Alex Macario spent 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 attended the University of Rochester on a Joseph C. Wilson Merit 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 as Program Director for the Stanford anesthesiology residency for the past 12 years, he has led the training of approximately 250 graduates who are now practicing anesthesiologists. He was the Inaugural recipient in 2015 of the Outstanding Contribution to Graduate Medical Education as Program Director award for Stanford University. He has led the creation of several new and innovative education initiatives:
1. The Stanford Anesthesia Faculty Teaching Scholars Program, which created structure for more than 35 faculty to obtain education in teaching, curriculum, and assessment.
2. 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.
3. The Stanford Fellowship in Anesthesia Research and Medicine residency track for anesthesiologists who want research-intensive careers. Many of the graduates have gone on to obtain NIH funding.
4. The Combined Residency Internal Medicine and Anesthesiology established in 2012 in which three Stanford residents a year participate.
5. The Combined Residency Pediatrics & Anesthesia. Eight years ago, this was one of the very first programs in the country to offer this combined training and has two residents per year.

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. More recently, Dr. Macario's research team has focused on medical education.

Google Scholar calculates Dr. Macario’s H-Index as 50 and his I-10 Index as 115. An index of h indicates an investigator has published h papers each of which has been cited in other papers at least h times. Thus, the h-index reflects both the number of publications and the number of citations per publication. Dr. Macario's scientific articles have been cited more than 8000 times.

Dr. Macario has also authored "A Sabbatical in Madrid: A Diary of Spain," an award winning travel memoir. Dr. Macario has two adult children working in San Francisco 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 playing tennis.

Why I Became an Anesthesiologist is available at

Clinical Focus

  • Multispecialty including for example anesthesia for orthopedics, urology, neurosurgery, ambulatory surgery, and general surgery
  • Anesthesia

Academic Appointments

Administrative Appointments

  • Program Director, Combined Internal Medicine-Anesthesiology residency (2013 - Present)
  • Associate Program Director, Combined Pediatrics and Anesthesiology Residency (2010 - Present)
  • Founder, Faculty Teaching Scholars Program, Department of Anesthesiology (2007 - Present)
  • Executive Committee, Faculty Senate, Stanford University School of Medicine (2007 - 2012)
  • Program Director, Anesthesiology Residency (2006 - Present)
  • Vice-Chairman for Education, Department of Anesthesiology (2006 - Present)
  • Finance Committee, Dept of Anesthesiology (2003 - Present)
  • Visiting Professor, TAISS, Madrid, Spain (2001 - 2002)
  • Governance Committee, Dept. of Anesthesiology (1997 - Present)
  • Program Director, Management of Perioperative Services Fellowship (1996 - Present)

Honors & Awards

  • Global Health Grant: Collaboration in Zimbabwe for anesthesiologist training and education research, Sponsor: Office of International Affairs, Stanford University (2015)
  • Inaugural recipient, Outstanding Contribution to Graduate Medical Education as Program Director, Stanford University (2015)
  • Medical technology grant: A monitoring system to prevent unnecessary blood wastage, Sponsor: Stanford Center for Clinical and Translational Research and Education (2015)
  • Faculty Mentor Award, American Society of Anesthesiology, Committee on Professional Diversity (2012-2013)
  • Charter member, Education Academy, Foundation for Anesthesia Education & Research (2012)
  • Education Advisory Board, Association of University Anesthesiologists (2012)
  • First place, “best article”, Journal of Medical Internet Research: 4th World Congress on Social Media & Web 2.0 Health & Medicine (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)
  • Research Incentive Award, Testing a secure Web based, decision support system for anesthesia, Stanford University Office of Technology Licensing (2001-2002)
  • Principal Investigator for grant on patient preferences for postoperative outcomes, Foundation for Anesthesia Education Research (1998)
  • Annual Resident Research Prize, 3rd Place, American Society of Anesthesiologists (1995)
  • Valdes - Dapena Research Prize, The Graduate Hospital, University of Pennsylvania (1991)
  • Graduation Speaker, College of Arts & Sciences, University of Rochester (1986)
  • Phi Beta Kappa, 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

  • Director, Board of Directors, American Board of Anesthesiology (2017 - Present)
  • Examiner, American Board of Anesthesiology (2011 - Present)
  • Editorial Board, Medscape Anesthesiology website at (2010 - Present)
  • Member, Association of University Anesthesiologists (honorific society) (2000 - Present)
  • Editorial Board, Anesthesiology News (1999 - Present)

Professional Education

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

Community and International Work

  • Zimbabwe Global Health elective for anesthesia residency



    Partnering Organization(s)

    University of Zimbabwe College of Health Sciences, Department of Anesthesiology

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Postgraduate Fellowship in Global Health





    Ongoing Project


    Opportunities for Student Involvement


  • Global Health Trip 1994, Vietnam


    Anesthesia for cleft lip and palate surgery on children

    Partnering Organization(s)


    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Dr. Macario studies health care economics and outcomes, with a special focus on surgery and anesthesia.

Dr. Macario is well known for helping develop the field of operating room management.

He is also passionate about cost-effectiveness analyses of drugs and devices.

For the past decade Dr. Macario has added research in medical education as a key focus to better understand methods to best teach residents.

Google Scholar calculates Dr. Macario’s H-Index as 45 and his I-10 as 99.

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


  • Collaboration in Zimbabwe for anesthesiologist training and education research, Stanford University, Department of Anesthesiology

    The University of Zimbabwe College of Health Sciences (UZCHS) partners with Stanford University to help improve medical education in Zimbabwe. The Department of Anesthesiology at Stanford is leading the anesthesia arm of the program. This year Drs. Crawford and McGoldrick completed a research initiative utilizing the "flipped classroom" technique, where trainees access videos for content, and classroom time focuses on interactive sessions. Results showed the local trainees had increased preparedness and knowledge of clinical scenarios involving anesthetic emergencies. Questions on relevance and adaptability of the information presented indicated a need for improvement. The residents voiced a desire for additional video lectures with interest in designing their own. One local trainee created two video lectures to incorporate into the newly developing regional anesthesia curriculum and several other Zimbabwe residents (registrars) have expressed interest in doing the same. The needs assessment also identified additional curriculum development for regional anesthesia specifically peripheral nerve blocks, a simulation lab, and video lectures covering topics in which they receive limited clinical experience. The opportunity to host faculty (Samson Shumbairerwa and Faraj Madzimbamuto) from UZCHS at Stanford to see our entire graduate medical education system would provide them with a research perspective so they can further determine what teaching methods will work best for them.


    University of Zimbabwe Campus Harare 00263 Zimbabwe



2017-18 Courses

Stanford Advisees

Graduate and Fellowship Programs


All Publications

  • Implementation of a Needs-Based, Online Feedback Tool for Anesthesia Residents With Subsequent Mapping of the Feedback to the ACGME Milestones ANESTHESIA AND ANALGESIA Tanaka, P., Merrell, S. B., Walker, K., Zocca, J., Scotto, L., Bogetz, A. L., Macario, A. 2017; 124 (2): 627-635
  • Occupational Radiation Exposure of Anesthesia Providers. Seminars in cardiothoracic and vascular anesthesia Wang, R. R., Kumar, A. H., Tanaka, P., Macario, A. 2017: 1089253217692110-?


    Anesthesia providers are frequently exposed to radiation during routine patient care in the operating room and remote anesthetizing locations. Eighty-two percent of anesthesiology residents (n = 57 responders) at our institution had a "high" or "very high" concern about the level of ionizing radiation exposure, and 94% indicated interest in educational materials about radiation safety. This article highlights key learning points related to basic physical principles, effects of ionizing radiation, radiation exposure measurement, occupational dose limits, considerations during pregnancy, sources of exposure, factors affecting occupational exposure such as positioning and shielding, and monitoring. The principle source of exposure is through scattered radiation as opposed to direct exposure from the X-ray beam, with the patient serving as the primary source of scatter. As a result, maximizing the distance between the provider and the patient is of great importance to minimize occupational exposure. Our dosimeter monitoring project found that anesthesiology residents (n = 41) had low overall mean measured occupational radiation exposure. The highest deep dose equivalent value for a resident was 0.50 mSv over a 3-month period, less than 10% of the International Commission on Radiological Protection occupational limit, with the eye dose equivalent being 0.52 mSv, approximately 4% of the International Commission on Radiological Protection recommended limit. Continued education and awareness of the risks of ionizing radiation and protective strategies will reduce exposure and potential for associated sequelae.

    View details for DOI 10.1177/1089253217692110

    View details for PubMedID 28190371

  • Implementation of a Needs-Based, Online Feedback Tool for Anesthesia Residents With Subsequent Mapping of the Feedback to the ACGME Milestones. Anesthesia and analgesia Tanaka, P., Bereknyei Merrell, S., Walker, K., Zocca, J., Scotto, L., Bogetz, A. L., Macario, A. 2017; 124 (2): 627-635


    Optimizing feedback that residents receive from faculty is important for learning. The goals of this study were to (1) conduct focus groups of anesthesia residents to define what constitutes optimal feedback; (2) develop, test, and implement a web-based feedback tool; and (3) then map the contents of the written comments collected on the feedback tool to the Accreditation Council for Graduate Medical Education (ACGME) anesthesiology milestones.All 72 anesthesia residents in the program were invited to participate in 1 of 5 focus groups scheduled over a 2-month period. Thirty-seven (51%) participated in the focus groups and completed a written survey on previous feedback experiences. On the basis of the focus group input, an initial online feedback tool was pilot-tested with 20 residents and 62 feedback sessions, and then a final feedback tool was deployed to the entire residency to facilitate the feedback process. The completed feedback written entries were mapped onto the 25 ACGME anesthesiology milestones.Focus groups revealed 3 major barriers to good feedback: (1) too late such as, for example, at the end of month-long clinical rotations, which was not useful because the feedback was delayed; (2) too general and not specific enough to immediately remedy behavior; and (3) too many in that the large number of evaluations that existed that were unhelpful such as those with unclear behavioral anchors compromised the overall feedback culture. Thirty residents (42% of 72 residents in the program) used the final online feedback tool with 121 feedback sessions with 61 attendings on 15 rotations at 3 hospital sites. The number of feedback tool uses per resident averaged 4.03 (standard deviation 5.08, median 2, range 1-21, 25th-75th % quartile 1-4). Feedback tool uses per faculty averaged 1.98 (standard deviation 3.2, median 1, range 1-25, 25th-75th % quartile 1-2). For the feedback question item "specific learning objective demonstrated well by the resident," this yielded 296 milestone-specific responses. The majority (71.3%) were related to the patient care competency, most commonly the anesthetic plan and conduct (35.8%) and airway management (11.1%) milestones; 10.5% were related to the interpersonal and communication skills competency, most commonly the milestones communication with other professionals (4.4%) or with patients and families (4.4%); and 8.4% were related to the practice-based learning and improvement competency, most commonly self-directed learning (6.1%). For the feedback tool item "specific learning objective that resident may improve," 67.0% were related to patient care, most commonly anesthetic plan and conduct (33.5%) followed by use/interpretation of monitoring and equipment (8.5%) and airway management (8.5%); 10.2% were related to practice-based learning and improvement, most commonly self-directed learning (6.8%); and 9.7% were related to the systems-based practice competency.Resident focus groups recommended that feedback be timely and specific and be structured around a tool. A customized online feedback tool was developed and implemented. Mapping of the free-text feedback comments may assist in assessing milestones. Use of the feedback tool was lower than expected, which may indicate that it is just 1 of many implementation steps required for behavioral and culture change to support a learning environment with frequent and useful feedback.

    View details for DOI 10.1213/ANE.0000000000001647

    View details for PubMedID 28099326

  • Mapping of Primary Instructional Methods and Teaching Techniques for Regularly Scheduled, Formal Teaching Sessions in an Anesthesia Residency Program. A & A case reports Vested Madsen, M., Macario, A., Yamamoto, S., Tanaka, P. 2016; 6 (11): 343-347


    In this study, we examined the regularly scheduled, formal teaching sessions in a single anesthesiology residency program to (1) map the most common primary instructional methods, (2) map the use of 10 known teaching techniques, and (3) assess if residents scored sessions that incorporated active learning as higher quality than sessions with little or no verbal interaction between teacher and learner. A modified Delphi process was used to identify useful teaching techniques. A representative sample of each of the formal teaching session types was mapped, and residents anonymously completed a 5-question written survey rating the session. The most common primary instructional methods were computer slides-based classroom lectures (66%), workshops (15%), simulations (5%), and journal club (5%). The number of teaching techniques used per formal teaching session averaged 5.31 (SD, 1.92; median, 5; range, 0-9). Clinical applicability (85%) and attention grabbers (85%) were the 2 most common teaching techniques. Thirty-eight percent of the sessions defined learning objectives, and one-third of sessions engaged in active learning. The overall survey response rate equaled 42%, and passive sessions had a mean score of 8.44 (range, 5-10; median, 9; SD, 1.2) compared with a mean score of 8.63 (range, 5-10; median, 9; SD, 1.1) for active sessions (P = 0.63). Slides-based classroom lectures were the most common instructional method, and faculty used an average of 5 known teaching techniques per formal teaching session. The overall education scores of the sessions as rated by the residents were high.

    View details for DOI 10.1213/XAA.0000000000000317

    View details for PubMedID 27243580

  • Analysis of Resident Case Logs in an Anesthesiology Residency Program. A & A case reports Yamamoto, S., Tanaka, P., Madsen, M. V., Macario, A. 2016; 6 (8): 257-262


    Our goal in this study was to examine Accreditation Council for Graduate Medical Education case logs for Stanford anesthesia residents graduating in 2013 (25 residents) and 2014 (26 residents). The resident with the fewest recorded patients in 2013 had 43% the number of patients compared with the resident with the most patients, and in 2014, this equaled 48%. There were residents who had 75% more than the class average number of cases for several of the 12 case types and 3 procedure types required by the Accreditation Council for Graduate Medical Education. Also, there were residents with fewer than half as many for some of the required cases or procedure types. Some of the variability may have been because of the hazards of self-reporting.

    View details for DOI 10.1213/XAA.0000000000000248

    View details for PubMedID 26517235

  • The Heart of the Matter: Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography. A & A case reports Sanford, J. A., Kadry, B., Oakes, D., Macario, A., Schmiesing, C. 2016; 6 (8): 249-252


    Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.

    View details for DOI 10.1213/XAA.0000000000000169

    View details for PubMedID 27082233

  • Impact of an Innovative Classroom-Based Lecture Series on Residents' Evaluations of an Anesthesiology Rotation. Anesthesiology research and practice Tanaka, P., Yanez, D., Lemmens, H., Djurdjulov, A., Scotto, L., Borg, L., Walker, K., Bereknyei Merrell, S., Macario, A. 2016; 2016: 8543809-?


    Introduction. Millennial resident learners may benefit from innovative instructional methods. The goal of this study is to assess the impact of a new daily, 15 minutes on one anesthesia keyword, lecture series given by faculty member each weekday on resident postrotation evaluation scores. Methods. A quasi-experimental study design was implemented with the residents' rotation evaluations for the 24-month period ending by 7/30/2013 before the new lecture series was implemented which was compared to the 14-month period after the lecture series began on 8/1/2013. The primary endpoint was "overall teaching quality of this rotation." We also collected survey data from residents at clinical rotations at two other different institutions during the same two evaluation periods that did not have the education intervention. Results. One hundred and thirty-one residents were eligible to participate in the study. Completed surveys ranged from 77 to 87% for the eight-question evaluation instrument. On a 5-point Likert-type scale the mean score on "overall teaching quality of this rotation" increased significantly from 3.9 (SD 0.8) to 4.2 (SD 0.7) after addition of the lecture series, whereas the scores decreased slightly at the comparison sites. Conclusion. Rotation evaluation scores for overall teaching quality improved with implementation of a new structured slide daily lectures series.

    View details for DOI 10.1155/2016/8543809

    View details for PubMedID 26989407

  • In Response. Anesthesia and analgesia Downey, L., Blaine, K., Sliwa, J., Macario, A., Brock-Utne, J. 2015; 121 (4): 1113-?

    View details for DOI 10.1213/ANE.0000000000000827

    View details for PubMedID 26378711

  • A Case Illustrating the Costs of Quality Improvement: Nine Months to Move Needles and Syringes on the Anesthesia Cart. A & A case reports Quick, A. K., Macario, A., Brock-Utne, J. G., Jaffe, R. A., Kadry, B. 2015; 5 (5): 88-90


    Powerful entities are pushing physicians to become more involved with quality improvement (QI). We report a QI project to standardize and improve the ergonomics of the anesthesia medication and supply cart. Simply obtaining approval to make minor changes to the cart involved 54 phone calls, 164 e-mails, 4 presentations, 2 forms, 9 meetings, and 4 months of time. Confusion over fiscal matters further delayed the project by an additional 3 months. A combination of competing regulations, administrative overprocessing, and the lack of dedicated QI financial resources made simple improvements a challenge. The costs of participating in QI deserve attention.

    View details for DOI 10.1213/XAA.0000000000000148

    View details for PubMedID 26323036

  • No Significant Association between Anesthesia Group Concentration and Private Insurer Payments in the United States ANESTHESIOLOGY Sun, E. C., Dexter, F., Macario, A., Miller, T. R., Baker, L. C. 2015; 123 (3): 507-514

    View details for DOI 10.1097/ALN.0000000000000779

    View details for Web of Science ID 000363536900005

    View details for PubMedID 26192028

  • Bariatric Surgery Operating Room Time-Size Matters OBESITY SURGERY Sanford, J. A., Kadry, B., Brodsky, J. B., Macario, A. 2015; 25 (6): 1078-1085


    The goal of this study was to document the relationship between BMI and the components of bariatric surgical operating room (OR) time.The Stanford Translational Research Integrated Database Environment identified all patients who underwent laparoscopic Roux-en-Y gastric bypass procedures at Stanford University Medical Center between May 2008 and November 2013. The 434 patients were divided into 3 groups: group 1 (n = 213) BMI ≥35 to <45 kg/m(2), group 2 (n = 188) BMI ≥45.0 to <60 kg/m(2), and group 3 (n = 33) BMI ≥60 kg/m(2). The primary variable measured was total operating room time, defined as beginning when the patient entered the OR until the moment the patient physically left the OR. Secondary variables were anesthetic induction time, nursing preparation time, operation time, time for emergence from anesthesia, and total length of hospital stay.Increasing BMI was associated with increased total OR time (group 1 = 202 min, group 2 = 215 min, group 3 = 235 min), mainly due to longer operation time (group 1 = 147 min, group 2 = 154 min, group 3 = 163 min). Anesthetic induction (group 1 = 17 min, group 2 = 18 min, group 3 = 23 min) and emergence times (group 1 = 12 min, group 2 = 12 min, group 3 = 22 min) were also significantly longer in the largest patients.Operating room schedules and plans for resource utilization should recognize that the same bariatric procedure will require more time for patients with BMI >60 kg/m(2) than for smaller bariatric patients.

    View details for DOI 10.1007/s11695-015-1651-5

    View details for Web of Science ID 000354216500022

    View details for PubMedID 25802066

  • Positive end-expiratory pressure to increase internal jugular vein size is poorly tolerated in obese anesthetized adults. Anesthesia and analgesia Downey, L. A., Blaine, K. P., Sliwa, J., Macario, A., Brock-Utne, J. 2014; 119 (3): 619-621


    Central venous cannulation is technically challenging in obese patients. We hypothesized that positive end-expiratory pressure (PEEP) increases the size of the internal jugular vein (IJV) in obese adults.The circumference and cross-sectional area of the IJV were measured in obese patients under general anesthesia at PEEP 0, 5, and 10 cm H2O. Results are reported as means ± SE.PEEP at 10 cm H2O was tolerated by 18 of 24 obese patients. Each 5 cm H2O of PEEP increased the cross-sectional area by 0.16 ± 0.02 cm (P < 0.0001) and the circumference by 0.23 ± 0.03 cm (P < 0.0001).PEEP modestly increases the size of the IJV in obese adults but was poorly tolerated because of hypotension.

    View details for DOI 10.1213/ANE.0000000000000347

    View details for PubMedID 25137000

  • Data, data, on the server: challenges in applying data analysis to operating room management. Anesthesiology Sanford, J. A., Macario, A. 2014; 121 (1): 6-8

    View details for DOI 10.1097/ALN.0000000000000288

    View details for PubMedID 24796683

  • Scheduling of procedures and staff in an ambulatory surgery center. Anesthesiology clinics Pash, J., Kadry, B., Bugrara, S., Macario, A. 2014; 32 (2): 517-527


    For ambulatory surgical centers (ASC) to succeed financially, it is critical for ASC managers to schedule surgical procedures in a manner that optimizes operating room (OR) efficiency. OR efficiency is maximized by using historical data to accurately predict future OR workload, thereby enabling OR time to be properly allocated to surgeons. Other strategies to maintain a well-functioning ASC include recruiting and retaining the right staff and ensuring patients and surgeons are satisfied with their experience. This article reviews different types of procedure scheduling systems. Characteristics of well-functioning ASCs are also discussed.

    View details for DOI 10.1016/j.anclin.2014.02.020

    View details for PubMedID 24882135

  • In response. Anesthesia and analgesia Macario, A., Carvalho, B., Tan, J. M., Sultan, P., El-Sayed, Y. Y. 2014; 118 (4): 884-885

    View details for DOI 10.1213/ANE.0000000000000114

    View details for PubMedID 24651247

  • Economic Burden of Back and Neck Pain: Effect of a Neuropathic Component. Population health management Kleinman, N., Patel, A. A., Benson, C., Macario, A., Kim, M., Biondi, D. M. 2014


    Abstract This was a retrospective database analysis (2001-2009) of employees' medical, prescription drug, and absence costs and days from sick leave, short- and long-term disability, and workers' compensation. Employees with an ICD-9 diagnostic code for back or neck pain and an ICD-9 for a back- or neck-related neuropathic condition (eg, myelopathy, compression of the spinal cord, neuritis, radiculitis) or radiculopathy were considered to have nociceptive back or neck pain with a neuropathic component. Employees with an ICD-9 for back pain or neck pain and no ICD-9 for a back- or neck-related neuropathic condition or radiculopathy were defined to have nociceptive back or neck pain. Patients with nociceptive back or neck pain with a neuropathic component were classified as having or not having prior nociceptive pain. Annual costs (medical and prescription drug costs and absence costs) and days from sick leave, short- and long-term disability, and workers' compensation were evaluated. Mean annual total costs were highest ($8512) for nociceptive pain with a neuropathic component with prior nociceptive pain (n=9162 employees), $7126 for nociceptive pain with a neuropathic component with no prior nociceptive pain (n=5172), $5574 for nociceptive pain only (n=35,347), and $3017 for control employees with no back or neck pain diagnosis (n=226,683). Medical, short-term disability, and prescription drugs yielded the highest incremental costs compared to controls. Mean total absence days/year were 8.26, 7.86, 5.70, and 3.44, respectively. The economic burden of back pain or neck pain is increased when associated with a neuropathic component. (Population Health Management 2014;xx:xxx-xxx).

    View details for DOI 10.1089/pop.2013.0071

    View details for PubMedID 24684443

  • Obesity increases operating room times in patients undergoing primary hip arthroplasty: a retrospective cohort analysis. PeerJ Kadry, B., Press, C. D., Alosh, H., Opper, I. M., Orsini, J., Popov, I. A., Brodsky, J. B., Macario, A. 2014; 2

    View details for DOI 10.7717/peerj.530

    View details for PubMedID 25210656

  • Obesity increases operating room times in patients undergoing primary hip arthroplasty: a retrospective cohort analysis. PeerJ Kadry, B., Press, C. D., Alosh, H., Opper, I. M., Orsini, J., Popov, I. A., Brodsky, J. B., Macario, A. 2014; 2


    Background. Obesity impacts utilization of healthcare resources. The goal of this study was to measure the relationship between increasing body mass index (BMI) in patients undergoing total hip arthroplasty (THA) with different components of operating room (OR) time. Methods. The Stanford Translational Research Integrated Database Environment (STRIDE) was utilized to identify all ASA PS 2 or 3 patients who underwent primary THA at Stanford Medical Center from February 1, 2008 through January 1, 2013. Patients were divided into five groups based on the BMI weight classification. Regression analysis was used to quantify relationships between BMI and the different components of total OR time. Results. 1,332 patients were included in the study. There were no statistically significant differences in age, gender, height, and ASA PS classification between the BMI groups. Normal-weight patients had a total OR time of 138.9 min compared 167.9 min (P < 0.001) for morbidly obese patients. At a BMI > 35 kg/m(2) each incremental BMI unit increase was associated with greater incremental total OR time increases. Conclusion. Morbidly obese patients required significantly more total OR time than normal-weight patients undergoing a THA procedure. This increase in time is relevant when scheduling obese patients for surgery and has an important impact on health resource utilization.

    View details for DOI 10.7717/peerj.530

    View details for PubMedID 25210656

    View details for PubMedCentralID PMC4157296

  • Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia. Anesthesiology research and practice Udani, A. D., Macario, A., Nandagopal, K., Tanaka, M. A., Tanaka, P. P. 2014; 2014: 659160-?


    Introduction. Properly performing a subarachnoid block (SAB) is a competency expected of anesthesiology residents. We aimed to determine if adding simulation-based deliberate practice to a base curriculum improved performance of a SAB. Methods. 21 anesthesia residents were enrolled. After baseline assessment of SAB on a task-trainer, all residents participated in a base curriculum. Residents were then randomized so that half received additional deliberate practice including repetition and expert-guided, real-time feedback. All residents were then retested for technique. SABs on all residents' next three patients were evaluated in the operating room (OR). Results. Before completing the base curriculum, the control group completed 81% of a 16-item performance checklist on the task-trainer and this increased to 91% after finishing the base curriculum (P < 0.02). The intervention group also increased the percentage of checklist tasks properly completed from 73% to 98%, which was a greater increase than observed in the control group (P < 0.03). The OR time required to perform SAB was not different between groups. Conclusions. The base curriculum significantly improved resident SAB performance. Deliberate practice training added a significant, independent, incremental benefit. The clinical impact of the deliberate practice intervention in the OR on patient care is unclear.

    View details for DOI 10.1155/2014/659160

    View details for PubMedID 25157263

  • Implementing operating room management science: From the bench to the scheduling office. European journal of anaesthesiology Macario, A. 2014; 31 (7): 355–60

    View details for DOI 10.1097/EJA.0000000000000026

    View details for PubMedID 24887131

  • Can physician performance be assessed via simulation? Anesthesiology Macario, A. 2014; 120 (1): 18-21

    View details for DOI 10.1097/ALN.0000000000000056

    View details for PubMedID 24195973

  • Opiates for Chronic Pain Management and Surgical Considerations Essentials of Pharmacology for Anesthesia, Pain Medicine, and Critical Care Esaki, R., Macario, A. Springer. 2014; 1
  • Brief report: 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


    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 PubMedID 23592608

  • 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
  • The stanford anesthesia faculty teaching scholars program: summary of faculty development, projects, and outcomes. Journal of graduate medical education Macario, A., Tanaka, P. P., Landy, J. S., Clark, S. M., Pearl, R. G. 2013; 5 (2): 294-298


    The Stanford Anesthesia Teaching Scholars Program was launched in 2007 to further pedagogic training of faculty and improve residency education.The goals of this article are to describe the program intervention and improvements made based on participant feedback, summarize the characteristics of the faculty enrolled and projects undertaken, and report on program outcomes tracked to date.THE TEACHING SCHOLARS PROGRAM HOUSED WITHIN THE DEPARTMENT OF ANESTHESIA SUPPORTS FACULTY IN THESE AREAS: (1) attending education-related meetings; (2) engaging in a monthly seminar on core topics paired with independent study reading; and (3) undertaking a project to improve resident education. Structured interviews with all graduates (n  =  19; 47% women) were conducted using a pilot-tested questionnaire.A total of 15 of 19 Scholars (79%) were instructors/assistant professors. Sixteen Scholars (84%) attended an off-site education meeting. The Scholars pursued a variety of projects, including curriculum (53%), teaching (26%), administration (11%), assessment (5%), and advising/mentoring (5%). Projects were fully completed by 13 of 19 participants (68%), and 12 of 19 projects (63%) are currently integrated into the residency. Completed projects were published/presented at conferences by 4 of 13 participants (31%), and education grants were received by 3 of 19 participants (16%).This is the first description of a faculty development (education) program in an anesthesiology department. The program has been well accepted by participants and resulted in increased educational products, some of which have become a permanent part of the residency curriculum. This educational innovation can be replicated in other departments of anesthesiology provided that funding is available for faculty time and meeting expenses.

    View details for DOI 10.4300/JGME-D-12-00246.1

    View details for PubMedID 24404276

  • The Use of Facebook Among Seventy-Seven Departments of Anesthesia in United States Medical Schools Cureus Landy, J., Macario, A. 2013

    View details for DOI 10.7759/cureus.102

  • 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


    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


    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

  • The Timing of Staffing Decisions in Hospital Operating Rooms: Incorporating Workload Heterogeneity into the Newsvendor Problem M&SOM-MANUFACTURING & SERVICE OPERATIONS MANAGEMENT He, B., Dexter, F., Macario, A., Zenios, S. 2012; 14 (1): 99-114
  • Cost identification analysis of anesthesia fiberscope use for tracheal intubation Journal of Anesthesia & Clinical Research Liu, S., Brodsky, J., Macario, A. 2012; 3 (5): 1-4
  • Book Review: ANESTHESIOLOGY CLINICS - Quality of Anesthesia Care Anesthesia & Analgesia Santiago, J., Macario, A. 2012; 114 (6): 1371
  • Leadership Principles Operating Room Leadership and Management Egger Halbeis, C., Macario, A. Cambridge University Press. 2012; 1: 1–15
  • The timing of staffing decisions in hospital operating room: incorporating workload heterogeneity into the newsvendor problem Manufacturing & Service Operations Management He, B., Dexter, F., Macario, A., Zenios, S. 2012; 14: 99-114
  • Technology and Anesthesia Education Technology and Anesthesia Education. Tanaka, P., Macario, A. 2012: e101
  • Smart Device Use Among Resident Physicians at Stanford Hospital Cureus Ositelu, O., Landy, J., Kadry, B., Macario, A. 2012; 4 (12)

    View details for DOI 10.7759/cureus.73

  • Vaporizers The Anesthesia Technician and Technologist's Manual: All You Need to Know for Study and Reference Esaki, R., Macario, A. Lippincott Williams & Wilkins. 2012; 1: 247–254
  • 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)


    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,,,,,,,,, and 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



    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. ( 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


    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

  • The IRB Process Needs to Be Reexamined ANESTHESIA AND ANALGESIA Esaki, R., Macario, A., Harrison, T. K., Brock-Utne, J. G. 2011; 112 (5): 1249-1250

    View details for DOI 10.1213/ANE.0b013e31821224d5

    View details for Web of Science ID 000289785100046

    View details for PubMedID 21515655

  • 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


    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

  • Management of staffing and case scheduling for anesthesia outside the operatng room Anesthesia Outside of the Operating Room Macario, A. Oxford University Press. 2011; 1: 42–48
  • Processed EEG and Awareness Monitoring Manual of Clinical Anesthesiology Desai, A., Macario, A. Lippincott Williams & Wilkins. 2011; 1: 96–100
  • Pharmacoeconomics Anesthetic Pharmacology: Basic Principles and Clinical Practice Macario, A. Cambridge University Press. 2011; 2: 166–176
  • 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

  • Restoration of disk height through non- surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study BMC MUSCULOSKELETAL DISORDERS Apfel, C. C., Cakmakkaya, O. S., Martin, W., Richmond, C., Macario, A., George, E., Schaefer, M., Pergolizzi, J. V. 2010; 11


    Because previous studies have suggested that motorized non-surgical spinal decompression can reduce chronic low back pain (LBP) due to disc degeneration (discogenic low back pain) and disc herniation, it has accordingly been hypothesized that the reduction of pressure on affected discs will facilitate their regeneration. The goal of this study was to determine if changes in LBP, as measured on a verbal rating scale, before and after a 6-week treatment period with non-surgical spinal decompression, correlate with changes in lumbar disc height, as measured on computed tomography (CT) scans.A retrospective cohort study of adults with chronic LBP attributed to disc herniation and/or discogenic LBP who underwent a 6-week treatment protocol of motorized non-surgical spinal decompression via the DRX9000 with CT scans before and after treatment. The main outcomes were changes in pain as measured on a verbal rating scale from 0 to 10 during a flexion-extension range of motion evaluation and changes in disc height as measured on CT scans. Paired t-test or linear regression was used as appropriate with p < 0.05 considered to be statistically significant.We identified 30 patients with lumbar disc herniation with an average age of 65 years, body mass index of 29 kg/m2, 21 females and 9 males, and an average duration of LBP of 12.5 weeks. During treatment, low back pain decreased from 6.2 (SD 2.2) to 1.6 (2.3, p < 0.001) and disc height increased from 7.5 (1.7) mm to 8.8 (1.7) mm (p < 0.001). Increase in disc height and reduction in pain were significantly correlated (r = 0.36, p = 0.044).Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. The correlation of these variables suggests that pain reduction may be mediated, at least in part, through a restoration of disc height. A randomized controlled trial is needed to confirm these promising results.NCT00828880.

    View details for DOI 10.1186/1471-2474-11-155

    View details for Web of Science ID 000280834100001

    View details for PubMedID 20615252

    View details for PubMedCentralID PMC2912793

  • Patient and physician perceptions of treatment of moderate-to-severe chronic pain with oral opioids CURRENT MEDICAL RESEARCH AND OPINION Duensing, L., Eksterowicz, N., Macario, A., Brown, M., Stern, L., Ogbonnaya, A. 2010; 26 (7): 1579-1585


    To study physician and patient perceptions of moderate-to-severe chronic pain and its management with oral opioids.Two separate surveys were developed and administered to one of two respective study groups: patients and physicians. All study participants recruited from a pool of individuals who had previously agreed to participate in market research. Survey questions addressed the impact of various factors (e.g., quality of life indicators, potential for opioid addiction, side-effects) on pain management decision making, patient satisfaction and compliance. Responses for the first 500 patients and 275 physicians to respond were assessed using descriptive statistics.On average, patients were 53 years of age, white (89%), and female (71%). The majority of patients (80%) had been taking oral opioids longer than 6 months. Physicians reported that 45% of their patients received schedule II opioids, with 27% having severe chronic pain. Patients indicated the most common activities interfered with by chronic pain were exercising (76% of patients), working outside the home (67%), and job responsibilities (60%). When developing a treatment approach physicians considered patients' sleeping (91%), walking (86%), maintaining an independent lifestyle (84%), and job responsibilities (83%). Patients and physicians both rated the ability to relieve pain and the duration of relief as the most important factors when considering opioid therapy. The majority (63%) of patients reported experiencing opioid side effects. When physicians discontinued opioids due to side effects, the most frequent reason was nausea (78%) for immediate-release opioids, and constipation (64%) for extended-release formulations.The ability to relieve pain and the duration of that pain relief are the most important factors for both patients and physicians when selecting an opioid. A high percentage of patients surveyed experienced side effects related to their treatment, which may impact adherence and overall treatment effectiveness. Study results should be assessed within study limitations including responder and selection biases, physicians responded about their patients, who were not the same patients surveyed, and the fact that the survey instruments were not formally validated. Further research is warranted to address these limitations.

    View details for DOI 10.1185/03007991003783747

    View details for Web of Science ID 000279704500004

    View details for PubMedID 20429822

  • 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


    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


    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


    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


    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


    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

  • Cost-effectiveness of external cephalic version for term breech presentation BMC PREGNANCY AND CHILDBIRTH Tan, J. M., Macario, A., Carvalho, B., Druzin, M. L., El-Sayed, Y. Y. 2010; 10


    External cephalic version (ECV) is recommended by the American College of Obstetricians and Gynecologists to convert a breech fetus to vertex position and reduce the need for cesarean delivery. The goal of this study was to determine the incremental cost-effectiveness ratio, from society's perspective, of ECV compared to scheduled cesarean for term breech presentation.A computer-based decision model (TreeAge Pro 2008, Tree Age Software, Inc.) was developed for a hypothetical base case parturient presenting with a term singleton breech fetus with no contraindications for vaginal delivery. The model incorporated actual hospital costs (e.g., $8,023 for cesarean and $5,581 for vaginal delivery), utilities to quantify health-related quality of life, and probabilities based on analysis of published literature of successful ECV trial, spontaneous reversion, mode of delivery, and need for unanticipated emergency cesarean delivery. The primary endpoint was the incremental cost-effectiveness ratio in dollars per quality-adjusted year of life gained. A threshold of $50,000 per quality-adjusted life-years (QALY) was used to determine cost-effectiveness.The incremental cost-effectiveness of ECV, assuming a baseline 58% success rate, equaled $7,900/QALY. If the estimated probability of successful ECV is less than 32%, then ECV costs more to society and has poorer QALYs for the patient. However, as the probability of successful ECV was between 32% and 63%, ECV cost more than cesarean delivery but with greater associated QALY such that the cost-effectiveness ratio was less than $50,000/QALY. If the probability of successful ECV was greater than 63%, the computer modeling indicated that a trial of ECV is less costly and with better QALYs than a scheduled cesarean. The cost-effectiveness of a trial of ECV is most sensitive to its probability of success, and not to the probabilities of a cesarean after ECV, spontaneous reversion to breech, successful second ECV trial, or adverse outcome from emergency cesarean.From society's perspective, ECV trial is cost-effective when compared to a scheduled cesarean for breech presentation provided the probability of successful ECV is > 32%. Improved algorithms are needed to more precisely estimate the likelihood that a patient will have a successful ECV.

    View details for DOI 10.1186/1471-2393-10-3

    View details for Web of Science ID 000296428000001

    View details for PubMedID 20092630

  • Anesthesia group management and strategies Handbook of Healthcare Delivery Systems Hass, W., Macario, A., Garner, R. CRC Press. 2010; 1
  • 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


    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


    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


    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


    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


    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

  • Part-time clinical anesthesia practice: a review of the economic, quality, and safety issues. Anesthesiology clinics McIntosh, C. A., Macario, A. 2008; 26 (4): 707-?


    Part-time clinical practice in anesthesia is increasing due to the feminization and the aging of the medical workforce, as well as the arrival of generations X and Y to the health care workforce. Recruiting the best and brightest physicians requires accommodating their needs and interests, as well as retaining older workers who wish to reduce their hours as they approach retirement. This article discusses steps to help departments or groups optimally manage the part-time anesthesia workforce.

    View details for DOI 10.1016/j.anclin.2008.07.004

    View details for PubMedID 19041625

  • How to evaluate whether a new technology in the operating room is cost-effective from society's viewpoint. Anesthesiology clinics Tan, J. M., Macario, A. 2008; 26 (4): 745-?


    The hospital operating room is one of the most important and costly environments in health care. Given the current reductions in reimbursement and limited resources, hospital administrators and operating room managers have to be careful about adopting new technologies into the operating room. Operating rooms must balance the improved care a new technology can provide with its additional costs. Economic analysis provides systematic methods to guide decisions by quantitatively assessing the value of a new technology.

    View details for DOI 10.1016/j.anclin.2008.07.003

    View details for PubMedID 19041627

  • 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


    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 38th Annual Meeting of the Society-for-Obstetric-Anesthesia-and-Perinatology Carvalho, B., Saxena, A., Butwick, A., Macario, A. CHURCHILL LIVINGSTONE. 2008: 212–16


    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


    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

  • Complications in Anesthesiology (book review) JAMA Macario, A. 2008; 299 (21): 2569-2570

    View details for DOI 10.1001/jama.299.21.2569

  • Management of the Difficult and Failed Airway JAMA Maxwell, B., Macario, A. 2008; 300 (7): 850-851
  • Tratado de anestesia y reanimacion Cost control and quality improvement in anesthesia Montejo, L., Macario, A. Aran Ediciones, S.A., Madrid, Spain. 2008; 2
  • Ambulatory surgery center profitability, efficiency and cost containment Handbook of Ambulatory Anesthesia Archer, T., Mannis, S., Macario, A. Springer. 2008; 2: 396–419
  • Geriatric Anesthesiology JAMA Macario, A. 2008; 299 (15): 1839-1840

    View details for DOI 10.1001/jama.299.15.1839

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

    View details for PubMedID 18196866

  • Identification of systematic underestimation (bias) of case durations during case scheduling would not markedly reduce overutilized operating room time Annual Meeting of the American-Society-of-Anesthesiologists Dexter, F., Macario, A., Ledolter, J. ELSEVIER SCIENCE INC. 2007: 198–203


    If a case has a high probability of taking longer than scheduled, then increasing the case's scheduled duration could reduce over-utilized operating room (OR) time. We studied surgeons' and schedulers' case scheduling behavior to evaluate whether such a strategy would be useful.Observational study.University hospital.The probability of each of 66,561 cases taking longer than scheduled was estimated with an accuracy to within 1-2%.Overall underestimation by surgeons and schedulers was 22 minutes for each 8 hours of used operating room (OR) time. If a 90% or 95% chance of taking longer than scheduled were required to conclude that a case's duration was deliberately underestimated, and if such cases' scheduled durations were changed, overall underestimation would be reduced by only 0.2 or 0.9 minutes per 8 hours of used OR time because only 0.1% or 0.6% of used OR time met that criterion. In contrast, underestimation would be reduced by 20 minutes if the cases identified were those with only a 50% to 60% chance of taking longer than scheduled because they accounted for more than 40% of OR time. Persistent underestimation of cases' durations was caused not by poor decisions for a few outlier cases, but instead by slight underestimation for many cases. Surgeons' and schedulers' behavior that fit cases into staffed (allocated) OR time was to underestimate slightly the duration of many cases.The impact of inaccurate, scheduled case duration on staffing costs and unpredictable work hours can be reduced by allocating appropriate total hours of OR time (ie, staffing) for the cases that will get done, regardless of the inaccuracy of the scheduled durations of those cases.

    View details for DOI 10.1016/j.jclinane.2006.10.009

    View details for Web of Science ID 000247128200007

    View details for PubMedID 17531728

  • Is external cephalic version cost-effective? 39th Annual Meeting of the Society-for-Obstetric-Anesthesia-and-Perinatology Tan, J. M., Macario, A., Carvalho, B., El-Sayed, Y. LIPPINCOTT WILLIAMS & WILKINS. 2007: B16–B16
  • A cost-analysis of neuraxial analgesia to facilitate external cephalic version 39th Annual Meeting of the Society-for-Obstetric-Anesthesia-and-Perinatology Tan, J. M., Macario, A., El-Sayed, Y., Carvalho, B. LIPPINCOTT WILLIAMS & WILKINS. 2007: B53–B53
  • Complications of Regional Anesthesia Peripheral Nerve Blocks on DVD: Upper Limbs and Lower Limbs (book and media reviews) JAMA Macario, A. 2007; 298 (21): 2546-2552

    View details for DOI 10.1001/jama.298.21.2546

  • Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: A retrospective, case-control, cost-minimization analysis REGIONAL ANESTHESIA AND PAIN MEDICINE Ilfeld, B. M., Mariano, E. R., Williams, B. A., Woodard, J. N., Macario, A. 2007; 32 (1): 46-54


    After total knee arthroplasty (TKA), hospitalization may be shortened by allowing patients to return home with a continuous femoral nerve block (CFNB). This study quantified the hospitalization costs for 10 TKA patients receiving ambulatory CFNB versus a matched cohort of 10 patients who received CFNB only during hospitalization.We examined the medical records (n = 125) of patients who underwent a unilateral, primary, tricompartment TKA with a postoperative CFNB by 1 surgeon at one institution in an 18-month period beginning January 2004. Each of the 10 patients discharged home with an ambulatory CFNB (cases) was matched with a patient with a hospital-only CFNB (controls) for age, gender, body mass index, and health status. Financial data were extracted from the hospital microcosting database.Nine patients with ambulatory CFNB (cases) were discharged home on postoperative day (POD) 1 and 1 on POD 4. Of the controls, 3 were discharged home on POD 3, 6 on POD 4, and 1 on POD 5. The median (range) costs of hospitalization (excluding implant and professional fees) was US dollars 5,292 (US dollars 4,326-US dollars 7,929) for ambulatory cases compared with US dollars 7,974 (US dollars 6,931-US dollars 9,979) for inpatient controls (difference = US dollars 2,682, 34% decrease, P < .001). The total charges for hospitalization, the implant, and professional fees was US dollars 33,646 (US dollars 31,816-US dollars 38,468) for cases compared with US dollars 39,100 (US dollars 36,096-US dollars 44,098) for controls (difference = US dollars 5,454, 14% decrease, P < .001).This study provides evidence that ambulatory CFNB for selected patients undergoing TKA has the potential to reduce hospital length of stay and associated costs and charges. However, the current study has significant inherent limitations based on the study design. Additional research is required to replicate these results in a prospective, randomized, controlled trial and to determine whether any savings exceed additional CFNB costs such as from complications, having caregivers provide care at home, and additional hospital/health care provider visits.

    View details for DOI 10.1016/j.rapm.2006.10.010

    View details for Web of Science ID 000243311100009

    View details for PubMedID 17196492

  • Economic analysis of perioperative optimization. Perioperative Medicine: Managing for Outcome Archer, T., Mannis, S., Macario, A. Saunders. 2007; 1: 673–687
  • Scheduling elective pediatric procedures that require anesthesia: The perspective of parents ANESTHESIA AND ANALGESIA Mariano, E. R., Chu, L. F., Ramamoorthy, C., Macario, A. 2006; 103 (6): 1426-1431


    Daily variability in volume of elective pediatric procedures that require anesthesia may lead to an imbalance between available operating room resources and case load. Longer intervals between scheduling and the surgical date generally result in higher operating room utilization. In this study, we sought to determine which factors influence when parents schedule their children for procedures. We also aimed to identify parents' ideal and longest acceptable waiting intervals and determine whether type of procedure, for example, affects scheduling. From a convenience sample of 250 randomly selected parents of children presenting for elective surgery, 236 completed surveys were analyzed. The remaining 14 surveys were not returned. Overall, parents scheduled their child's procedure a median of 4.3 wk (interquartile range 2.0-8.6) in advance and reported an ideal waiting interval of 3 wk (interquartile range 2-4), and longest acceptable interval of 6 wk (interquartile range 4-10). Parents were willing to wait longer to schedule cardiac (4 wk, P = 0.004) and plastic (3.5 wk, P = 0.024) surgery when compared with general surgical procedures. Overall, parents ranked severity of the child's illness, earliest available time, and surgeon's suggested date as the three most important factors influencing when their child's surgery is scheduled. The timetable for scheduling procedures was highly correlated with both mother and father having available time off work (tau(b) = 0.72, P < 0.0001). Surprisingly, parents did not show a preference for scheduling cases during vacation or summer months.

    View details for DOI 10.1213/01.ane.0000244596.03605.3e

    View details for Web of Science ID 000242289100019

    View details for PubMedID 17122217

  • 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


    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


    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

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


    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 ANESTHESIOLOGY Halbeis, C. B., Macario, A. 2006; 19 (2): 207-212


    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 Web of Science ID 000209631900016

  • The drive for operating room efficiency will increase quality of patient care CURRENT OPINION IN ANESTHESIOLOGY Archer, T., Macario, A. 2006; 19 (2): 171-176
  • 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


    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-?


    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

  • Operating Room Management: an update Current Reviews in Clinical Anesthesia (CME) Macario , A. Frank Moya Continuing Education Programs. 2006: 27–34
  • Anesthesiology (book review) JAMA Macario, A. 2006; 295 (9): 1067-1072
  • 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-?


    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

  • Validity and usefulness of a method to monitor surgical services' average bias in scheduled case durations CANADIAN JOURNAL OF ANAESTHESIA-JOURNAL CANADIEN D ANESTHESIE Dexter, F., Macario, A., Epstein, R. H., Ledolter, J. 2005; 52 (9): 935-939


    Unbiased prediction of case durations is an integral part of matching operating room (OR) staffing to workload. Monitoring systematic bias in surgeons' scheduled case durations can identify those services with estimates sufficiently inaccurate that statistical analysis of historical data may be useful in preference to the surgeons' estimates. We describe a method to monitor surgical services' average bias in scheduled case durations.Actual case duration, predicted (scheduled) case duration, and service were obtained for all 58,291 cases during 39 four-week periods at an academic hospital. For each four-week period, a ratio was computed for each service. The numerator for each service equalled the sum of the differences in minutes between actual case duration and scheduled case duration. The denominator equalled the sum in hours of the actual durations of all of the service's cases. The ratio was multiplied by eight hours to yield the number of minutes of underestimated case duration per eight hours of OR time during the four-week period.The ratios followed a normal distribution for each service. Using the Student's t distribution, the 95% lower confidence bounds for the average underestimate of case duration ranged from three to 65 min per eight hours of used OR time.To reduce over-utilized OR time, we recommend monitoring each service's 95% lower confidence bound of the bias in scheduled case durations. For services consistently underestimating their case durations, schedule their cases using statistical estimates of case durations based on their historical data, and disregard their own estimates.

    View details for Web of Science ID 000233532700007

    View details for PubMedID 16251558

  • 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


    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

  • Quantifying effect of a hospital's caseload for a surgical specialty on that of another hospital using multi-attribute market segments. Health care management science Dexter, F., Wachtel, R. E., Sohn, M., Ledolter, J., Dexter, E. U., Macario, A. 2005; 8 (2): 121-131


    Inpatient and outpatient data were used to create market segments consisting of hierarchical combinations of surgical procedure, then type of payer, and then location of patients' residences. The competitive effect of one hospital's caseload for a given surgical specialty on the caseload of another hospital was determined from the numbers of patients in each segment. Earlier methods for estimating surgical competition that ignored market segments over-estimated the competitive effects of one hospital on another. Thus, results differed from those obtained previously for all types of hospital admissions. When actual market segments with homogeneous groups of patients are used, competitive effects of hospitals in the same market area are far less than expected.

    View details for PubMedID 15952609

  • Meta-analysis of trial comparing postoperative recovery after anesthesia with sevoflurane or desflurane 13th World Congress of Anesthesiologists Macario, A., Dexter, F., Lubarsky, D. AMER SOC HEALTH-SYSTEM PHARMACISTS. 2005: 63–68


    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

  • Urine drug testing in chronic pain patients taking opioids: a clinical practice update Macario A, Pergolizzi J. Urine drug testing in chronic pain patients taking opioids: a clinical practice update. The International Journal of Pain Medicine and Palliative Care (Journal no longer published) Macario, A., Pergolizzi , J. 2005; 4 (1): 17-23
  • The Post Anesthesia Care Unit Miller's Anesthesia Feeley, T., Macario, A. Churchill Livingstone . 2005; 6
  • Systematic literature review of economics of IV patient controlled analgesia. Pharmacy and Therapeutics (ISSN 1052-1372) Macario, A. 2005; 30 (7): 392-399
  • Improving the quality of anesthesia care Current Reviews in Clinical Anesthesia (CME) Macario, A. 2005; 25 (25): 323-331
  • 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

  • Patient preferences regarding cesarean section anesthesia outcomes 36th Annual Meeting of the Society-for-Obstetric-Anesthesia-and-Perinatology Carvalho, B., Macario, A., Lipman, S., Muthusamy, A. D., Fuller, A., Brummel, C., Cohen, S. E. LIPPINCOTT WILLIAMS & WILKINS. 2004: B37–B37
  • When to release allocated operating room time to increase operating room efficiency ANESTHESIA AND ANALGESIA Dexter, F., Macario, A. 2004; 98 (3): 758-762


    We studied when allocated, but unfilled, operating room (OR) time of surgical services should be released to maximize OR efficiency. OR time was allocated for two surgical suites based on OR efficiency. Then, we analyzed real OR schedules. We added new hypothetical cases lasting 1, 2, or 3 h into OR time of the service that had the largest difference between allocated and scheduled cases (i.e., the most unfilled OR time) 5 days before the day of surgery. The process was repeated using the updated OR schedule available the day before surgery. The pair-wise difference in resulting overutilized OR time was calculated for n = 754 days of data from each of the two surgical suites. We found that postponing the decision of which service gets the new case until early the day before surgery reduces overutilized OR time by <15 min per OR per day as compared to releasing the allocated OR time 5 days before surgery. These results show that when OR time is released has a negligible effect on OR efficiency. This is especially true for ambulatory surgery centers with brief cases or large surgical suites with specialty-specific OR teams. What matters much more is having the correct OR allocations and, if OR time needs to be released, making that decision based on the scheduled workload.Provided operating room (OR) time is allocated and cases are scheduled based on maximizing OR efficiency, then whether OR time is released five days or one day before the day of surgery has a negligible effect on OR efficiency.

    View details for Web of Science ID 000189250000036

    View details for PubMedID 14980933

  • Profit maximization in an ambulatory surgery cente Ambulatory Anesthesia and Perioperative Analgesia Archer, T., Mannis, S., Macario, A. McGraw-Hill Professional. 2004; 1
  • Pain and nausea management after surgery The International Journal of Pain Medicine and Palliative Care (journal no longer published) Macario, A., Pergolizzi, J. 2004; 3 (3): 91-100
  • Pharmacoeconomics Anesthetic Pharmacology: Physiologic Principles and Clinical Practice Macario, A. Churchill Livingstone. 2004: 91–103
  • 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


    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/

    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


    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

  • Operating room utilization alone is not an accurate metric for the allocation of operating room block time to individual surgeons with low caseloads ANESTHESIOLOGY Dexter, F., Macario, A., Traub, R. D., Lubarsky, D. A. 2003; 98 (5): 1243-1249


    Many surgical suites allocate operating room (OR) block time to individual surgeons. If block time is allocated to services/groups and yet the same surgeon invariably operates on the same weekday, for all practical purposes block time is being allocated to individual surgeons. Organizational conflict occurs when a surgeon with a relatively low OR utilization has his or her allocated block time reduced. The authors studied potential limitations affecting whether a facility can accurately estimate the average block time utilizations of individual surgeons performing low volumes of cases.Discrete-event computer simulation.Neither 3 months nor 1 yr of historical data were enough to be able to identify surgeons who had persistently low average OR utilizations. For example, with 3 months of data, the widths of the 95% CIs for average OR utilization exceeded 10% for surgeons who had average raw utilizations of 83% or less. If during a 3-month period a surgeon's measured adjusted utilization is 65%, there is a 95% chance that the surgeon's average adjusted utilization is as low as 38% or as high as 83%. If two surgeons have measured adjusted utilizations of 65% and 80%, respectively, there is a 16% chance that they have the same average adjusted utilization. Average OR utilization can be estimated more precisely for surgeons performing more cases each week.Average OR utilization probably cannot be estimated precisely for low-volume surgeons based on 3 months or 1 yr of historical OR utilization data. The authors recommend that at surgical suites trying to allocate OR time to individual low-volume surgeons, OR allocations be based on criteria other than only OR utilization (e.g., based on OR efficiency).

    View details for Web of Science ID 000182523200028

    View details for PubMedID 12717148

  • Physicians' perceptions of minimum time that should be saved to move a surgical case from one operating room to another: Internet-based survey of the membership of the association of anesthesia clinical directors (AACD) JOURNAL OF CLINICAL ANESTHESIA Dexter, F., Smith, T. C., Tatman, D. J. 2003; 15 (3): 206-210


    Moving the last case of the day from one operating room (OR) to another OR can increase OR efficiency. However, there is a penalty cost for moving a case. The goal of the study was to measure perceptions of the minimum time that needs to be saved for it to be worthwhile to move a case from a late-running OR to another OR.Internet-based survey of the Association of Anesthesia Clinical Directors (AACD) and/or attendees at one of its courses. As subjects completed the computer-assisted survey, answers to test questions were checked immediately to ensure respondents understood the relevant concepts.Respondents were asked to complete the statement: "I would move the case if I would expect to save ____ hours of overutilized OR time."234 E-mail invitations to complete the survey were transmitted. Of that number, 87 completed surveys were returned. Respondents were physicians, mostly from the United States. The 25th, 50th, and 75th percentiles of the penalty cost were 1.0 hour of overutilized OR time. The 95% confidence intervals were 0.5 to 1.0 hour for the 25th percentile, 1.0 to 1.0 hour for the 50th percentile, and 1.0 to 2.0 hours for the 75th percentile. There was no significant correlation between the penalty cost and the number of ORs at the respondent's facility, number of times the survey was submitted until it was completed correctly, or total number of errors in responses.Members of the AACD perceive the penalty cost for moving a case to be 1 hour.

    View details for DOI 10.1016/S0952-8180(03)00018-7

    View details for Web of Science ID 000183360400009

    View details for PubMedID 12770657

  • 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


    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

  • How to release allocated operating room time to increase efficiency: Predicting which surgical service will have the most underutilized operating room time ANESTHESIA AND ANALGESIA Dexter, F., Traub, R. D., Macario, A. 2003; 96 (2): 507-512


    At many facilities, surgeons and patients choose the day of surgery, cases are not turned away, and staffing is adjusted to maximize operating room (OR) efficiency. If a surgical service has already filled its allocated OR time, but has an additional case to schedule, then OR efficiency is increased by scheduling the new case into the OR time of a different service with much underutilized OR time. The latter service is said to be "releasing" its allocated OR time. In this study, we analyzed 3 years of scheduling data from a medium-sized and a large surgical suite. Theoretically, the service that should have its OR time released is the service expected to have the most underutilized OR time on the day of surgery (i.e., any future cases that may be scheduled into that service's time also need to be factored in). However, we show that OR efficiency is only slightly less when the service whose time is released is the service that has the most allocated but unscheduled (i.e., unfilled) OR time at the moment the new case is scheduled. In contrast, compromising by releasing the OR time of a service other than the one with the most allocated but unscheduled OR time markedly reduces OR efficiency. OR managers can use these results when releasing allocated OR time.

    View details for DOI 10.1213/01.ANE.0000042450.45778.AB

    View details for Web of Science ID 000180601400036

    View details for PubMedID 12538204

  • A Sabbatical in Madrid travel memoir book Alex Macario 2003
  • Technology and computing in the surgical suite: Key features of an OR management information system and opportunities for the future ANESTHESIA AND ANALGESIA Macario, A., Vasanawala, M. 2002; 95 (4): 1120-1121
  • Development of an appropriate list of surgical procedures of a specified maximum anesthetic complexity to be performed at a new ambulatory surgery facility ANESTHESIA AND ANALGESIA Dexter, F., Macario, A., Penning, D. H., Chung, P. 2002; 95 (1): 78-82


    A common but difficult task for a hospital when it decides to open a freestanding ambulatory surgery facility is how to decide which surgical procedures should be done at the new facility. This is necessary in order to determine how many operating rooms to plan for the new facility and which ancillary services are needed on-site. In this case study, we describe a novel methodology that we used to develop a comprehensive list of procedures to be done at a new ambulatory facility. The level of anesthetic complexity of a procedure was defined by its number of ASA Relative Value Guide basic units. Broad categories of procedures (e.g., eye surgery) were defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification. We identified 22 categories that are of a type that every procedure in the category has no more than seven basic units. In addition, by analyzing all procedures that the hospital being studied actually performed on an ambulatory basis, we identified six other categories of procedures that were of a type that all procedures eligible for surgery at the new facility had seven or fewer basic units.We describe a novel method to develop a comprehensive list of procedures that have a prespecified maximum level of anesthetic complexity to be performed at a new ambulatory surgery facility.

    View details for Web of Science ID 000176634100014

    View details for PubMedID 12088947

  • 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


    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

  • Changing allocations of operating room time from a system based on historical utilization to one where the aim is to schedule as many surgical cases as possible ANESTHESIA AND ANALGESIA Dexter, F., Macario, A. 2002; 94 (5): 1272-1279


    Many facilities allocate operating room (OR) time based on historical utilization of OR time. This assumes that there is a fixed amount of regularly scheduled OR time, called "block time". This "Fixed Hours" system does not apply to many surgical suites in the US. Most facilities make OR time available for all its surgeons' patients, even if cases are expected to finish after the end of block time. In this setting, OR time should be allocated to maximize OR efficiency, not historical utilization. Then, cases are scheduled either on "Any Workday" (i.e., date chosen by patient and surgeon) or within a reasonable time (e.g., "Four Weeks"). In this study, we used anesthesia billing data from two facilities to study statistical challenges in converting from a Fixed Hours to an Any Workday or Four Weeks patient scheduling system. We report relationships among the number of staffed ORs (i.e., first case of the day starts), length of the regularly scheduled OR workday, OR efficiency, OR staffing cost, and changes in services' OR allocations. These relationships determine the expected changes in each service's OR allocation, when a facility using Fixed Hours considers converting to the Any Workday or Four Weeks systems.We investigated the complex relationships among the number of surgical services, number of staffed operating rooms (ORs), length of the regularly scheduled OR workday, efficiency of use of OR time, OR staffing cost, and changes in each services' allocated OR time.

    View details for Web of Science ID 000175284500043

    View details for PubMedID 11973204

  • Is noncontact normothermic wound therapy cost effective for the treatment of stages 3 and 4 pressure ulcers? WOUNDS-A COMPENDIUM OF CLINICAL RESEARCH AND PRACTICE Macario, A., Dexter, F. 2002; 14 (3): 93-106
  • 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


    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

  • Is non-contact thermal wound therapy cost-effective for the treatment of stage 3 and 4 pressure ulcers? Wounds (ISSN 1044-7946) Macario, A., Dexter, F. 2002; 14 (3): 1-14
  • Economic considerations related to providing adequate pain relief for women in labour - Comparison of epidural and intravenous analgesia PHARMACOECONOMICS Huang, C., Macario, A. 2002; 20 (5): 305-318


    Epidural analgesia and intravenous analgesia with opioids are two techniques for providing pain relief for women in labour. Labour pain is comparable to surgical pain in its severity, and epidural analgesia provides better relief from this pain than intravenous analgesia; a meta-analysis quantified this improvement to be 40 mm on a 100mm pain scale during the first stage of labour. Epidural analgesia also has fewer adverse effects. However, providing epidural analgesia for labour pain costs more. The full cost of providing epidural analgesia can be divided into two components: a baseline-cost component, which captures the costs of hospital care to parturients receiving intravenous analgesia for labour pain; and an incremental-cost component, which estimates the costs arising from incremental care specific to epidural analgesia. The baseline component may be constructed using hospital cost-accounting data pertaining to actual obstetric patients. The incremental component is constructed from a set of recognised complications of epidural and intravenous analgesia, associated incidence rates and estimates of the costs involved, from society's perspective. The incremental expected cost per patient to society of providing epidural analgesia was calculated to be approximately $US338 (1998 values). This cost difference results primarily from increased professional costs (and is particularly sensitive to the method used to estimate the cost of anaesthesia professional services) and increased complication costs associated with epidural analgesia. A rational social policy for providing labour analgesia must weigh the value of improved pain relief from epidural analgesia against the increased cost of epidural analgesia.

    View details for Web of Science ID 000175870700002

    View details for PubMedID 11994040

  • 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


    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

  • Hospital profitability per hour of operating room time can vary among surgeons 94th Annual Meeting of the Southern-Medical-Association Macario, A., Dexter, F., Traub, R. D. LIPPINCOTT WILLIAMS & WILKINS. 2001: 669–75


    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

  • 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


    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


    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

  • The impact on revenue of increasing patient volume at surgical suites with relatively high operating room utilization ANESTHESIA AND ANALGESIA Dexter, F., Macario, A., Lubarsky, D. A. 2001; 92 (5): 1215-1221


    We previously studied hospitals in the United States of America that are losing money despite limiting the hours that operating room (OR) staff are available to care for patients undergoing elective surgery. These hospitals routinely keep utilization relatively high to maximize revenue. We tested, using discrete-event computer simulation, whether increasing patient volume while being reimbursed less for each additional patient can reliably achieve an increase in revenue when initial adjusted OR utilization is 90%. We found that increasing the volume of referred patients by the amount expected to fill the surgical suite (100%/90%) would increase utilization by <1% for a hospital surgical suite (with longer duration cases) and 4% for an ambulatory surgery suite (with short cases). The increase in patient volume would result in longer patient waiting times for surgery and more patients leaving the surgical queue. With a 15% reduction in payment for the new patients, the increase in volume may not increase revenue and can even decrease the contribution margin for the hospital surgical suite. The implication is that for hospitals with a relatively high OR utilization, signing discounted contracts to increase patient volume by the amount expected to "fill" the OR can have the net effect of decreasing the contribution margin (i.e., profitability).Hospitals may try to attract new surgical volume by offering discounted rates. For hospitals with a relatively high operating room utilization (e.g., 90%), computer simulations predict that increasing patient volume by the amount expected to "fill" the operating room can have the net effect of decreasing contribution margin (i.e., profitability).

    View details for Web of Science ID 000168335900024

    View details for PubMedID 11323349

  • Optimal number of beds and occupancy to minimize staffing costs in an obstetrical unit? CANADIAN JOURNAL OF ANAESTHESIA-JOURNAL CANADIEN D ANESTHESIE Dexter, F., Macario, A. 2001; 48 (3): 295-301


    We describe how the science of analyzing patient arrival and discharge data can be used to determine the optimal number of staffed OB beds to minimize labour costs.The number of staffed beds represents a balance between having as few staffed beds as possible to care properly for parturients vs having enough capacity to assure available staff for new admissions. The times of admission and discharge of patients from the OB unit can be used to calculate an average census. From this average census, and the properties of the Poisson distribution, the optimal number of staffed beds can be estimated. This calculation requires specification of the risk of having all in-house and on-call staff caring for patients, such that additional staff are unavailable should another parturient arrive. As an example, patient admission and discharge times were obtained for 777 successive patients cared for at an obstetrical unit. The numbers of patients present in the OB unit each two-hour period were calculated and analyzed statistically.There was variation in the average census among hours of the day and days of the week. Poisson distributions fit the data for each of four periods throughout the week. Simply benchmarking the current average occupancy and comparing it to a desired occupancy would have been inadequate as this neglected consideration of the risk of being unable to appropriately care for an additional patient.The optimal number of beds and occupancy of an OB unit to minimize staffing costs can be determined using straightforward statistical methods.

    View details for Web of Science ID 000167487700015

    View details for PubMedID 11305833

  • Can peri-operative quality be maintained in the drive for operating room efficiency? An American perspective. Best Practice and Research Clinical Anaesthesiology Canales, M., Macario, A. 2001; 15 (4): 607-619

    View details for DOI 10.1053/bean.2002.0194

  • Improving quality of anesthesia care: opportunities for the new decade CANADIAN JOURNAL OF ANAESTHESIA-JOURNAL CANADIEN D ANESTHESIE Macario, A., Vasanawala, A. 2001; 48 (1): 6-11

    View details for Web of Science ID 000166585000001

    View details for PubMedID 11212052

  • Regional anesthesia and pediatric cardiac surgery - In response ANESTHESIA AND ANALGESIA Hammer, G. B., Ngo, K., Macario, A. 2000; 91 (6): 1562-1562
  • Enterprise-wide patient scheduling information systems to coordinate surgical clinic and operating room scheduling can impair operating room efficiency ANESTHESIA AND ANALGESIA Dexter, F., Macario, A., Traub, R. D. 2000; 91 (3): 617-626

    View details for Web of Science ID 000088973700023

    View details for PubMedID 10960388

  • Is a trial of labor in a patient who has had a previous cesarean delivery cost-effective? Chung, A. J., Macario, A., El-Sayed, Y. Y., Riley, E. T., Druzin, M. L. LIPPINCOTT WILLIAMS & WILKINS. 2000: U212–U212
  • Quantitative description of the workload associated with airway management procedures Annual Meeting of the American-Society-of-Anesthesiologists Weinger, M. B., Vredenburgh, A. G., Schumann, C. M., Macario, A., Williams, K. J., Kalsher, M. J., Smith, B., Truong, P. C., Kim, A. ELSEVIER SCIENCE INC. 2000: 273–82


    To measure the workload associated with specific airway management tasks.Written survey instrument.166 Stanford University and 75 University of California, San Diego, anesthesia providers.Subjects were asked to use a seven-point Likert-type scale to rate the level of perceived workload associated with different airway management tasks with respect to the physical effort, mental effort, and psychological stress they require to perform in the typical clinical setting. The 126 subjects completing questionnaires (overall 52% response rate) consisted of 43% faculty, 26% residents, 23% community practitioners, and 8% certified registered nurse-anesthetists (CRNAs). Faculty physicians generally scored lower workload measures than residents, whereas community practitioners had the highest workload scores. Overall, workload ratings were lowest for laryngeal mask airway (LMA) insertion and highest for awake fiberoptic intubation. Airway procedures performed on sleeping patients received lower workload ratings than comparable procedures performed on awake patients. Direct visualization procedures received lower workload ratings than fiberoptically guided procedures.These kinds of data may permit more objective consideration of the nonmonetary costs of technical anesthesia procedures. The potential clinical benefits of the use of more complex airway management techniques may be partially offset by the impact of increased workload on other clinical demands.

    View details for Web of Science ID 000088827800004

    View details for PubMedID 10960198

  • What is the relative frequency of uncommon ambulatory surgery procedures performed in the United States with an anesthesia provider? ANESTHESIA AND ANALGESIA Dexter, F., Macario, A. 2000; 90 (6): 1343-1347


    Between 1994 and 1996, the National Center for Health Statistics used sophisticated sampling methods to measure the number and types of ambulatory surgery cases performed in the United States. We reanalyzed raw data obtained from this National Survey of Ambulatory Surgery to select cases with an anesthesia provider and here report characteristics of these 228,332 cases (e.g., patient age, anesthetic type). The goal of our study was to estimate what percentage of cases, of a specified surgical procedure or combination of procedures, may have been performed less than once per year per facility. Previous studies suggest the most important source of scheduling inaccuracy can be the absence of recently performed cases on which to base predictions of case duration. We found that 36% +/- 1% (SE) of all cases in the United States were a type of procedure or combination of procedures that occurred <6984 times per year (the number of surgery facilities performing ambulatory surgery in the United States). Approximately one third of all ambulatory cases were of a procedure or combination of procedures that may have been performed as infrequently as once per year per facility. This could impair the effectiveness of predicting the durations of ambulatory cases by using historical case-duration data. Implications: Approximately one third of all ambulatory cases were a procedure or combination of procedures possibly performed as infrequently as once per year per facility. This could impair the effectiveness of predicting the durations of ambulatory cases by using historical case-duration data.

    View details for Web of Science ID 000087266400015

    View details for PubMedID 10825318

  • 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


    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-?


    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

  • Is a trial of labor in a patient who has had a previous cesarean delivery cost-effective? Chung, A., Macario, A., El-Sayed, Y., Riley, E. T., Duncan, B., Sheinberg, D. LIPPINCOTT WILLIAMS & WILKINS. 2000: U11–U11
  • Scheduling surgical cases into overflow block time - Computer simulation of the effects of scheduling strategies on operating room labor costs Computers in Anesthesia Conference Dexter, F., Macario, A., O'Neill, L. LIPPINCOTT WILLIAMS & WILKINS. 2000: 980–88


    "Overflow" block time is operating room (OR) time for a surgical group's cases that cannot be completed in the regular block time allocated to each surgeon in the surgical group. Having such overflow block time increases OR utilization. The optimal way to schedule patients into a surgical group's overflow block time is unknown. In this study, we developed a scheduling strategy that balances the OR manager's need to reduce staffing costs and the needs of patients and surgeons for flexibility in choosing the dates and times of cases. We used computer simulation to evaluate our scheduling strategy. Surgeons and patients (i) can schedule the case into any overflow block within 2 wk; (ii) can only schedule the case into a "first case of the day" start time more than 2 wk in the future if there is not enough open time for the case within 2 wk; (iii) must schedule the case to be done within 4 wk; and (iv) are encouraged to perform the case on the earliest possible date. Staffing costs were lowest when the OR manager did not incorporate surgeon and patient preferences when scheduling cases into overflow block time. The strategy we developed provides surgeons and patients with some flexibility in scheduling, while only increasing OR staffing costs slightly over the minimum achieved when the OR manager controls scheduling.The strategy we developed provides surgeons and patients with some flexibility in scheduling, while increasing OR staffing costs only slightly over the minimum achieved when the OR manager controls scheduling. Staffing costs were lowest when the operating room (OR) manager did not incorporate surgeon and patient preferences when scheduling cases into overflow block time.

    View details for Web of Science ID 000086191800038

    View details for PubMedID 10735811

  • Analgesia for labor pain: A cost model Annual Meeting of the American-Society-of-Anesthesiologists Macario, A., Scibetta, W. C., Navarro, J., Riley, E. LIPPINCOTT WILLIAMS & WILKINS. 2000: 841–50


    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

  • Statistical method using operating room information system data to determine anesthetist weekend call requirements. AANA journal Dexter, F., Macario, A., Traub, R. D. 2000; 68 (1): 21-26


    We present a statistical method that uses data from surgical services information systems to determine the minimum number of anesthetists to be scheduled for weekend call in an operating room suite. The staffing coverage is predicted that provides for sufficient anesthetists to cover each hour of a 24-hour weekend period, while satisfying a specified risk for being understaffed. The statistical method incorporates shifts of varying start times and durations, as well as historical weekend operating room caseload data. By using this method to schedule weekend staff, an anesthesia group can assure as few anesthetists are on call as possible, and for as few hours as possible, while maintaining the level of risk of understaffing that the anesthesia group is willing to accept. An anesthesia group also can use the method to calculate its risk of being understaffed in the surgical suite based on its existing weekend staffing plan.

    View details for PubMedID 10876448

  • Calculating the cost of anesthesia care Current Anesthesiology Reports (ISSN: 1523-3855) Chung, A., Macario, A. 2000; 2 (5): 409-417
  • Common problems in the postanesthetic care unit Contemporary Surgery (ISSN: 0045-8341) Vasanawala, M., Macario, A., Canales, M. 2000; 56 (11): 691-700
  • 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


    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

  • Forecasting surgical groups' total hours of elective cases for allocation of block time - Application of time series analysis to operating room management ANESTHESIOLOGY Dexter, F., Macario, A., Qian, F., Traub, R. D. 1999; 91 (5): 1501-1508


    Allocation of the correct amount of operating room (OR) "block time" can provide surgeons with access to sufficient OR time to complete their elective cases while optimally matching staffing with the elective case workload (to maximize labor productivity). To evaluate how to predict accurately total hours of elective cases performed by a surgical group using data from surgical services information systems, the authors addressed the following questions: (1) How many previous 4-week periods of data should be used to minimize error in forecasting a surgical group's total hours of elective cases? (2) Using the number of 4-week periods from question #1, can we detect trends or correlations between successive periods that could be used to improve forecasting accuracy? (3) How can results from questions #1 and #2 be used to calculate an upper prediction bound (upper limit) for the total hours of elective cases that will be completed in a future period? Prediction bounds can be used to budget staffing accurately.Time series analysis was performed on total hours of elective cases over 39 consecutive 4-week periods from 17 surgical groups.The average of 12 consecutive periods' total hours of elective cases had an appropriate error profile. The observations within each series of 12 consecutive 4-week periods followed a normal distribution, with each observation of total hours of elective cases not correlated with the subsequent observation.The average of the most recent 12 4-week periods can be used to predict surgical groups' future use of block time.

    View details for Web of Science ID 000083335200040

    View details for PubMedID 10551603

  • Relying solely on historical surgical times to estimate accurately future surgical times is unlikely to reduce the average length of time cases finish late JOURNAL OF CLINICAL ANESTHESIA Zhou, J. S., Dexter, F., Macario, A., Lubarsky, D. A. 1999; 11 (7): 601-605


    To determine whether using only previous cases' surgical times for predicting accurately surgical times of future cases is likely to reduce the average length of time cases finish late (after their scheduled finish times).Computer simulation.Data from an operating room (OR) information system for two surgical suites were analyzed. For each case performed in fiscal year 1996, we searched backward for 1 year and counted the number of previous cases that were the same type of procedure performed by the same surgeon. Then, for each suite, surgical times were fitted to a statistical model estimating the effect of the type of procedure and who the surgeon was on surgical time. The estimated "variance components" were used in Monte-Carlo computer simulations to evaluate whether a hypothetical increase in the number of previous cases available to estimate the next case's surgical time would improve scheduling accuracy. Predictions of how long newly scheduled cases should take were impaired because 36.5% +/- 0.4% (mean +/- SE) of cases at a tertiary surgical suite and 28.6% +/- 0.7% of cases at an ambulatory surgery center did not have any cases in the previous year with the same procedure type and surgeon. Computer simulation was used to generate additional hypothetical cases. Using this data, even having many previous cases on which to base predictions of future surgical times would only decrease the average length of time that cases finish late by a few minutes.An OR manager considering using only historical surgical times to estimate future surgical times should first investigate, using data from their own surgical suite, what percentage of cases do not have historical data. Even if there are sufficient historical data to estimate future surgical times accurately, relying solely on historical times is probably an ineffective strategy to have future cases finish on time.

    View details for Web of Science ID 000084383600015

    View details for PubMedID 10624647

  • Which algorithm for scheduling add-on elective cases maximizes operating room utilization? Use of bin packing algorithms and fuzzy constraints in operating room management ANESTHESIOLOGY Dexter, F., Macario, A., Traub, R. D. 1999; 91 (5): 1491-1500


    The algorithm to schedule add-on elective cases that maximizes operating room (OR) suite utilization is unknown. The goal of this study was to use computer simulation to evaluate 10 scheduling algorithms described in the management sciences literature to determine their relative performance at scheduling as many hours of add-on elective cases as possible into open OR time.From a surgical services information system for two separate surgical suites, the authors collected these data: (1) hours of open OR time available for add-on cases in each OR each day and (2) duration of each add-on case. These empirical data were used in computer simulations of case scheduling to compare algorithms appropriate for "variable-sized bin packing with bounded space." "Variable size" refers to differing amounts of open time in each "bin," or OR. The end point of the simulations was OR utilization (time an OR was used divided by the time the OR was available).Each day there were 0.24 +/- 0.11 and 0.28 +/- 0.23 simulated cases (mean +/- SD) scheduled to each OR in each of the two surgical suites. The algorithm that maximized OR utilization, Best Fit Descending with fuzzy constraints, achieved OR utilizations 4% larger than the algorithm with poorest performance.We identified the algorithm for scheduling add-on elective cases that maximizes OR utilization for surgical suites that usually have zero or one add-on elective case in each OR. The ease of implementation of the algorithm, either manually or in an OR information system, needs to be studied.

    View details for Web of Science ID 000083335200039

    View details for PubMedID 10551602

  • 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


    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

  • A strategy for deciding operating room assignments for second-shift anesthetists ANESTHESIA AND ANALGESIA Dexter, F., Macario, A., O'Neill, L. 1999; 89 (4): 920-924


    We developed a relief strategy for assigning second-shift anesthetists to late-running operating rooms. The strategy relies on a statistical method which analyzes historical case durations available from surgical services information systems to estimate the expected (mean) remaining hours in cases after they have begun. We tested our relief strategy by comparing the number of hours that first-shift anesthetists would work overtime if second-shift anesthetists were assigned using our strategy versus if the anesthesia coordinator knew in advance the exact amount of time remaining in each case. Our relief strategy resulted in 3.4% to 4.9% more overtime hours for first-shift anesthetists than the theoretical minimum, as would have been obtained had perfect retrospective knowledge been available. Few additional staff hours would have been saved by supplementing our relief strategy with other methods to monitor case durations (e.g., real-time patient tracking systems or closed circuit cameras in operating rooms).A relief strategy that relies only on analyzing historical case durations from an operating room information system to predict the time remaining in cases performs well at minimizing anesthetist staffing costs.

    View details for Web of Science ID 000082827700019

    View details for PubMedID 10512265

  • 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


    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

  • Spinal vs. epidural anesthesia and analgesia in children undergoing open heart surgery Hammer, G. B., Ngo, K., Macario, A., Boltz, M. G., Hill, L. LIPPINCOTT WILLIAMS & WILKINS. 1999: U497–U497
  • 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 1998 Annual Meeting of the Association-of-Anesthesia-Clinical-Directors Dexter, F., Macario, A., Traub, R. D., Hopwood, M., Lubarsky, D. A. LIPPINCOTT WILLIAMS & WILKINS. 1999: 7–20


    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

  • Statistical method to evaluate management strategies to decrease variability in operating room utilization: Application of linear statistical modeling and Monte Carlo simulation to operating room management ANESTHESIOLOGY Dexter, F., Macario, A., Lubarsky, D. A., Burns, D. D. 1999; 91 (1): 262-274


    Operating room (OR) managers seeking to maximize labor productivity in their OR suite may attempt to reduce day-today variability in hours of OR time for which there are staff but for which there are no cases ("underutilized time"). The authors developed a method to analyze data from surgical services information systems to evaluate which management interventions can most effectively decrease variability in underutilized time.The method uses seven summary statistics of daily workload in a surgical suite: daily allocated hours of OR time, estimated hours of elective cases, actual hours of elective cases, estimated hours of add-on cases, actual hours of add-on cases, hours of turnover time, and hours of underutilized time. Simultaneous linear statistical equations (a structural equation model) specify the relationship among these variables. Estimated coefficients are used in Monte Carlo simulations.The authors applied the analysis they developed to two OR suites: a tertiary care hospital's suite and an ambulatory surgery center. At both suites, the most effective strategy to decrease variability in underutilized OR time was to choose optimally the day on which to do each elective case so as to best fill the allocated hours. Eliminating all (1) errors in predicting how long elective or add-on cases would last, (2) variability in turnover or delays between cases, or (3) day-to-day variation in hours of add-on cases would have a small effect.This method can be used for decision support to determine how to decrease variability in underutilized OR time.

    View details for Web of Science ID 000081188400034

    View details for PubMedID 10422952

  • 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


    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

  • Optimal sequencing of urgent surgical cases JOURNAL OF CLINICAL MONITORING AND COMPUTING Dexter, F., Macario, A., Traub, R. D. 1999; 15 (3-4): 153-162


    Optimal sequencing of urgent cases (i.e., selecting which urgent case should be performed first and which second) may enhance patient safety, increase patient satisfaction with timeliness of surgery, and minimize surgeons' complaints. Before determining the optimal sequence of urgent cases, an operating room (OR) suite must identify the primary scheduling objective to be satisfied when prioritizing pending urgent cases. These scheduling objectives may include: 1) perform the cases in the sequence that minimizes the average length of time each surgeon and patient waits; 2) perform the cases in the order that they were submitted; or 3) perform the cases based on medical priority, as prioritized by an OR director, or surgeons discussing the cases among themselves. We provide mathematical structure which can be used to program a computerized surgical services information system to assist in optimizing the sequence of urgent cases. We use an example to illustrate that the optimal sequence varies depending on the scheduling objective chosen.

    View details for Web of Science ID 000081074400002

    View details for PubMedID 12568166

  • Another use of a bronchoscopic swivel adapter ANESTHESIA AND ANALGESIA Torralva, P. R., Macario, A., Brock-Utne, J. G. 1999; 88 (5): 1187-1188

    View details for Web of Science ID 000080063000043

    View details for PubMedID 10320195

  • Computer simulation to determine how rapid anesthetic recovery protocols to decrease the time for emergence or increase the phase I postanesthesia care unit bypass rate affect staffing of an ambulatory surgery center ANESTHESIA AND ANALGESIA Dexter, F., Macario, A., Manberg, P. J., Lubarsky, D. A. 1999; 88 (5): 1053-1063


    Ambulatory surgery centers (ASC) are implementing new anesthetic techniques and rapid recovery protocols in the postanesthesia care unit (PACU) to achieve earlier discharge after general anesthesia. Using computer simulation, we addressed two questions. First, what is the decrease in an ASC's operating room (OR) staff if the time from which the surgery is finished to the time the patient leaves the OR is decreased? Second, what is the decrease in PACU nursing staffing if patients bypass phase I PACU (i.e., proceed from the OR directly to the phase II PACU)? The decrease in labor costs from rapid emergence or fast-tracking depends on how staff are compensated, how many ORs routinely run concurrently, and what percentage of patients undergo general anesthesia. The results show potential decreases in ASCs' labor costs ($7.39 per case) from technologies (e.g., new anesthetics or Bispectral Index [Aspect Medical Systems, Natick, MA] monitoring) to decrease emergence times or increase the phase I bypass rates.Decreases in operating room and postanesthesia care unit labor costs resulting from faster emergence and phase I postanesthesia care unit bypass vary depending on the amount of routine overtime, how the staff are compensated, and how many patients are routinely anesthetized each day.

    View details for Web of Science ID 000080063000016

    View details for PubMedID 10320168

  • Selecting double-lumen tubes for small patients ANESTHESIA AND ANALGESIA Brodsky, J. B., Fitzmaurice, B. G., Macario, A. 1999; 88 (2): 466-466

    View details for Web of Science ID 000078404300050

    View details for PubMedID 9972778

  • Decrease in case duration required to complete an additional case during regularly scheduled hours in an operating room suite: A computer simulation study ANESTHESIA AND ANALGESIA Dexter, F., Macario, A. 1999; 88 (1): 72-76


    We used Monte-Carlo computer simulation to determine whether surgical or anesthetic interventions to achieve small decreases in case duration may create enough new open operating room (OR) time to permit an additional case to be scheduled for completion in an OR suite during regular working hours. We used rules for scheduling of cases assuming that OR personnel are compensated so that the OR suite can profit financially from decreasing case duration to complete an additional case during regularly scheduled hours. The decreases in each case's duration required to create enough new open OR time to reliably (> or =95%) schedule another case were 30-39 min, 79-110 min, and 105-206 min for OR suites with 1-15 ORs and mean case durations of 1, 2, or 3 h, respectively.Computer simulation shows decreasing case duration is unlikely to create sufficient operating room time to reliably permit an additional case to be scheduled for completion during working hours. Additional cases may best be added to the operating room suite schedule by optimizing case scheduling, not by decreasing the duration of all cases in the suite.

    View details for Web of Science ID 000077901200013

    View details for PubMedID 9895069

  • Management of the operating room. A new practice opportunity for anesthesiologists Anesthesiology Clinics of North America Glenn, D., Macario, A. 1999; 17 (2): 365-394
  • How do hospitals account for costs in the operating room? Current Reviews in Clinical Anesthesia (CME) Macario, A. Frank Moya Continuing Education Programs. 1999: 193–204
  • Delivering value to the customers of anesthesia service Current Reviews in Clinical Anesthesia (CME) Macario, A. Frank Moya Continuing Education Programs. 1999: 253–264
  • The economics of delivering surgical care in the OR suite Progress in Anesthesiology (Dannemiller Memorial Educational Foundation) ISSN: 0891-5784 Macario, A. 1999; 8 (17): 315-328
  • Do clinical pathways improve efficiency? Seminars in Anesthesia, Perioperative Medicine and Pain (incorporated into Journal of Critical Care) Glenn, D., Macario, A. 1999; 18 (4): 281-288
  • Defining quality in medicine to determine how to improve the value of anesthesia care. Progress in Anesthesiology Macario, A. Dannemiller Memorial Educational Foundation. 1999: 375–388
  • Macario A. Defining quality in medicine to determine how to improve the value of anesthesia care. Progress in Anesthesiology issn: 0891-5784 Macario, A. 1999; VIII (21): 375-388
  • Obstetric postanesthesia care unit stays - Reevaluation of discharge criteria after regional anesthesia Annual Meeting of the American-Society-of-Anesthesiologists Cohen, S. E., Hamilton, C. L., Riley, E. T., Walker, D. S., Macario, A., Halpern, J. W. LIPPINCOTT WILLIAMS & WILKINS. 1998: 1559–65


    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

  • Computer simulation of changes in nursing productivity from early tracheal extubation of coronary artery bypass graft patients JOURNAL OF CLINICAL ANESTHESIA Dexter, F., Macario, A., Dexter, E. U. 1998; 10 (7): 593-598


    To determine whether the results from a clinical trial, which showed that early extubation of elective coronary artery bypass graft (CABG) patients can reduce hospital costs by more rapid discharge of patients from the intensive care unit (ICU), are likely to apply to other hospitals.Discrete-event computer simulation.We (1) generated simulated CABG patients, (2) had them "flow" from one condition to the next according to specified rules, and (3) calculated the labor productivity of simulated nurses who would be caring for the patients. We defined nursing labor productivity as the number of patients undergoing elective CABG cared for each year per nursing full-time equivalent working 40 hours per week. Our simulations predict that the increase in nursing labor productivity achieved by early extubation of CABG patients is sensitive to the number of elective CABG cases performed each year at the hospital and the method of compensating nurses. Hospitals with an "hourly workforce" and many cases per year are predicted to achieve a greater increase in productivity from early extubation than are hospitals with a "salaried workforce" and less active volume. At hospitals with a salaried workforce, increasing the percentage of patients extubated early may have no effect on labor productivity.Although "fast-tracking" protocols may offer benefits other than increasing nursing labor productivity (i.e., saving money), the results of clinical trials that demonstrate cost savings from clinical pathways that include early tracheal extubation are likely to apply only to hospitals that have similar annual CABG volume and method of compensating nurses as those in the clinical trial. To estimate the likely economic impact from early extubation protocols, a hospital should complete a simulation study with parameter values appropriate to its institution.

    View details for Web of Science ID 000076637900010

    View details for PubMedID 9805701

  • Hospital profitability for a surgeon's common procedures predicts the surgeon's overall profitability for the hospital JOURNAL OF CLINICAL ANESTHESIA Dexter, F., Macario, A., Cerone, S. M. 1998; 10 (6): 457-463


    To evaluate whether a hospital's profitability for a surgeon's common procedures predicts the surgeon's overall profitability for the hospital.Observational study.Community and university-affiliated tertiary hospital with 21,903 surgical procedures performed per year.7,520 patients having surgery performed by one of 46 surgeons.None.Financial data were obtained for all patients cared for by all the surgeons who performed at least ten cases of one of the hospital's six most common procedures. A surgeon's overall profitability for the hospital was measured using his or her contribution margin ratio (i.e., total revenue for all of the surgeon's patients divided by total variable cost for the patients). Contribution margin was calculated twice: once with all of a surgeon's patients, and second, limiting consideration to those patients who underwent one of the six common procedures. The common procedures accounted for 22 +/- 15% of the 46 surgeons' overall caseload, 29 +/- 10% of their patients' hospital costs, and 30 +/- 12% of the hospital revenue generated by the surgeons. Hospital contribution margin ratios ranged from 1.4 to 4.2. Contribution margin ratios for common procedures and contribution margin ratios for all patients were correlated (tau = 0.58, n = 46, p < 0.0001).Even though most surgical cases were for uncommon procedures, a surgeon's hospital profitability on common procedures predicted the surgeon's overall financial performance. Perioperative incentive programs based on common surgical procedures (clinical pathways) are likely to accurately reflect a surgeon's financial performance on their other surgeries.

    View details for Web of Science ID 000076413500003

    View details for PubMedID 9793808

  • Analgesia for labor pain: An economic model Scibetta, W., Navarro, J., Macario, A., Washington, D., Rieder, A., Holland, M., Cohen, S. E., Vitez, T. LIPPINCOTT WILLIAMS & WILKINS. 1998: U866–U866
  • Postoperative epidural injection of saline can shorten postanesthesia care unit time for knee arthroscopy patients Feminist Theory and Music 4 Conference Brock-Utne, J. G., Macario, A., Dillingham, M. F., Fanton, G. S. W B SAUNDERS CO-ELSEVIER INC. 1998: 247–51


    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


    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


    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


    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

  • Evaluating operating room anesthesia staffing American Journal of Anesthesiology ISSN: 1078-4500 Navarro, J., Macario, A. 1998; 15 (3): 105-106
  • 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

  • Does early extubation (''fast-tracking'') of coronary artery bypass graft surgery patients truly decrease perioperative costs?: Appropriate analysis of direct variable costs ANESTHESIOLOGY Dexter, F., Macario, A. 1997; 87 (1): 181-181

    View details for Web of Science ID A1997XJ86200038

    View details for PubMedID 9232158

  • Economics of anesthesia care - A call to arms! ANESTHESIOLOGY Fisher, D. M., Macario, A. 1997; 86 (5): 1018-1019

    View details for Web of Science ID A1997WX85900003

    View details for PubMedID 9158348

  • 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


    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

  • Computers: a practical guide for anesthesiologists Advances in Anesthesia Garman, J., Macario, A. 1997; 14: 29-53
  • Applications of information systems to operating room scheduling ANESTHESIOLOGY Dexter, F., Macario, A. 1996; 85 (6): 1232-1234

    View details for Web of Science ID A1996VX62100003

    View details for PubMedID 8968168

  • 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

  • Severity of illness does not predict hospital costs for three types of elective surgery Macario, A., Vitez, T., Dunn, B., McDonald, T., Brown, B. LIPPINCOTT WILLIAMS & WILKINS. 1996: A981–A981
  • Improved outcome with chronic subcutaneous infusion of ondansetron for intractable nausea and vomiting ANESTHESIA AND ANALGESIA Macario, A., RONQUILLO, R. B., Brose, W. G., Gaeta, R. R. 1996; 83 (1): 194-195

    View details for Web of Science ID A1996UT70200042

    View details for PubMedID 8659741

  • 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



    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

  • Modified BronchoCath double-lumen tube JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Brodsky, J. B., Macario, A. 1995; 9 (6): 784-785

    View details for Web of Science ID A1995TM82400028

    View details for PubMedID 8664477

  • 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


    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



    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



    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



    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 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


    View details for Web of Science ID A1995QP80500019

    View details for PubMedID 7598931

  • Comparison of estimated variable costs is a surrogate for actual cost experience (correspondence reply) Anesthesiology Macario, A., Chang, P., Stempel, D., Brock-Utne, J. 1995: 6

    View details for Web of Science ID A1994PL75500024

    View details for PubMedID 8001204


    View details for Web of Science ID A1994NZ33700043

    View details for PubMedID 7639391

  • COSTS OF INHALED ANESTHETICS .3. ANESTHESIOLOGY Macario, A. 1994; 80 (6): 1405-1405

    View details for Web of Science ID A1994NR92600037

    View details for PubMedID 8010491



    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