Insurance Premiums Cut in New Jersey
Who deserves the credit for the recent improvements in anesthesia morbidity and mortality? This was the topic of a breakfast panel sponsored by the Society for Technology in Anesthesia last October at the ASA Annual Meeting.
Nine speakers and moderator N. Ty Smith, M.D., president of the society, discussed & proposition that anesthesia care is now safer and that specific factors can be cited as contributing to this improvement. Each speaker was assigned one factor to analyze. Many of them suggested that it was difficult or impossible to dissect out the role of any one factor, but that they would accept the assignment of advocacy for their specialty in the spirit of an intellectual exercise.
Monitors: William New Jr, M.D. of Nellcor Corp. noted that monitors am “many unsleeping eyes” that allow us to “see the invisible,” especially early hypoxia and desaturation. He related that all anesthesia providers sometimes deal with hypoxemic patients, giving the monitoring concept significant clinical immediacy and a marketing advantage The positive aspect of monitoring is verifiable in both lab testing and clinical practice, according to Dr. New. In a light vein, monitors were referred to as “salvation in a box,” with serious follow-up comments on how electronic monitoring is helping anesthesiologists take charge of their own clinical futures.
Educators: Susan L Polk, M.D. of the University of Chicago stated that monitors were not likely to be of any value unless the user can recognize and act on what he sees. She maintained that the essential elements of an anesthesia education are knowledge, skills, attitude, humbleness and fright. Also, Dr. Polk was the fast to question whether there really has been a reduction in mortality and morbidity. However, accepting that promise, she noted the often-quoted statistic that 70-80% of all anesthesia mishaps involve human error. Which practitioners have problems can be evaluated in fight of the impact of age, type and place of training, board certification status and tune in practice. Further, the definite general improvement of the quality of anesthesia residents can be expected to contribute to an eventual parallel improvement in anesthesia practice.
Concerning these trainees, Dr. Folk concluded by stating that anesthesia educators “are responsible for attracting and choosing the buffable and then buffing them.
The Clinicians: William K. Hamilton, M.D. of U.C. San Francisco opened with & observation that there are no “real” data on anesthesia outcome, so he is not sure there is improvement for which to take credit. He did state that he felt there has been a significant increase in the number and quality of people entering anesthesiology and that this should go credit (or blame). Improved residency education upgraded, longer, more material to W6 from, as well as evolution of the profession and & ability to learn from the mistakes of others contribute to better clinicians who we, by definition, the ones who are the instruments of improved clinical care
Standards: Frederick W Cheney, M.D. of the University of Washington spoke on anesthesia standards and their role in unproved care. He quoted a plaintiffs malpractice attorney who has said that he is simply not seeing anesthesia cases any mom Dr. Cheney felt that it was not the monitoring standards themselves but, rather, all the publicity surrounding them that attracted the attention of the average practicing anesthesiologist and eventually had an impact on him. Now, some years later, we are seeing the benefits “on the front fine” with fewer anesthesia catastrophes.
The Researchers: Jeffrey B Cooper, Ph.D. of the Massachusetts General Hospital noted that there must be research behind all progress and, therefore, referring to improved anesthesia practice, researchers should be credited with starting it all. He suggested them is “real data” in the form of reduced anesthesiologist malpractice insurance premiums to support the claim that anesthesia mortality and morbidity has improved. To the extent that new machines, new monitors and new drugs play a role in this progress, researchers come before the clinicians as trail blazers. Studies of human error highlighted the clinicians’ fallability and made it more acceptable to try to address this issue. Standards followed and led to widespread conscientiousness-rising of all involved. Dr. Cooper stated that the “constant bubbling” of research is the hope for the future; research has to be supported. It is the first thing cut in a budget crunch, and this is totally inappropriate because of the consequent inability for practice to change and progress.
As an important aside, Dr. Cooper commented that the lawyers had to be given indirect credit for increased anesthesia safety because they precipitated an economic crisis that led to research and a subsequent cascade of positive events. The Anesthesia Patient Safety Foundation: E.C. Pierce, Jr., M.D., President of the APSF, recounted some of the four-year history of the Foundation. He described his own experience with a mishap. Overall, he opined, economics of medical care is an increasingly important driving force Dr. Pierce noted that he believed that the APSF is contributing to the unquestionable improvement in anesthesia care through various of its activities: from this Newsletter to educational sessions at meetings (such as the study booth in the ASA exhibit) and at its sponsored meetings (e.g. anesthesia simulators) to the safety research grants given by the organization. He stressed the need for support of the Foundation if all these efforts are to continue to contribute to improved anesthesia safety.
Insurance Companies : Mr. Mark Wood of the St. Paul Fire and Marine Insurance Company noted that in whatever organizational form, insurance organizations must at least break even or, better, make a profit to exist. Insurers have three ways to deal with problem losses: 1) increase premiums, 2) increase claims staff efforts to cut expenses on both sides of a case and, 3) work to prevent claims. It is in this List area that recent efforts have come. Companies have tried to identify the causes of loss and then inform their insured so that action can be taken to prevent repeat episodes. He cited the example of the rapid boom in hospital construction in the early 1970s leading to many crossed gas pipelines and resultant oxygen supply problem causing hypoxic accidents; insurers responded by pushing anesthesiologists very hard to have oxygen concentration monitors at all times. In the 1980s, the issue was sudden cardiac arrest which turned out, on later investigations, to be due to unrecognized hypoxia. This led to a strong push (including restrictive covenants and incentive discounts) for anesthesiologists to use pulse oximeter and capnography at all times to help insure appropriate oxygenation and ventilation.
Mr. Wood stated that there are fewer and less severe anesthesia-related insurance claims of all types, not only hypoxic catastrophes, since the time of the inception of the patient safety “movement” in anesthesia so that it is difficult to sort out what contributions various factors have made.
The Lawyers: Richard E Gibbs, M.D., J.D. from the Brigham and Women’s Hospital in Boston discussed what impact the legal profession has had in ” area. LESO cases tend to help define the standard of care with plaintiffs’ experts trying to push it higher and higher and defense experts attempting to be realistic. Both are important because out of such discussions evolve expected behavior, which has included a high expectation for safe anesthesia care. Anesthetists are generally better today. Likewise, attorneys are much more sophisticated in prosecuting their cases. Dr. Gibbs stated that lawyers forced the malpractice issue and thus “tossed the hall to the anesthesiology profession, which caught it and ran with it.”
Anesthetic Agents: Mr. George Griffiths of the Jansen Research Foundation suggested that improved anesthetic agents do have a role in the decrease in mortality and morbidity. He cited the development of current and future inhalation agents, beta blockers and opioids that allow smoother anesthesia with less stress to the patient. As he was the last speaker, he summed up by noting that, almost by definition, it is everybody involved all together who is responsible for the improvement in anesthesia care.
Several points in the discussion period centered around the question of whether the improvements in care were simply a result of the natural evolution of practice and would have occurred anyway or whether the specific patient safety movement had made a special impact that would not have been otherwise seen. Opinions on both sides were voiced. Mr. Wood made a strong statement in favor of the safety efforts having definite benefits by noting that the profession of anesthesiology is the best example of an organized group effectively doing something constructive in the areas of risk management and quality assurance. Some members of the audience reminded the group not to underrate the importance of the individual clinician, the one who takes the blame when things go wrong and who should get the credit when things do better.
Dr. Eichhorn, Harvard Medical School and Beth Israel Hospital, Boston, is the Editor of the APSF Newsletter.