No abstract

Background The goal of this study was to evaluate the effect of regional anesthesia using paravertebral block (PVB) on postoperative pain after breast surgery. Methods Patients undergoing unilateral breast surgery without reconstruction were randomized to general anesthesia (GA) only or PVB with GA and pain scores assessed. Results Eighty patients were randomized (41 to GA and 39 to PVB with GA). Operative times were not significantly different between groups. Pain scores were lower after PVB compared to GA at 1 hour (1 versus 3, p=0.006) and 3 hours (0 versus 2, p=0.001), but not at later time points. The overall worst pain experienced was lower with PVB (3 versus 5, p=0.02). More patients were pain free in the PVB group at 1 hour (44% versus 17%, p=0.014) and 3 hours (54% versus 17%, p=0.005) postoperatively. Conclusions Paravertebral block significantly decreases postoperative pain up to 3 hours after breast cancer surgery. Summary This paper reports on the findings from a prospective randomized trial of paravertebral block (PVB) for breast surgery. Paravertebral block significantly decreased postoperative pain up to 3 hours after breast cancer surgery.

We observed the greatest improvement in guideline compliance with ongoing personal performance feedback. Provider feedback can be an effective tool to modify clinical practice but can have unanticipated consequences.

Thoracic paravertebral block (PVB) in breast surgery can provide regional anesthesia during and after surgery with the potential advantage of decreasing postoperative pain. We report our institutional experience with PVB over the initial 8 months of use. All patients undergoing breast operations at the ambulatory care building from September 09, 2005 to June 28, 2005 were reviewed. Comparison was performed between patients receiving PVB and those who did not. Pain scores were assessed immediately, 4 hours, 8 hours and the morning after surgery. 178 patients received PVB and 135 patients did not. Patients were subdivided into three groups: Group A-segmental mastectomy only (n = 89), Group B-segmental mastectomy and sentinel node surgery (n = 111) and Group C-more extensive breast surgery (n = 113). Immediately after surgery there was a statistically significant difference in the number of patients reporting pain between PVB patients and those without PVB. At all time points up until the morning after surgery PVB patients were significantly less likely to report pain than controls. Patients in Group C who received PVB were significantly less likely to require overnight stay. The average immediate pain scores were significantly lower in PVB patients than controls in both Group B and Group C and approached significance in Group A. PVB in breast surgical patients provided improved postoperative pain control. Pain relief was improved immediately postoperatively and this effect continued to the next day after surgery. PVB significantly decreased the proportion of patients that required overnight hospitalization after major breast operations and therefore may decrease cost associated with breast surgery.

Background With the movement towards bundled payments, stakeholders should know the true cost of the care they deliver. Time-driven activity-based costing (TDABC) can be used to estimate costs for each episode of care. In this analysis, TDABC is used to both estimate the costs of anesthesia care and identify the primary drivers of those costs of 11 common oncologic outpatient surgical procedures. Methods Personnel cost were calculated by determining the hourly cost of each provider and the associated process time of the 11 surgical procedures. Using the anesthesia record, drugs, supplies and equipment costs were identified and calculated. The current staffing model was used to determine baseline personnel costs for each procedure. Using the costs identified through TDABC analysis, the effect of different staffing ratios on anesthesia costs could be predicted. Results Costs for each of the procedures were determined. Process time and costs are linearly related. Personnel represented 79% of overall cost while drugs, supplies and equipment represented the remaining 21%. Changing staffing ratios shows potential savings between 13-28% across the 11 procedures. Conclusions TDABC can be used to estimate the costs of anesthesia care. This costing information is critical to assessing the anesthesiology component in a bundled payment. It can also be used to identify areas of cost savings and model costs of anesthesia care. CRNA to anesthesiologist staffing ratios profoundly influence the cost of care. This methodology could be applied to other medical specialties to help determine costs in the setting of bundled payments.