymptomatic. Complications included adhesion (31%), abscess (24%), and fistula (20%). Risk factors were case specific (e.g. emergency) or related to the surgical environment (e.g. poor communication). Most gossypibomas occurred when the sponge count was falsely pronounced correct at the end of surgery.More is being discovered about the patterns leading to a retained sponge. Multidisciplinary approaches and new technologies may help reduce this low frequency but clinically significant event. However, given the complexity of surgical care, eliminating retained sponges may prove elusive.

    View details for DOI 10.1097/ACO.0b013e328324f82d

    View details for Web of Science ID 000265349200011

    View details for PubMedID 19390247

  • Managing quality in an anesthesia department CURRENT OPINION IN ANESTHESIOLOGY McIntosh, C. A., Macario, A. 2009; 22 (2): 223-231

    Abstract

    To provide a practical approach to measure and then improve the quality of an academic anesthesia department.The quality of any entity is defined by the user. Anesthesia departments should adopt practices that meet their specific operational needs. The relative importance of each of the user groups will be determined by the purpose of an individual department. Four categories of users will be considered: patients, surgeons (and other proceduralists), the hospital organization and the department itself (i.e. faculty and trainees). Patients value avoiding nausea and vomiting and pain after surgery, surgeons want cases to start on time with low turnover times, and the hospital desires high throughput of surgical cases, all facilitated by department faculty who value professional development. Quality improvement efforts in anesthesia should be aligned with broad healthcare quality improvement initiatives and avoid distortions in perceptions of quality by over-emphasizing what is easily measurable at the expense of what is important.Departments of anesthesia should develop performance criteria in multiple domains and recognize the importance of human relationships (between staff and between staff and patients) in quality and safety. To improve the value of anesthesia services, departments should identify their user groups, survey them to determine what attributes are important to the user, then deliver, measure, monitor and improve them on an ongoing basis.

    View details for DOI 10.1097/ACO.0b013e328324f810

    View details for Web of Science ID 000265349200013

    View details for PubMedID 19390249

  • Can anesthesia information management systems improve quality in the surgical suite? CURRENT OPINION IN ANESTHESIOLOGY Balust, J., Macario, A. 2009; 22 (2): 215-222

    Abstract

    To summarize developments related to the use of anesthesia information management systems (AIMS) and quality assurance and quality improvement.A real challenge for AIMS is that the technology is too often seen as a solution. The reality is that the technology is simply a tool, which is increasingly being installed by hospitals to give anesthesiologists better capabilities for managing quality assurance programs, developing guidelines, facilitating computerized decision support, and standardizing care in the surgical suite so that every patient receives optimal care. Anesthesia groups will likely have to assign a dedicated biomedical team and programmer to fully realize the clinical and business benefits of AIMS.Implementation of information technologies in anesthesia as well as in all aspects of healthcare redesigns how patients receive care. AIMS accurately measure, store, query, and recall vital sign data, and enable the systematic analysis of anesthesia-related perioperative data. Using AIMS, quality management programs will be able to study more incidents and analyze them more quickly. Ideally, decision-support systems with practice guidelines delivered via AIMS should help overcome the usual barriers to guideline adherence, and improve care and safety.

    View details for DOI 10.1097/ACO.0b013e328324b9e6

    View details for Web of Science ID 000265349200012

    View details for PubMedID 19390248

  • Should I get a Master of Business Administration? The anesthesiologist with education training: training options and professional opportunities CURRENT OPINION IN ANESTHESIOLOGY Desai, A. M., Trillo, R. A., Macario, A. 2009; 22 (2): 191-198

    Abstract

    Many physicians want to know whether they should get a Master of Business Administration (MBA), what type of program is best, and what career paths exist.It is commonly (incorrectly) assumed that a physician successful in clinical practice can easily transfer to managing/leading an organization. To be effective, the MD/MBA must bridge the cultures of the business world and medicine. Often just a single management course is sufficient to give the physician the knowledge they seek. MBA programs come in many forms and require choosing from a range of time commitments. Leaving a good clinical job in favor of the less-defined course of an MD/MBA can be daunting. Although a wide spectrum of opportunities are available, the MD/MBA may have to start over professionally, most likely with a pay cut, and will have to 'work their way up' again. A stigma exists for MD/MBAs because they are often perceived as caring more about business than about patients. Many MD/MBAs eventually choose to stay in full-time medical practice because financial and geographic stability may be more easily attained.The MBA is a good idea for the physicians who enjoy the intellectual challenges of business administration and proactively plan their own career.

    View details for DOI 10.1097/ACO.0b013e3283232c4e

    View details for Web of Science ID 000265349200009

    View details for PubMedID 19307894

  • Truth in Scheduling: Is It Possible to Accurately Predict How Long a Surgical Case Will Last? ANESTHESIA AND ANALGESIA Macario, A. 2009; 108 (3): 681-685

    View details for DOI 10.1213/ane.0b013e318196a617

    View details for Web of Science ID 000263537300001

    View details for PubMedID 19224765

  • Operative Time and Other Outcomes of the Electrothermal Bipolar Vessel Sealing System (LigaSure (TM)) Versus Other Methods for Surgical Hemostasis: A Meta-Analysis SURGICAL INNOVATION Macario, A., Dexter, F., Sypal, J., Cosgriff, N., Heniford, B. T. 2008; 15 (4): 284-291

    Abstract

    A meta-analysis was performed of 29 prospective, randomized trials (published January 1, 2000, to August 14, 2007) comparing an electrothermal bipolar vessel sealing system (EBVS-LigaSure, Covidien) (total n = 1107 patients) with either clamping with suture ligation/ electrocauterization (n = 1079 patients) or ultrasonic energy (eg, Harmonic Scalpel, Johnson & Johnson). Hemorrhoidectomy (12 articles), hysterectomy (4 articles), and thyroidectomy (3 articles) were the most common procedures. For 15 of 26 studies reporting standard deviations, the normalized mean operative time reduction for EBVS equaled 28% (95% confidence interval [CI] 18%-39%, P < .0001) compared with conventional surgical hemostasis. Operative time was reduced with EBVS in 24 of 26 studies (P < .0001). EBVS was associated with 43 mL (95% CI 14-73 mL, P = .0021) less blood loss, fewer complications (odds ratio 0.66, 95% CI 0.47-0.92, P = .02), and mean reduction in postoperative pain of 2.8 units (95% CI 1.5-4.1, P < .0001). Five studies used ultrasonic energy as the comparator, but none reported standard deviation so data could not be pooled.

    View details for DOI 10.1177/1553350608324933

    View details for Web of Science ID 000261137700008

    View details for PubMedID 18945705

  • Anesthesiology clinics. Value-based anesthesia. Preface. Anesthesiology clinics Macario, A. 2008; 26 (4): xiii-xiv

    View details for DOI 10.1016/j.anclin.2008.08.002

    View details for PubMedID 19041618

  • Adoption of anesthesia information management systems by academic departments in the United States ANESTHESIA AND ANALGESIA Halbeis, C. B., Epstein, R. H., Macario, A., Pearl, R. G., Grunwald, Z. 2008; 107 (4): 1323-1329

    Abstract

    Information technology has been promoted as a way to improve patient care and outcomes. Whereas information technology systems for ancillary hospital services (e.g., radiology, pharmacy) are deployed commonly, it has been estimated that anesthesia information management systems (AIMS) are only installed in a small fraction of United States (US) operating rooms. In this study, we assessed the adoption of AIMS at academic anesthesia departments and explored the motivations for and resistance to AIMS adoption.Members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors were solicited by e-mail to participate in an online survey of AIMS adoption. Two months after closing the survey, another e-mail was sent with a single question asking for an update to their AIMS implementation status.Surveys were fully completed by 48 (34%) of the 140 Society of Academic Anesthesiology Chairs and Association of Anesthesiology Program Directors departments surveyed, with 72 (51%) providing AIMS status information. Twenty of these 72 departments have an AIMS installed, 12 are currently implementing, 11 have selected but not yet installed, and 18 are planning to purchase an AIMS in 2008 or 2009. Therefore, at least 61 (44%) of all 140 US academic anesthesia departments have committed to AIMS. This estimated adoption rate is conservative because the numerator equals the affirmative responses, whereas the denominator equals the total population of academic departments. Among adopters, the top ranked anticipated benefits from installing an AIMS included improved clinical documentation, improved data collection for clinical research, enhancement of quality improvement programs, and compliance with requirements of regulatory authorities. The hospital provided funding in almost all facilities (90%), with co-funding by the anesthesia group in 35%.At least 61 or 44% of the 140 US academic departments surveyed in this study have already implemented, are planning to acquire, or are currently searching for an AIMS. Adoption of AIMS technology appears to have reached sufficient momentum within academic anesthesiology departments to result in a fundamental change.

    View details for DOI 10.1213/ane.0b013e31818322d2

    View details for Web of Science ID 000259522100042

    View details for PubMedID 18806048

  • Vaginal twin delivery: a survey and review of location, anesthesia coverage and interventions INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA Carvalho, B., Saxena, A., Butwick, A., Macario, A. 2008; 17 (3): 212-216

    Abstract

    Twin pregnancies are associated with increased perinatal morbidity and mortality. No consensus exists whether vaginal twin delivery should take place in the labor room or operating room, or whether anesthesiologists should be present. We surveyed members of the California Society of Anesthesiologists (CSA) to review management of vaginal twin delivery, and examined anesthetic intervention retrospectively at our institution.230 CSA members were asked to complete an online survey on location of vaginal twin delivery in their institution and whether they were required to be present throughout. We then retrospectively reviewed charts of vaginal twin deliveries at our institution over a 36-month period to analyze frequency and type of anesthetic intervention.The online survey response rate was 58%; 64% of responders reported that vaginal twin deliveries were performed in the operating room and 55% that an anesthesiologist was present. There was a strong association between anesthesiologist's presence and delivery in the operating room (OR 7; 95% CI 3-20). We reviewed 81 charts of women who underwent vaginal twin delivery. The median (range) time that the anesthesiologist was present for each delivery was 60 (20-380) min. Of women undergoing vaginal twin delivery, 27% required anesthetic intervention during the second stage of labor with 6% having emergency cesarean delivery.There is a lack of consensus regarding the appropriate location for vaginal twin delivery and the role of anesthesiologists. A significant percentage of women undergoing vaginal twin delivery in our institution received anesthetic intervention in the immediate delivery period.

    View details for DOI 10.1016/j.ijoa.2007.04.004

    View details for Web of Science ID 000257844200003

    View details for PubMedID 17881218

  • Training attendings to be expert teachers: the Stanford Anesthesia Teaching Scholars Program JOURNAL OF CLINICAL ANESTHESIA Macario, A., Edler, A., Pearl, R. 2008; 20 (3): 241-242
  • The reuse of anesthesia breathing systems: another difference of opinion and practice between the United States and Europe JOURNAL OF CLINICAL ANESTHESIA Halbeis, C. B., Macario, A., Brock-Ume, J. G. 2008; 20 (2): 81-83
  • Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: a retrospective chart review. Pain practice Macario, A., Richmond, C., Auster, M., Pergolizzi, J. V. 2008; 8 (1): 11-17

    Abstract

    This study's goal was a retrospective chart audit of 100 outpatients with discogenic low back pain (LBP) lasting more than 12 weeks treated with a 2-month course of motorized spinal decompression via the DRX9000 (Axiom Worldwide, Tampa, FL, U.S.A.).Patients at a convenience sample of four clinics received 30-minute DRX9000 sessions daily for the first 2 weeks tapering to 1 session/week. Treatment protocol included lumbar stretching, myofascial release, or heat prior to treatment, with ice and/or muscle stimulation afterwards. Primary outcome was verbal numerical pain intensity rating (NRS) 0 to 10 before and after the 8-week treatment.Of the 100 initial subjects, three withdrew their protected health information, and three were excluded because their LBP duration was less than 12 weeks. The remaining 94 subjects (63% female, 95% white, age = 55 (SD 16) year, 52% employed, 41% retired, LBP median duration of 260 weeks) had diagnoses of herniated disc (73% of patients), degenerative disc disease (68%), or both (27%). Mean NRS equaled 6.05 (SD 2.3) at presentation and decreased significantly to 0.89 (SD 1.15) at end of 8-week treatment (P < 0.0001). Analgesic use also appeared to decrease (charts with data = 20) and Activities of Daily Living improved (charts with data = 38). Follow-up (mean 31 weeks) on 29/94 patients reported mean 83% LBP improvement, NRS of 1.7 (SD 1.15), and satisfaction of 8.55/10 (median 9).This retrospective chart audit provides preliminary data that chronic LBP may improve with DRX9000 spinal decompression. Randomized double-blind trials are needed to measure the efficacy of such systems.

    View details for DOI 10.1111/j.1533-2500.2007.00167.x

    View details for PubMedID 18211590

  • Are your operating rooms 'efficient'? OR manager Macario, A. 2007; 23 (12): 16-18

    View details for PubMedID 18196866

  • Systematic literature review of spinal decompression via motorized traction for chronic discogenic low back pain. Pain practice Macario, A., Pergolizzi, J. V. 2006; 6 (3): 171-178

    Abstract

    The objective of this study was to systematically review the literature to assess the efficacy of nonsurgical spinal decompression achieved with motorized traction for chronic discogenic lumbosacral back pain.Computer-aided systematic literature search of MEDLINE and the Cochrane collaboration for prospective clinical trials on adults with low back pain in the English literature from 1975 to October 2005. Methodologic quality for each study was assessed. Studies were included if the intervention group received motorized spinal decompression and the comparison group received sham or another type of nonsurgical treatment.Data from 10 studies were fully analyzed. Seven studies were randomized controlled trials using various apparatus types. Because of this low number, we also analyzed three nonrandomized case series studies of spinal decompression systems. As the overall quality of studies was low and the patient groups heterogeneous, a meta-analysis was not appropriate and a qualitative review was undertaken. Sample sizes averaged 121 patients (range 27-292), with six of the seven randomized studies reporting no difference with motorized spinal decompression and one study reporting reduced pain but not disability. The three unrandomized studies (no control group) of motorized spinal decompression found a 77% to 86% reduction in pain.These data suggest that the efficacy of spinal decompression achieved with motorized traction for chronic discogenic low back pain remains unproved. This may be, in part, due to heterogeneous patient groups and the difficulties involved in properly blinding patients to the mechanical pulling mechanism. Scientifically more rigorous studies with better randomization, control groups, and standardized outcome measures are needed to overcome the limitations of past studies.

    View details for PubMedID 17147594

  • Staffing and case scheduling for anesthesia in geographically dispersed locations outside of operating rooms. Current opinion in anaesthesiology Dexter, F., Macario, A., Cowen, D. S. 2006; 19 (4): 453-458

    Abstract

    Scheduling and staffing for anesthetics outside of the operating room that are geographically dispersed is different than for operating room cases. Whereas methods to predict how long such cases take were published recently, this article reviews staffing and case scheduling.Methods have been developed based on the assumption that physicians doing procedures requiring anesthesia are provided open access to anesthesia time within a reasonable number of days (e.g., 2 weeks) or on any future workday. The latter is commonly used in operating rooms. Outside of operating rooms, the former is more practical economically. Statistical forecasting of anesthesia staffing months ahead is conducted by using billing data with the objective of maximizing the efficiency of use of anesthesia time. Calculations assume that anesthesia time that would otherwise be underutilized is released for use by services that would otherwise work in overutilized anesthesia time. Forecasting is different for services with many patients hospitalized preoperatively (e.g., electroconvulsive therapy). Implementation encourages longer-term changes benefiting the anesthesia group (e.g., services choose to work longer hours for fewer days of the week).Plan staffing based on providing open access to anesthesia time within a reasonable number of days (e.g., 2 weeks). Schedule cases and release allocated time based on reducing overutilized anesthesia time.

    View details for PubMedID 16829731

  • Are your hospital operating rooms "efficient"? A scoring system with eight performance indicators ANESTHESIOLOGY Macario, A. 2006; 105 (2): 237-240

    View details for Web of Science ID 000239411600003

    View details for PubMedID 16871055

  • Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology ARCHIVES OF SURGERY Macario, A., Morris, D., Morris, S. 2006; 141 (7): 659-662

    Abstract

    A handheld wand-scanning device (1.5 lb, battery powered, 10 x 10 x 1.5 in) has been developed to detect commonly used surgical gauze sponges, which have been tagged with a radiofrequency identification (RFID) chip. We tested the hypothesis that this wand device has a successful detection rate of 100%, with 100% specificity and 100% sensitivity.Prospective, blinded, experimental clinical trial.Stanford University Medical Center, Stanford, Calif.Eight patients undergoing abdominal or pelvic surgery.Eight untagged sponges (1 control per patient) and 28 RFID sponges were placed in the patients. Just before closure, the first surgeon placed 1 RFID sponge (adult laparotomy tape; 18 x 18 in, 4-ply) in the surgical site, while the second surgeon looked away so as to be blinded to sponge placement. The edges of the wound were pulled together so that the inside of the cavity was not exposed during the detection experiments. The second (blinded) surgeon used the wand-scanning device to try to detect the RFID sponge.A successful detection was defined as detection of an RFID sponge within 1 minute. We also administered a questionnaire to the surgeon and nurse involved in the detections to assess ease of use.The RFID wand device detected all sponges correctly, in less than 3 seconds on average. There were no false-positive or false-negative results.We found a detection accuracy of 100% for the RFID wand device. Despite this engineering success, the possibility of human error and retained sponges remains because handheld scanning can be performed incorrectly.

    View details for Web of Science ID 000238914400009

    View details for PubMedID 16847236

  • Is there value in obtaining a patient's willingness to pay for a particular anesthetic intervention? ANESTHESIOLOGY Macario, A., Fleisher, L. A. 2006; 104 (5): 906-909

    View details for Web of Science ID 000237375400002

    View details for PubMedID 16645439

  • Factors affecting supply and demand of anesthesiologists in Western Europe. Current opinion in anaesthesiology Egger Halbeis, C. B., Macario, A. 2006; 19 (2): 207-212

    Abstract

    Current demographic and macroeconomic trends indicate that, in Western Europe, the demand for anesthesia services will continue to increase. It is, however, questionable whether there will be sufficient supply.In Western Europe, admission to medical schools is typically restricted. The European Working Time Directive has decreased the clinical exposure of residents. Also, increasing feminization of the physician workforce and the aging of current practitioners may change the available workforce. Current healthcare reforms that include demand-lowering elements may also negatively affect supply and demand for anesthesiologists.Steps must be taken to augment the number of practitioners to ensure a sufficient number of anesthesiologists. Employers will have to offer flexible working practices and adequate compensation to attract new anesthesiologists. Alternatively, more responsibilities and tasks may be allocated to well-trained anesthesia assistants (e.g. nurses). National anesthesia associations must improve and coordinate resident training, which may alleviate the recruitment problem. A European training standard in anesthesia might adjust the regional disequilibrium of supply and demand, as might salary competition. In the long run, the undersupply of anesthesiologists may be offset by factors such as more procedures being performed non-invasively and further demand-lowering healthcare policies.

    View details for PubMedID 16552229

  • The drive for operating room efficiency will increase quality of patient care. Current opinion in anaesthesiology Archer, T., Macario, A. 2006; 19 (2): 171-176

    Abstract

    The public is demanding that medicine both increase its efficiency and lower its costs. 'Watchdog' groups are scrutinizing our performance, publicizing our results, and forcing us to compete. They want doctors first to use evidence-based medicine to identify truly beneficial healthcare interventions and then to use continuous quality improvement to perform those beneficial interventions consistently at lower costs.A renaissance is underway in our thinking about quality and efficiency in the operating room. 'Work process redesign' and 'the systems approach' are starting to be more than slogans, as researchers redesign the physical environment of the operating room, along with its 'workflow' and methods of communication.Soon physicians and hospitals will be receiving 'pay-for-performance', whereby our income will depend on our ability to demonstrate both good patient care processes and good outcomes. Medicine is starting to act like a competitive industry, and this tendency will be good for quality and efficiency in the operating room. Community and academic practitioners need to understand and participate in this transformation in order to be able to influence its evolution and to survive financially.

    View details for PubMedID 16552224

  • A Markov computer simulation model of the economics of neuromuscular blockade in patients with acute respiratory distress syndrome. BMC medical informatics and decision making Macario, A., Chow, J. L., Dexter, F. 2006; 6: 15-?

    Abstract

    Management of acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) is clinically challenging and costly. Neuromuscular blocking agents may facilitate mechanical ventilation and improve oxygenation, but may result in prolonged recovery of neuromuscular function and acute quadriplegic myopathy syndrome (AQMS). The goal of this study was to address a hypothetical question via computer modeling: Would a reduction in intubation time of 6 hours and/or a reduction in the incidence of AQMS from 25% to 21%, provide enough benefit to justify a drug with an additional expenditure of $267 (the difference in acquisition cost between a generic and brand name neuromuscular blocker)?The base case was a 55 year-old man in the ICU with ARDS who receives neuromuscular blockade for 3.5 days. A Markov model was designed with hypothetical patients in 1 of 6 mutually exclusive health states: ICU-intubated, ICU-extubated, hospital ward, long-term care, home, or death, over a period of 6 months. The net monetary benefit was computed.Our computer simulation modeling predicted the mean cost for ARDS patients receiving standard care for 6 months to be $62,238 (5%-95% percentiles $42,259-$83,766), with an overall 6-month mortality of 39%. Assuming a ceiling ratio of $35,000, even if a drug (that cost $267 more) hypothetically reduced AQMS from 25% to 21% and decreased intubation time by 6 hours, the net monetary benefit would only equal $137.ARDS patients receiving a neuromuscular blocker have a high mortality, and unpredictable outcome, which results in large variability in costs per case. If a patient dies, there is no benefit to any drug that reduces ventilation time or AQMS incidence. A prospective, randomized pharmacoeconomic study of neuromuscular blockers in the ICU to asses AQMS or intubation times is impractical because of the highly variable clinical course of patients with ARDS.

    View details for PubMedID 16539706

  • Anesthesiologists' practice patterns for treatment of postoperative nausea and vomiting in the ambulatory Post Anesthesia Care Unit. BMC anesthesiology Macario, A., Claybon, L., Pergolizzi, J. V. 2006; 6: 6-?

    Abstract

    When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV). Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1) If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU)?; 2) Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3) If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment?A questionnaire with five short hypothetical clinical vignettes was mailed to 300 randomly selected USA anesthesiologists. The types of pharmacological and nonpharmacological interventions for PONV treatment were analyzed.The questionnaire was completed by 106 anesthesiologists (38% response rate), who reported that on average 52% of their practice was ambulatory. If a patient develops PONV and received no prophylaxis, 67% (95% CI, 62%-79%) of anesthesiologists reported they would administer a 5-HT3-antagonist as first choice for treatment, with metoclopramide and dexamethasone being the next two most common choices. 65% (95% CI, 55%-74%) of anesthesiologists reported they would also use non-pharmacologic interventions to treat PONV in the PACU, with an i.v. fluid bolus or nasal cannula oxygen being the most common. When PONV prophylaxis was given during the anesthetic, the preferred PONV treatment choice changed. Whereas 3%-7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% (95% confidence intervals, 18%-36%) of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.5-HT3-antagonists are the most common choice for treatment of established PONV for outpatients when no prophylaxis is used, and also following prophylactic regimens that include a 5HT3 antagonist, regardless of the number of prophylactic antiemetics given. Whereas 3%-7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.

    View details for PubMedID 16740165

  • Patient preferences for anesthesia outcomes associated with Cesarean delivery ANESTHESIA AND ANALGESIA Carvalho, B., Cohen, S. E., Lipman, S. S., Fuller, A., Mathusamy, A. D., Macario, A. 2005; 101 (4): 1182-1187

    Abstract

    When deciding on neuraxial medication (e.g., spinal opioids) for cesarean delivery (CS) under regional anesthesia, anesthesiologists make treatment decisions that "trade off" relieving pain with the potential for increased risk of side effects. No previous studies have examined obstetric patients' anesthesia preferences. Researchers administered 100 written surveys to pregnant women attending our institutions' expectant parent class. We determined patients' preferences for importance of specific intraoperative and postoperative anesthesia outcomes using priority ranking and relative value scales. We also explored patients' fears, concerns, and tolerance regarding CS and analgesics. Eighty-two of 100 surveys were returned and analyzed. Pain during and after CS was the greatest concern followed by vomiting, nausea, cramping, pruritus, and shivering. Ranking and relative value scores were closely correlated (R2 = 0.7). Patients would tolerate a visual analog pain score (0-100 mm) of 56 +/- 22 before exposing their baby to the potential effects of analgesics they receive. In contrast to previous general surgical population surveys that found nausea and vomiting as primary concerns, we found pain during and after CS as parturients' most important concern. Common side effects such as pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, e.g., inclusion of spinal opioids given in adequate doses.Medical care can be improved by incorporating patients' preferences into medical decision making. We surveyed obstetric patients to determine their preferences regarding potential cesarean delivery anesthesia outcomes. Unlike general surgical patients who rate nausea and vomiting highest, parturients considered pain during and after cesarean delivery the most important concern.

    View details for DOI 10.1213/01.ane.0000167774.36833.99

    View details for Web of Science ID 000232115400045

    View details for PubMedID 16192541

  • Meta-analysis of trial comparing postoperative recovery after anesthesia with sevoflurane or desflurane AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY Macario, A., Dexter, F., Lubarsky, D. 2005; 62 (1): 63-68

    Abstract

    Results of published, randomized controlled trials comparing sevoflurane and desflurane were pooled to measure differences in times until patients obeyed commands, were extubated, were oriented, were discharged from the postanesthesia care unit (PACU), and were ready to be discharged to home, as well as the occurrence of postoperative nausea and vomiting (PONV).We reviewed all randomized clinical trials in MEDLINE through December 18, 2003, with a title or abstract containing the words sevoflurane and desflurane. Two reviewers independently extracted study data from papers that met inclusion criteria. Endpoints were pooled using random-effects meta-analysis.Twenty-two reports of 25 studies (3 reports each described 2 studies) met our inclusion criteria. A total of 746 patients received sevoflurane, and 752 received desflurane. Patients receiving desflurane recovered 1-2 minutes quicker in the operating room than patients receiving sevoflurane. They obeyed commands 1.7 minutes sooner (p < 0.001; 95% confidence interval [CI], 0.7-2.7 minutes), were extubated 1.3 minutes sooner (p = 0.003; 95% CI, 0.4-2.2 minutes), and were oriented 1.8 minutes sooner (p < 0.001; 95% CI, 0.7-2.9 minutes). No significant differences were detected in the phase I or II PACU recovery times or in the rate of PONV.Meta-analysis of studies in which the duration of anesthesia was up to 3.1 hours indicated that patients receiving either desflurane or sevoflurane did not have significant differences in PACU time or PONV frequency. Patients receiving desflurane followed commands, were extubated, and were oriented 1.0-1.2 minutes earlier than patients receiving sevoflurane.

    View details for Web of Science ID 000226150100013

    View details for PubMedID 15658074

  • Cost-effectiveness of a trial of labor after previous cesarean delivery depends on the a priori chance of success CLINICAL OBSTETRICS AND GYNECOLOGY Macario, A., El-Sayed, Y. Y., Druzin, M. L. 2004; 47 (2): 378-385

    View details for Web of Science ID 000231530600009

    View details for PubMedID 15166861

  • Economics of one-stage versus two-stage bilateral total knee arthroplasties CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Macario, A., Schilling, P., Rubio, R., Goodman, S. 2003: 149-156

    Abstract

    Patients requiring bilateral total knee arthroplasties may have both joints replaced simultaneously during one hospitalization (one-stage) or during two separate hospitalizations (two-stage). The goals of the current study were to retrospectively analyze discharge patterns for 91 patients who had one-stage bilateral total knee arthroplasties and 32 patients who had two-stage surgeries, and to quantify their in-hospital costs and their costs if the patients were discharged from the hospital to an inpatient unit. Patients having one-stage and two-stage surgery were similar in age, gender, severity of illness (as measured by the American Society of Anesthesiologists Physical Status score), principal diagnosis, and ethnicity. Using a microcosting approach, the authors found that the average in-hospital costs for one-stage total knee arthroplasty (27,468 US dollars) were significantly lower (by 24%) than for two-stage total knee arthroplasty. However, 38% of patients who had the one-stage bilateral total knee arthroplasties were admitted to an acute rehabilitation unit, which had a mean cost of 6469 US dollars and length of stay of 9 days. In contrast, none of the patients who had the two-stage procedure required acute rehabilitation. Patients who had the two-stage procedure were discharged directly home (or with home health services) 42% of the time, versus 21% for patients who had the one-stage procedure. Patients from both groups were discharged to a skilled nursing facility approximately (1/2) of the time, accruing similar costs. Economic analyses of the one-stage procedure need to consider that these patients will require increased use of acute inpatient rehabilitation after hospital discharge.

    View details for DOI 10.1097/01.blo.0000079265.91782.ca

    View details for Web of Science ID 000185343800020

    View details for PubMedID 12966288

  • What questions do patients undergoing lower extremity joint replacement surgery have? BMC HEALTH SERVICES RESEARCH Macario, A., Schilling, P., Rubio, R., Bhalla, A., Goodman, S. 2003; 3

    Abstract

    The value of the Internet to deliver preoperative education would increase if there was variability in questions patients want answered. This study's goal was to have patients consulting an orthopedic surgeon about undergoing either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA) rate the importance of different questions concerning their care.We assembled questions patients might have about joint replacement surgery by analyzing the literature and querying a pilot group of patients and surgeons. Twenty-nine patients considering undergoing THA and 19 patients considering TKR completed a written survey asking them to rate 30 different questions, with a 5 point Likert scale from 1 (least important)--5 (most important).For patients considering THA or TKR, the 4 highest rated questions were: Will the surgery affect my abilities to care for myself?, Am I going to need physical therapy?, How mobile will I be after my surgery?, When will I be able to walk normally again? The mean percentage disagreement was 42% for questions answered by TKR patients and 47% for the THA group. Some patients gave a high rating to questions lowly rated by the rest of the group.Although there was enough agreement to define a core set of questions that should be addressed with most patients considering THA or TKA, some of the remaining questions were also highly important to some patients. The Web may offer a flexible medium for accommodating this large variety of information needs.

    View details for Web of Science ID 000184096900001

    View details for PubMedID 12823860

  • The pharmacy cost of delivering postoperative analgesia to patients undergoing joint replacement surgery JOURNAL OF PAIN Macario, A., McCoy, M. 2003; 4 (1): 22-28

    Abstract

    Few data exist on the distribution of pharmaceutical costs for inpatient surgical procedures across different drug categories (eg, analgesia, anti-infectives). The goals of this study were to categorize pharmaceuticals administered to patients after joint replacement surgery and then to take the hospital's perspective and quantify the pharmacy cost of delivering postoperative analgesia to these patients. Two hundred ninety-eight patients undergoing unilateral hip replacement (n = 145), unilateral knee replacement (n = 121), or bilateral knee replacement (n = 32) were studied retrospectively. For each patient, we determined what hospital resources (eg, supplies) were utilized by each patient in each of 12 different hospital departments. This was done to determine what fraction of overall hospital costs was incurred as a result of pharmacy. Then, we classified the hundreds of items (from acetaminophen to warfarin) included as pharmacy costs into 1 of the following categories: postoperative epidural analgesia, opioids, nonopioids, respiratory, gastrointestinal, naloxone, anti-infective, anticoagulant/antiplatelets, miscellaneous, cardiovascular, pharmacist clinical intervention, intravenous fluids, and benzodiazepines. The pharmacy costs for epidural analgesia, opioids, and nonopioids were summed to compute the fraction of pharmacy costs attributed to postoperative analgesia. The results showed that 3.3% (95% confidence interval CI, 2.7% to 3.6%) of total hospitalization costs were pharmacy costs, which averaged 560 US dollars (95% CI, 500 US dollars to 620 US dollars) for hip replacement, 595 US dollars (95% CI, 551 to 639 US dollars) for knee replacement, and 922 US dollars (95% CI, 588 US dollars to 1256 US dollars) for bilateral knee replacement surgery. An average of 9.9% (95% CI, 7.37% to 12.43%) of total pharmacy costs for the 3 surgery types were for postoperative epidural analgesia, whereas opioids averaged 19.9% (95% CI, 18.67% to 21.13%), and nonopioids averaged 0.8% (95% CI 0.65% to 0.95%) of pharmacy costs. Thus, analgesics accounted for approximately 31% of pharmacy costs. The pharmacy cost of delivering postoperative analgesia to patients undergoing joint replacement surgery represents 1% of the total costs of surgery. Almost two thirds of the analgesic costs were for opioids.

    View details for DOI 10.1054/jpai.2003.2

    View details for Web of Science ID 000181068000002

    View details for PubMedID 14622724

  • A Sabbatical in Madrid travel memoir book Alex Macario 2003
  • Economic evaluation of noncontact normothermic wound therapy for treatment of pressure ulcers. Expert review of pharmacoeconomics & outcomes research Macario, A. 2002; 2 (3): 211-217

    Abstract

    New adjunctive treatments for pressure ulcers have become available to complement standard care. The economic benefits of new advanced wound care treatments like noncontact normothermic wound therapy are related to: the costs of adequately providing standard care treatment, the baseline probability of healing a pressure ulcer to closure with standard care, the relative improvement in healing rates with the advanced wound care treatment and the acquisition cost of the advanced treatment. Healing data from preliminary clinical trials suggest that pressure ulcer healing in long-term care patients is accelerated two-fold with noncontact normothermic wound therapy. At this healing rate, noncontact normothermic wound therapy for stage III and IV pressure ulcer is an economically attractive intervention. Additional well-controlled clinical trials are necessary.

    View details for DOI 10.1586/14737167.2.3.211

    View details for PubMedID 19807413

  • What is quality improvement in the preoperative period? International anesthesiology clinics Archer, T., Schmiesing, C., Macario, A. 2002; 40 (2): 1-16

    View details for PubMedID 11897932

  • What are the most important risk factors for a patient's developing intraoperative hypothermia? ANESTHESIA AND ANALGESIA Macario, A., Dexter, F. 2002; 94 (1): 215-220

    Abstract

    Anesthesiologists attempt to maintain perioperative normothermia for surgical patients. We surveyed clinical anesthesiologists and physician researchers and asked them to prioritize risk factors for a patient to develop intraoperative hypothermia. The questionnaire included 41 factors associated with changes in patient temperature identified during a computerized literature search. We asked respondents to estimate the relative importance of each risk factor on a 10-point scale. The survey was mailed to two groups: 1) 180 anesthesiologists (n = 84 respondents) randomly selected from the 1999 American Society of Anesthesiologists Members Directory and to 2) 24 physician researchers (n = 12 respondents) in thermoregulation. Researchers rated the following to be the most important risk factors for hypothermia (in sequence): neonates, a low ambient operating room temperature, burn injuries, general anesthesia with neuraxial anesthesia, geriatric patients, low temperature of the patient before induction, a thin body type, and large blood loss. The results for the clinician group were similar, because the median differences between the groups' results were two or fewer units for all items. The risk factors identified to be most important can now be further evaluated in clinical trials to develop a multivariate predictive tool for calculating a patient's a priori risk for developing hypothermia.Surveys of clinicians and physician researchers identified what they consider to be the most important risk factors for perioperative hypothermia (e.g., neonates, a low ambient operating room temperature, burn patients, and general anesthesia with neuraxial anesthesia).

    View details for Web of Science ID 000173082800042

    View details for PubMedID 11772832

  • Ketorolac in the era of cyclo-oxygenase-2 selective nonsteroidal anti-inflammatory drugs: A systematic review of efficacy, side effects, and regulatory issues PAIN MEDICINE Macario, A., Lipman, A. G. 2001; 2 (4): 336-351

    Abstract

    The recent introduction of oral COX-2 selective NSAIDs with potential for perioperative use, and the ongoing development of intravenous formulations, stimulated a systemic review of efficacy, side effects, and regulatory issues related to ketorolac for management of postoperative analgesia.To examine the opioid dose sparing effect of ketorolac, we compiled published, randomized controlled trials of ketorolac versus placebo, with opioids given for breakthrough pain, published in English-language journals from 1986-2001. Odds ratios were computed to assess whether the use of ketorolac reduced the incidence of opioid side effects or improved the quality of analgesia.Depending on the type of surgery, ketorolac reduced opioid dose by a mean of 36% (range 0% to 73%). Seventy percent of patients in control groups experienced moderate-severe pain 1 hour postoperatively, while 36% of the control patients had moderate to severe pain 24 hours postoperatively. Analgesia was improved in patients receiving ketorolac in combination with opioids. However, we did not find a concomitant reduction in opioid side effects (e.g., nausea, vomiting). This may be due to studies having inadequate (to small) sample sizes to detect differences in the incidence of opioid related side effects. The risk for adverse events with ketorolac increases with high doses, with prolonged therapy (>5 days), or invulnerable patients (e.g. the elderly). The incidence of serious adverse events has declined since dosage guidelines were revised.Ketorolac should be administered at the lowest dose necessary. Analgesics that provide effective analgesia with minimal adverse effects are needed.

    View details for Web of Science ID 000173125200011

    View details for PubMedID 15102238

  • Variation in practice patterns of anesthesiologists in California for prophylaxis of postoperative nausea and vomiting JOURNAL OF CLINICAL ANESTHESIA Macario, A., Chung, A., Weinger, M. B. 2001; 13 (5): 353-360

    Abstract

    To assess the responses to a survey asking anesthesiologists to report their clinical practice patterns for postoperative nausea and vomiting (PONV) prophylaxis. These practice patterns data may be useful for understanding how to optimize the decision to provide PONV prophylaxis.A written questionnaire with three detailed clinical scenarios with differing levels of a priori risk of PONV (a low-risk patient, a medium-risk patient, and a high-risk patient) was mailed to 454 anesthesiologists.Survey was completed by anesthesiologists (n = 240) in 3 university and 3 community practices in California.Type and number of pharmacological and nonpharmacological interventions for PONV prophylaxis were recorded. To assess the variability in the responses (by the a priori risk of patient), we counted the number of different regimens that would be necessary to account for 80% of the responses.For the 240 respondents, we found that 1, 9, and 11 different pharmacological prophylaxis regimens were required to account for 80% of the variability in practice patterns for the low-, medium-, and high-risk patients, respectively. For the low-risk patient, 19% of practitioners would use pharmacological prophylaxis, and 37% would use nonpharmacological prophylaxis. For the medium-risk patient, 61% would use nonpharmacological prophylaxis and 67% of practitioners would use multidrug prophylaxis: 45% of patients would receive a 5HT(3) antagonist, 35% would receive metoclopramide, and 16% would receive droperidol. For the high-risk patient, 94% of practitioners would administer a 5HT(3) antagonist, whereas 84% would use multi-drug prophylaxis.We found a wide range of PONV prophylaxis management patterns. This variation in clinical practice may reflect uncertainty about the efficacy of available interventions, or differences in practitioners' clinical judgment and beliefs about how to treat PONV. Some therapies with proven benefit for PONV may be underused. Our results may be useful for designing studies aimed at determining the impact on PONV rates when physicians develop and implement guidelines for PONV prophylaxis.

    View details for Web of Science ID 000170504200007

    View details for PubMedID 11498316

  • Cost-effectiveness of a trial of labor after previous cesarean OBSTETRICS AND GYNECOLOGY Chung, A., Macario, A., El-Sayed, Y. Y., Riley, E. T., Duncan, B., Druzin, M. L. 2001; 97 (6): 932-941

    Abstract

    To determine the cost-effective method of delivery, from society's perspective, in patients who have had a previous cesarean.We completed an incremental cost-effectiveness analysis of a trial of labor relative to cesarean using a computerized model for a hypothetical 30-year old parturient. The model incorporated data from peer-reviewed studies, actual hospital costs, and utilities to quantify health-related quality of life. A threshold of $50,000 per quality-adjusted life-years was used to define cost-effective.The model was most sensitive to the probability of successful vaginal delivery. If the probability of successful vaginal birth after cesarean (VBAC) was less than 0.65, elective repeat cesarean was both less costly and more effective than a trial of labor. Between 0.65 and 0.74, elective repeat cesarean was cost-effective (the cost-effectiveness ratio was less than $50,000 per quality-adjusted life-years), because, although it cost more than VBAC, it was offset by improved outcomes. Between 0.74 and 0.76, trial of labor was cost-effective. If the probability of successful vaginal delivery exceeded 0.76, trial of labor became less costly and more effective. Costs associated with a moderately morbid neonatal outcome, as well as the probabilities of infant morbidity occurring, heavily impacted our results.The cost-effectiveness of VBAC depends on the likelihood of successful trial of labor. Our modeling suggests that a trial of labor is cost-effective if the probability of successful vaginal delivery is greater than 0.74. Improved algorithms are needed to more precisely estimate the likelihood that a patient with a previous cesarean will have a successful vaginal delivery.

    View details for Web of Science ID 000169206300013

    View details for PubMedID 11384699

  • The surgical suite meets the new health economy JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Canales, M. G., Macario, A., Krummel, T. 2001; 192 (6): 768-776

    View details for Web of Science ID 000169043500014

    View details for PubMedID 11400971

  • A retrospective examination of regional plus general anesthesia in children undergoing open heart surgery ANESTHESIA AND ANALGESIA Hammer, G. B., Ngo, K., Macario, A. 2000; 90 (5): 1020-1024

    Abstract

    The use of regional anesthesia in combination with general anesthesia for children undergoing cardiac surgery is receiving increasing attention from clinicians. The addition of regional anesthesia may improve clinical outcomes and decrease costs as a result of the reduced need for postoperative mechanical ventilation. The goal of this retrospective chart review was to evaluate whether spinal anesthesia (SAB) or epidural anesthesia (EPID) in combination with general anesthesia was associated with circulatory stability, satisfactory postoperative sedation/analgesia, and a low incidence of adverse effects. The medical records of 50 consecutive children having open heart surgery with SAB or EPID and general anesthesia between September 1996 and December 1997 were reviewed. We found no significant differences in the incidence of clinically significant changes in vital signs, oxygen desaturation, hypercarbia, or vomiting. Patients in the SAB group received significantly more sedative/analgesic interventions than those in the EPID group.

    View details for Web of Science ID 000086764200003

    View details for PubMedID 10781446

  • Effect of compensation and patient scheduling on OR labor costs. AORN journal Macario, A., Dexter, F. 2000; 71 (4): 860-?

    Abstract

    To determine whether to accept a contract to provide additional surgical cases, OR managers must determine the incremental costs of caring for the new patients. The expected profitability of the contract can be computed by subtracting the incremental costs from the revenue. For surgical procedures, the incremental costs of OR labor significantly depend on how employees are paid (e.g., part-time versus full-time). If a surgical suite employs full-time staff members, incremental labor costs also are affected by how the day and time of patients' cases are selected (e.g., whether new cases are scheduled weeks in advance by the surgeon and the patient, or are performed on short notice based on the discretion of the surgical suite). This article explains how to estimate the incremental costs of staffing an OR for a case and discusses the use of internet-based online exchanges to match demand for OR time for additional cases to available unused OR capacity in variety of surgical suites.

    View details for PubMedID 10806540

  • Estimating the duration of a case when the surgeon has not recently scheduled the procedure at the surgical suite ANESTHESIA AND ANALGESIA Macario, A., Dexter, F. 1999; 89 (5): 1241-1245

    Abstract

    For some scheduled cases, there may be no previous cases of the same procedure type by the same surgeon for use in estimating the duration of the new case. We evaluated which of 16 different methods of analysis of other surgeons' cases of the same procedure type resulted in the most accurate prediction of the duration of the case that the surgeon had not recently scheduled. We analyzed durations for 4,955 cases, from an operating room information system, for which a surgeon had only scheduled the procedure once, and for which other surgeons had scheduled that same procedure one or more times. Using these data, we determined the difference between the actual duration of the new case and the estimated duration of the new case as calculated by each of the methods (average absolute error of 1.1 h with average case duration of 3.1 h).When no recent historical time data are available for a surgeon doing a given procedure, the mean of the durations of cases of the same scheduled procedure performed by other surgeons is as accurate an estimate as more sophisticated analyses. More research is needed to improve the precision of estimates of case durations.

    View details for Web of Science ID 000083498200030

    View details for PubMedID 10553843

  • What can the postanesthesia care unit manager do to decrease costs in the postanesthesia care unit? Journal of perianesthesia nursing Macario, A., Glenn, D., Dexter, F. 1999; 14 (5): 284-293

    Abstract

    The economic structure of the PACU dictates whether a cost-reducing intervention (e.g., reducing the length of time patients stay in the PACU) is likely to decrease hospital costs. Cost-reducing interventions, such as changes in medical practice patterns (e.g., to reduce PACU length of stay), only impact variable costs. How PACU nurses are paid (e.g., salaried v hourly) affects which strategies to decrease PACU staffing costs will actually save money. For example, decreases in PACU labor costs resulting from increases in the number of patients that bypass the PACU vary depending on how the staff is compensated. The choice of anesthetic drugs and the elimination of low morbidity side effects of anesthesia, such as postoperative nausea, are likely to have little effect on the peak numbers of patients in a PACU and PACU staffing costs. Because the major determinant of labor productivity in the PACU is hour-to-hour and day-to-day variability in the timing of admissions from the operating room, a more even inflow of patients into the PACU could be attained by appropriate sequencing of cases in the operating room suite (e.g., have long cases scheduled at the beginning of the day). However, this mathematically proven solution may not be desirable. Surgeons, for example, may not want to lose control over the order of their cases. Guidelines for analysis of past daily peak numbers of patients are provided that will provide data to predict the minimum adequate number of nurses needed. Though many managers already do this manually on an ad hoc basis statistical methods summarized in this article may increase the accuracy.

    View details for PubMedID 10827638

  • Which clinical anesthesia outcomes are important to avoid? the perspective of patients ANESTHESIA AND ANALGESIA Macario, A., Weinger, M., Carney, S., Kim, A. 1999; 89 (3): 652-658

    Abstract

    Healthcare quality can be improved by eliciting patient preferences and customizing care to meet the needs of the patient. The goal of this study was to quantify patients' preferences for postoperative anesthesia outcomes. One hundred one patients in the preoperative clinic completed a written survey. Patients were asked to rank (order) 10 possible postoperative outcomes from their most undesirable to their least undesirable outcome. Each outcome was described in simple language. Patients were also asked to distribute $100 among the 10 outcomes, proportionally more money being allocated to the more undesirable outcomes. The dollar allocations were used to determine the relative value of each outcome. Rankings and relative value scores correlated closely (r2 = 0.69). Patients rated from most undesirable to least undesirable (in order): vomiting, gagging on the tracheal tube, incisional pain, nausea, recall without pain, residual weakness, shivering, sore throat, and somnolence (F-test < 0.01).Although there is variability in how patients rated postoperative outcomes, avoiding nausea/vomiting, incisional pain, and gagging on the endotracheal tube was a high priority for most patients. Whether clinicians can improve the quality of anesthesia by designing anesthesia regimens that most closely meet each individual patient's preferences for clinical outcomes deserves further study.

    View details for Web of Science ID 000082249700022

    View details for PubMedID 10475299

  • Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists ANESTHESIA AND ANALGESIA Macario, A., Weinger, M., Truong, P., Lee, M. 1999; 88 (5): 1085-1091

    Abstract

    Anesthesia groups may need to determine which clinical anesthesia outcomes to track as part of quality improvement efforts. The goal of this study was to poll a panel of expert anesthesiologists to determine which clinical anesthesia outcomes associated with routine outpatient surgery were judged to occur frequently and to be important to avoid. Outcomes scoring highly in both scales could then be prioritized for measurement and improvement in ambulatory clinical practice. A mailed survey instrument instructed panel members to rate 33 clinical anesthesia outcomes in two scales: how frequently they believe the outcomes occur and which outcomes they expect patients find important to avoid. A feedback process (Delphi process) was used to gain consensus rankings of the outcomes for each scale. Importance and frequency scores were then weighted equally to qualitatively rank order the outcomes. Of the 72 anesthesiologists, 56 (78%) completed the questionnaire. The five items with the highest combined score were (in order): incisional pain, nausea, vomiting, preoperative anxiety, and discomfort from IV insertion. To increase quality of care, reducing the incidence and severity of these outcomes should be prioritized.Expert anesthesiologists reached a consensus on which low-morbidity clinical outcomes are common and important to the patient. The outcomes identified may be reasonable choices to be monitored as part of ambulatory anesthesia clinical quality improvement efforts.

    View details for Web of Science ID 000080063000023

    View details for PubMedID 10320175

  • Obstetric postanesthesia care unit stays - Reevaluation of discharge criteria after regional anesthesia ANESTHESIOLOGY Cohen, S. E., Hamilton, C. L., Riley, E. T., Walker, D. S., Macario, A., Halpern, J. W. 1998; 89 (6): 1559-1565

    Abstract

    Obstetric patients may have long postanesthesia care unit (OB-PACU) stays after surgery because of residual regional block or other conditions. This study evaluated whether modified discharge criteria might allow for earlier discharge without compromising patient safety.Data were prospectively collected for 6 months for all patients (N=358) who underwent cesarean section or tubal ligation and recovered in the OB-PACU. Regional anesthesia was used in 94% of patients. The duration of anesthesia and PACU stays, the presence and treatment of events in the PACU, and the regression of neural blockade were recorded. Discharge from the OB-PACU required a 60-min minimum stay, stable vital signs, adequate analgesia, and ability to flex the knees. After completion of prospective data collection, events that kept patients in the PACU after 60 min were reevaluated as to whether patients needed to stay in the PACU for medical reasons. "Needed to stay" events included bleeding, cardiorespiratory problems, sedation, dizziness, and pain. "Safe to leave" conditions included pruritus, nausea, and residual neural blockade. The cumulative duration of OB-PACU stays not clearly justifiable for medical reasons was calculated.Residual block and spinal opioid side effects accounted for the majority of "unnecessary" stays. Annually, 429 h of PACU time could have been saved using the revised criteria. Complications did not develop subsequently in any patient deemed "safe to leave."In many obstetric patients, the duration of PACU stays could safely be shortened by continuing observation in a lower-acuity setting. This may result in greater flexibility and more efficient use of nursing personnel.

    View details for Web of Science ID 000077376100035

    View details for PubMedID 9856733

  • Postoperative epidural injection of saline can shorten postanesthesia care unit time for knee arthroscopy patients REGIONAL ANESTHESIA AND PAIN MEDICINE Brock-Utne, J. G., Macario, A., Dillingham, M. F., Fanton, G. S. 1998; 23 (3): 247-251

    Abstract

    The goal of this prospective, double-blind study was to ascertain if the postanesthesia care unit (PACU) stay of outpatients receiving epidural anesthesia for knee arthroscopy is decreased by injection of epidural saline at the end of the case.Twenty healthy patients undergoing knee arthroscopy received lumbar epidural anesthesia with 2% lidocaine. At the end of surgery, in a double-blind design, group 1 patients (intervention group) received 20 mL 0.9% saline injected into the epidural catheter. Patients in group 2 (control group) had 1 mL 0.9% saline injected into the epidural catheter. In the PACU, the epidural catheter was removed, and motor block was assessed at 15-minute intervals according to the Bromage scale. Standard discharge criteria for our ambulatory surgery center were followed.Patients who received 20 mL epidural 0.9% saline remained in phase I (intensive nursing) 83 +/- 8 minutes compared with control patients who stayed 110 +/- 8 minutes (P < .01). Nonmedical issues related to the unavailability of the patients transportation or waiting for medications to be issued from the pharmacy delayed discharge from phase II (non-nursing) in 70% of group 1 patients and 60% of group 2 patients. Time to actual hospital dismissal for group I was 119 +/- 14 minutes, compared with 159 +/- 13 minutes (P < .05) for group 2.Patients receiving epidural anesthesia for knee arthroscopy had a shorter PACU stay if they received an injection of saline into the epidural space at the end of surgery.

    View details for Web of Science ID 000073676900003

    View details for PubMedID 9613534

  • The effect of a perioperative clinical pathway for knee replacement surgery on hospital costs ANESTHESIA AND ANALGESIA Macario, A., Horne, M., Goodman, S., Vitez, T., Dexter, F., Heinen, R., Brown, B. 1998; 86 (5): 978-984

    Abstract

    Clinical pathways are being introduced by hospitals to reduce costs and control unnecessary variation in care. We studied 766 inpatients to measure the impact of a perioperative clinical pathway for patients undergoing knee replacement surgery on hospital costs. One hundred twenty patients underwent knee replacement surgery before the development of a perioperative clinical pathway, and 63 patients underwent knee replacement surgery after pathway implementation. As control groups, we contemporaneously studied 332 patients undergoing radical prostatectomy (no clinical pathway in place for these patients) and 251 patients undergoing hip replacement surgery without a clinical pathway (no clinical pathway and same surgeons as patients having knee replacement surgery). Total hospitalization costs (not charges), excluding professional fees, were computed for all patients. Mean (+/-SD) hospital costs for knee replacement surgery decreased from $21,709 +/- $5985 to $17,618 +/- $3152 after implementation of the clinical pathway. The percent decrease in hospitalization costs was 1.56-fold greater (95% confidence interval 1.02-2.28) in the knee replacement patients than in the radical prostatectomy patients and 2.02-fold greater (95% confidence interval 1.13-5.22) than in the hip replacement patients. If patient outcomes (e.g., patient satisfaction) remain constant with clinical pathways, clinical pathways may be a useful tool for incremental improvements in the cost of perioperative care. Implications: Doctors and nurses can proactively organize and record the elements of hospital care results in a clinical pathway, also known as "care pathways" or "critical pathways." We found that implementing a clinical pathway for patients undergoing knee replacement surgery reduced the hospitalization costs of this surgery.

    View details for Web of Science ID 000073404900012

    View details for PubMedID 9585280

  • The impact of managed care on anesthesia residency training and clinical practice. Current opinion in anaesthesiology Scibetta, W. C., Macario, A. 1998; 11 (2): 221-224

    Abstract

    In this review, we attempt to summarize some of the complex issues surrounding managed care and discuss the resultant changes in anesthesiology practice and residency training in the USA. These changes have affected physician autonomy, job availability for graduates of residency training, and interest by medical students in the specialty. Anesthesiologists are focusing on increasing the value of the anesthesia service to patients, surgeons, hospitals, and managed care organizations, thereby securing the future growth of the specialty.

    View details for PubMedID 17013225

  • Setting performance standards for an anesthesia department JOURNAL OF CLINICAL ANESTHESIA Vitez, T. S., Macario, A. 1998; 10 (2): 166-175

    Abstract

    The Stanford University Department of Anesthesia established performance standards by identifying aspects of their service that were related to an important "customer's" perception of quality. A "quality grid" targeted service attributes that surgeons scored high for importance and low for performance. Control charts and flow charts helped establish reasonable performance levels for "timely first case starts" and "turnaround time." Control charts indicated that a reasonable performance standard for timely first case starts was "less than 20% of first case delays will be related to anesthesia activities." For turnaround time, the standard was set at "less than 10% of all turnaround times will be greater than 15 minutes, because of anesthesia-related activities." After instituting performance standards, the performance for first case start times improved from a 36% defective rate to a 9% defective rate. Anesthesia-related delays in turnaround times stabilized at a 16% defective rate. Using appropriate service standards can improve performance.

    View details for Web of Science ID 000072403200017

    View details for PubMedID 9524906

  • Bilateral vocal cord paralysis after radical cystectomy in a patient with a history of bulbar polio ANESTHESIA AND ANALGESIA Macario, A., Mackey, S., Terris, D. 1997; 85 (5): 1171-1172

    View details for Web of Science ID A1997YD31300040

    View details for PubMedID 9356120

  • Hospital costs and severity of illness in three types of elective surgery ANESTHESIOLOGY Macario, A., Vitez, T. S., Dunn, B., McDonald, T., Brown, B. 1997; 86 (1): 92-100

    Abstract

    If patients who are more severely ill have greater hospital costs for surgery, then health-care reimbursements need to be adjusted appropriately so that providers caring for more seriously ill patients are not penalized for incurring higher costs. The authors' goal for this study was to determine if severity of illness, as measured by either the American Society of Anesthesiologists Physical Status (ASA PS) or the comorbidity index developed by Charlson, can predict anesthesia costs, operating room costs, total hospital costs, or length of stay for elective surgery.The authors randomly selected 224 inpatients (60% sampling fraction) having either colectomy (n = 30), total knee replacement (n = 100), or laparoscopic cholecystectomy (n = 94) from September 1993 to September 1994. For each surgical procedure, backward-elimination multiple regression was used to build models to predict (1) total hospital costs, (2) operating room costs, (3) anesthesia costs, and (4) length of stay. Explanatory candidate variables included patient age (years), sex, ASA PS, Charlson comorbidity index (which weighs the number and seriousness of coexisting diseases), and type of insurance (Medicare/Medicaid, managed care, or indemnity). These analyses were repeated for the pooled data of all 224 patients. Costs (not patient charges) were obtained from the hospital cost accounting software.Mean total hospital costs were $3,778 (95% confidence interval +/- 299) for laparoscopic cholecystectomy, $13,614 (95% CI +/- 3,019) for colectomy, and $18,788 (95% CI +/- 573) for knee replacement. The correlation (r) between ASA PS and Charlson comorbidity scores equaled 0.34 (P < .001). No consistent relation was found between hospital costs and either of the two severity-of-illness indices. The Charlson comorbidity index (but not the ASA PS) predicted hospital costs only for knee replacement (P = .003). The ASA PS, but not the Charlson index, predicted operating room and anesthesia costs only for colectomy (P < .03).Severity of illness, as categorized by ASA PS categories 1-3 or by the Charlson comorbidity index, was not a consistent predictor of hospital costs and lengths of stay for three types of elective surgery. Hospital resources for these lower-risk elective procedures may be expended primarily to manage the consequences of the surgical disease, rather than to manage the patient's coexisting diseases.

    View details for Web of Science ID A1997WB86800013

    View details for PubMedID 9009944

  • Fuzzy logic: Theory and medical applications JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Vitez, T. S., Wada, R., Macario, A. 1996; 10 (6): 800-808

    View details for Web of Science ID A1996VP29100019

    View details for PubMedID 8910164

  • Tracheal diameter predicts double-lumen tube size: A method for selecting left double-lumen tubes ANESTHESIA AND ANALGESIA Brodsky, J. B., Macario, A., Mark, J. B. 1996; 82 (4): 861-864

    View details for Web of Science ID A1996UC48200032

    View details for PubMedID 8615510

  • WHERE ARE THE COSTS IN PERIOPERATIVE CARE - ANALYSIS OF HOSPITAL COSTS AND CHARGES FOR INPATIENT SURGICAL CARE ANESTHESIOLOGY Macario, A., Vitez, T. S., Dunn, B., McDonald, T. 1995; 83 (6): 1138-1144

    Abstract

    Many health-care institutions are emphasizing cost reduction programs as a primary tool for managing profitability. The goal of this study was to elucidate the proportion of anesthesia costs relative to perioperative costs as determined by charges and actual costs.Costs and charges for 715 inpatients undergoing either discectomy (n = 234), prostatectomy (n = 152), appendectomy (n = 122) or laparoscopic cholecystectomy (n = 207) were retrospectively analyzed at Stanford University Medical Center from September 1993 to September 1994. Total hospital costs were separated into 11 hospital departments. Cost-to-charge ratios were calculated for each surgical procedure and hospital department. Hospitalization costs were also divided into variable and fixed costs (costs that do and do not change with patient volume). Costs were further partitioned into direct and indirect costs (costs that can and cannot be linked directly to a patient).Forty-nine (49%) percent of total hospital costs were variable costs. Fifty-seven (57%) percent were direct costs. The largest hospital cost category was the operating room (33%) followed by the patient ward (31%). Intraoperative anesthesia costs were 5.6% of the total hospital cost. The overall cost-to-charge ratio (0.42) was constant between operations. Cost-to-charge ratios varied threefold among hospital departments. Patient charges overestimated resource consumption in some hospital departments (anesthesia) and underestimated resource consumption in others (ward).Anesthesia comprises 5.6% of perioperative costs. The influence of anesthesia practice patterns on "downstream" events that influence costs of hospitalization requires further study.

    View details for Web of Science ID A1995TJ32900002

    View details for PubMedID 8533904

  • Defining value in health care: Outcomes INTERNATIONAL ANESTHESIOLOGY CLINICS Macario, A. 1995; 33 (4): 15-31

    View details for Web of Science ID A1995TN56600002

    View details for PubMedID 8964623

  • BLIND PLACEMENT OF PLASTIC LEFT DOUBLE-LUMEN TUBES ANAESTHESIA AND INTENSIVE CARE Brodsky, J. B., Macario, A., Cannon, W. B., Mark, J. B. 1995; 23 (5): 583-586

    Abstract

    A prospective analysis of placement of left-sided plastic double-lumen tubes in 100 patients is presented. Intubation of the left bronchus was successfully accomplished using only auscultation and clinical signs ("blind" placement) in 91 patients. Double-lumen tubes were positioned in less than five minutes in 84 patients. The most common problem encountered (30%) was initial intubation of the right main bronchus. Seven of these patients required bronchoscopic assistance to guide the tube into the left bronchus. There were four minor intraoperative complications due to DLT malposition that were recognized and corrected by withdrawing the tube slightly back in the bronchus. The plastic double-lumen tubes functioned properly during the procedure in all 100 patients.

    View details for Web of Science ID A1995RX49400009

    View details for PubMedID 8787258

  • PAIN OUTCOMES AFTER THORACOTOMY - LUMBAR EPIDURAL HYDROMORPHONE VERSUS INTRAPLEURAL BUPIVACAINE JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Gaeta, R. R., Macario, A., Brodsky, J. B., BROCKUTNE, J. G., MARK, B. D. 1995; 9 (5): 534-537

    Abstract

    To evaluate postthoractomy analgesia in patients receiving lumbar epidural hydromorphone versus intrapleural bupivacaine.A randomized, prospective, double-blind study.A university-affiliated medical center.Twenty patients undergoing lateral thoracotomy for either pulmonary wedge resection, lobectomy, or pneumonectomy.Nine patients received epidural hydromorphone, and 11 patients received intrapleural bupivacaine in the postoperative period.Severity of pain was assessed using a visual analog pain scale (VAPS) (0 to 100 mm) at 1, 3, and 5 hours. Patients receiving epidural hydromorphone had a statistically significant improvement in VAPS scores. Patients who received intrapleural bupivacaine did not achieve a significant reduction in pain scores. Nine of 11 patients in the intrapleural bupivacaine group had "failed" postoperative analgesia as defined by a VAPS greater than 30. Only 3 of 9 patients in the continuous epidural hydromorphone group had "failed" analgesia.Epidural hydromorphone is superior to intrapleural bupivacaine in achieving satisfactory pain outcomes during the first 5 hours after thoracotomy.

    View details for Web of Science ID A1995TB74600009

    View details for PubMedID 8547554

  • THE DEMOGRAPHICS OF INPATIENT PEDIATRIC ANESTHESIA - IMPLICATIONS FOR CREDENTIALING POLICY JOURNAL OF CLINICAL ANESTHESIA Macario, A., Hackel, A., Gregory, G. A., FORSETH, D. 1995; 7 (6): 507-511

    Abstract

    To examine the demographics of inpatient anesthesia care for infants and children in a specific region to determine if there were sufficient numbers of procedures to permit credentialing to take place, as a first step in understanding the consequences of implementing credentialing policies based on caseload.Retrospective computerized review of discharge abstracts.All hospitals in northern California.Surgical procedures and date of surgery were linked to create "procedure-days." Each procedure-day counted as one anesthesia case. Annual hospital caseloads (procedure-days) were tabulated for three separate age subgroups under six years of age. The proximity of hospitals with smaller surgical volumes to those with larger volumes was determined. Of the 205 hospitals in the region, 162 had at least one procedure-day for children less than 6 years of age for a total of 14,435 procedure-days (anesthesia cases). For each of three age groups studied--0 to 6 months, 7 to 24 months, and 25 to 72 months--85%, 90%, and 81%, respectively, of hospitals had caseloads of 1 to 50 per year. When procedure days from all three age groups were totalled, 59% of hospitals had less than 20 cases per year and 72% of hospitals had less than 50 cases per year; 86% of hospitals had less than 100 cases per year. Of hospitals with less than 100 cases per year, 75% were within 50 miles of a hospital with more than 100 cases.Performance based credentialing for pediatric anesthesia based on caseload may be problematic for many hospitals due to the distribution of cases: a majority of hospitals care for a few children, and most children are cared for in a few hospitals.

    View details for Web of Science ID A1995RU81700013

    View details for PubMedID 8534469

  • A COST-ANALYSIS OF THE LARYNGEAL MASK AIRWAY FOR ELECTIVE SURGERY IN ADULT OUTPATIENTS ANESTHESIOLOGY Macario, A., Chang, P. C., STEMPEL, D. B., BROCKUTNE, J. G. 1995; 83 (2): 250-257

    Abstract

    Since the introduction of the laryngeal mask airway (LMA) into the United States in 1991, the device has become widely used in anesthesia practice. The purpose of this economic analysis was to use existing data to evaluate the costs of the LMA relative to three other common airway management techniques and to identify the variables that had the greatest effect on cost efficiency.We evaluated four airway management techniques for healthy adults receiving an isoflurane-nitrous oxide-oxygen anesthetic for elective outpatient surgery: (1) LMA with spontaneous ventilation; (2) face mask with spontaneous ventilation; (3) tracheal intubation after succinylcholine with subsequent spontaneous ventilation; and (4) tracheal intubation after nondepolarizing neuromuscular blockade and controlled ventilation. We analyzed published clinical studies of the LMA and obtained cost data from Stanford University Medical Center. The best available estimates of the independent variables were incorporated into a baseline case. For each airway technique we derived cost equations that excluded costs common to all four techniques.Relative to airway management with an LMA, calculated values for the baseline analysis included additional isoflurane costs for use of a face mask ($ 0.12/min) and for tracheal intubation with ($ 0.043/min) and without neuromuscular blockade ($ 0.06/min). With a neuromuscular blocking drug cost of $ 0.21/min and an LMA cost per use of $ 20, the face mask with spontaneous ventilation was the cost-efficient airway choice for anesthetics lasting as long as 100 min. Increasing the LMA reuse rate from 10 to 25 made the LMA the least costly airway technique for cases lasting more than 70 min.If the LMA is reused 40 times, the LMA is the cost-efficient airway choice for outpatients receiving an isoflurane-nitrous oxide-oxygen anesthetic lasting longer than 40 min. This finding does not change if the cost of neuromuscular blockade or the incidence of airway-related complications is varied over a clinically relevant range.

    View details for Web of Science ID A1995RM71100004

    View details for PubMedID 7631945

  • SPINAL VERSUS EPIDURAL-ANESTHESIA FOR CESAREAN-SECTION - A COMPARISON OF TIME EFFICIENCY, COSTS, CHARGES, AND COMPLICATIONS ANESTHESIA AND ANALGESIA Riley, E. T., Cohen, S. E., Macario, A., Desai, J. B., Ratner, E. F. 1995; 80 (4): 709-712

    Abstract

    Spinal anesthesia recently has gained popularity for elective cesarean section. Our anesthesia service changed from epidural to spinal anesthesia for elective cesarean section in 1991. To evaluate the significance of this change in terms of time management, costs, charges, and complication rates, we retrospectively reviewed the charts of patients who had received epidural (n = 47) or spinal (n = 47) anesthesia for nonemergent cesarean section. Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 +/- 20 vs 83 +/- 16 min, [mean +/- SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 +/- 11 vs 29 +/- 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (i.v.) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections.

    View details for Web of Science ID A1995QP46200010

    View details for PubMedID 7893022

  • REASSESSMENT OF PREOPERATIVE LABORATORY TESTING HAS CHANGED THE TEST-ORDERING PATTERNS OF PHYSICIANS SURGERY GYNECOLOGY & OBSTETRICS Macario, A., Roizen, M. F., Thisted, R. A., Kim, S., Orkin, F. K., Phelps, C. 1992; 175 (6): 539-547

    Abstract

    To test the hypothesis that physicians have substantially reduced the ordering of unwarranted preoperative tests, the authors reviewed 2,093 medical records of patients having four surgical procedures performed at three institutions in three cities in 1979, 1981, 1983, 1985 or 1987. Excluding hemoglobin measurements, the incidence of ordering preoperative laboratory tests unwarranted by findings on history or physical examination decreased from 32.2 to 25.9 percent during this decade, representing a 19.6 percent reduction. This decrease was irregular and varied from operation to operation, test to test and institution to institution. Overall, the percentage of preoperative tests ordered that were unwarranted decreased from 66.9 percent in 1979 to 60.1 percent in 1987. Extrapolating these results, the authors estimate that more than $320 million was saved annually by elimination of unwarranted tests and that the potential savings could exceed $1.35 billion a year. Unexpectedly, the preoperative ordering of medically indicated tests also decreased (from 92.9 to 80.9 percent, representing a 12.9 percent reduction). Because the benefit of performing justified tests is probably greater than the benefit of avoiding unwarranted tests, the net change has probably not been beneficial. A better system for obtaining justified tests and for eliminating the unwarranted tests may be necessary before a net benefit occurs. Punitive measures to reduce testing without prior establishment of such a system may save money, but impair health.

    View details for Web of Science ID A1992KA77100009

    View details for PubMedID 1448735

Conference Proceedings


  • Hospital profitability per hour of operating room time can vary among surgeons Macario, A., Dexter, F., Traub, R. D. LIPPINCOTT WILLIAMS & WILKINS. 2001: 669-675

    Abstract

    The operating margins (i.e., profits) of hospitals are decreasing. An important aspect of a hospital's finances is the profitability of individual surgical cases, which is measured by contribution margin. We sought to determine the extent to which contribution margin per hour of operating room (OR) time can vary among surgeons. We retrospectively analyzed 2848 elective cases performed by 94 surgeons at the Stanford University School of Medicine. For each case, we subtracted variable costs from the total payment to the hospital to compute contribution margin. We found moderate variability in contribution margin per hour of OR time among surgeons, relative to the variability in contribution margins per OR hour among each surgeon's cases (Cohen's f equaled 0.29, 95% lower confidence interval bound 0.27). Contribution margin per OR hour was negative for 26% of the cases. These results have implications for hospitals for which OR utilization is extensive, and for which elective cases are only scheduled if they can be completed during regularly scheduled hours. To increase or achieve profitability, managers need to increase the hours of lucrative cases, rather than encourage surgeons to do more and more cases. Whether the variability in contribution margin among surgeons should be used to more optimally (profitably) allocate OR time depends on the scheduling objectives of the surgical suite.

    View details for Web of Science ID 000170672100028

    View details for PubMedID 11524339

  • Analgesia for labor pain: A cost model Macario, A., Scibetta, W. C., Navarro, J., Riley, E. LIPPINCOTT WILLIAMS & WILKINS. 2000: 841-850

    Abstract

    Epidural analgesia and intravenous analgesia with opioids are two techniques for the relief of labor pain. The goal of this study was to develop a cost-identification model to quantify the costs (from society's perspective) of epidural analgesia compared with intravenous analgesia for labor pain. Because there is no valid method to assign a dollar value to differing levels of analgesia, the cost of each technique can be compared with the analgesic benefit (patient pain scores) of each technique.The authors created a cost model for epidural and intravenous analgesia by reviewing the literature to determine the rates of associated clinical outcomes (benefit of each technique to produce analgesia) and complications (e.g., postdural puncture headache). The authors then analyzed data from their institution's cost-accounting system to determine the hospital cost for parturients admitted for delivery, estimated the cost of each complication, and performed a sensitivity analysis to evaluate the cost impact of changing key variables. A secondary analysis was performed assuming that the cost of nursing was fixed (did not change depending on the number of nursing interventions).If the cesarean section rate equals 20% for both intravenous and epidural analgesia, the additional expected cost per patient to society of epidural analgesia of labor pain ranges from $259 (assuming nursing costs in the labor and delivery suite do not vary with the number of nursing interventions) to $338 (assuming nursing costs do increase as the number of interventions increases) relative to the expected cost of intravenous analgesia for labor pain. This cost difference results from increased professional costs and complication costs associated with epidural analgesia.Epidural analgesia is more costly than intravenous analgesia. How the cost of the anesthesiologist and nursing care is calculated affects how much more costly epidural analgesia is relative to intravenous analgesia. Published studies have determined that epidural analgesia provides relief of labor pain superior to intravenous analgesia, quantified in one study as 40 mm better on a 100-mm scale during the first stage of labor and 29 mm better during the second stage of labor. Patients, physicians, and society need to weigh the value of improved pain relief from epidural analgesia versus the increased cost of epidural analgesia.

    View details for Web of Science ID 000085628800026

    View details for PubMedID 10719963

  • An operating room scheduling strategy to maximize the use of operating room block time: Computer simulation of patient scheduling and survey of patients' preferences for surgical waiting time Dexter, F., Macario, A., Traub, R. D., Hopwood, M., Lubarsky, D. A. LIPPINCOTT WILLIAMS & WILKINS. 1999: 7-20

    Abstract

    Determining the appropriate amount of block time to allocate to surgeons and selecting the days on which to schedule elective cases can maximize operating room (OR) use. We used computer simulation to model OR scheduling. Inputs in the computer model included different methods to determine when a patient will have surgery (on-line bin-packing algorithms), case durations, lengths of time patients wait for surgery (2 wk is the median longest length of time that the outpatients [n = 367] surveyed considered acceptable), hours of block time each day, and number of blocks each week. For block time to be allocated to maximize OR utilization, two parameters must be specified: the method used to decide on what day a patient will have surgery and the average length of time patients wait to have surgery. OR utilization depends greatly on, and increases as, the average length of time patients wait for surgery increases.Operating room utilization can be maximized by allocating block time for the elective cases based on expected total hours of elective cases, scheduling patients into the first available date provided open block time is available within 4 wk, and otherwise scheduling patients in "overflow" time outside of the block time.

    View details for Web of Science ID 000081101100003

    View details for PubMedID 10389771

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