Flood Pamela, Dexter Franklin, Ledolter Johannes, Dutton Richard P
From the *Department of Anesthesiology, Stanford University, Stanford, California; †Division of Management Consulting, Department of Anesthesia, and ‡Department of Management Sciences, University of Iowa, Iowa City, Iowa; and §Anesthesia Quality Institute, Schaumburg, Illinois.
Anesth Analg. 2015 Nov;121(5):1283-9. doi: 10.1213/ANE.0000000000000897.
Variability in the mean durations of labor analgesia for vaginal delivery among hospitals is unknown. Such differences in means among hospitals would influence appropriate equitable fee-for-service payment to US anesthesia groups. Equitable payment is the foundational principle of relative value unit payment, which, for anesthesia in the United States, means use of the American Society of Anesthesiologist's Relative Value Guide.
We analyzed data from the American Society of Anesthesiologists' Anesthesia Quality Institute to test whether there are large differences in mean durations of labor analgesia for vaginal delivery among US hospitals. We choose the statistical methodology for that analysis using detailed data from 2 individual hospitals. Analyses of the means were performed for the 172 hospitals reporting a total of at least 200 durations; having no greater than 5.0% of durations 1.0 hour or less; and at least 5 four-week periods each having a mean of at least one epidural every couple of days. The 172 hospitals provided for n = 5671 combinations of hospital and 4-week period and 551,707 labor epidurals, with an overall mean duration of 6.12 hours (SE, 0.001 hour).
55.2% of the 172 hospitals had mean durations of labor analgesia for vaginal delivery that each differed (P < 0.001) from the overall mean. Among those 55.2% were the 9.9% of hospitals with means ≤5.12 hours. Those mean durations on the low end ranged from 2.68 (SE, 0.17) to 5.10 (SE, 0.07) hours. Also, among the 55.2% were the 12.2% of hospitals with means ≥7.12 hours. Those mean durations at the high end ranged from 7.13 (SE, 0.08) to 12.03 (SE, 0.23) hours. The heterogeneity in the mean durations among hospitals would have been greater had the inclusion criteria not been applied.
Our results show that the number of labor epidurals alone is not a valid measure to quantify obstetrical anesthesia productivity. In addition, payment to US anesthesia groups for labor analgesia based solely on the number of labor epidurals initiated is not equitable. Previous work showed lack of validity and equality of payment based on face-to-face time with the patient (i.e., like a surgical anesthetic). The use of base and time units, with one time unit per hour, is a suitable payment system.
各医院阴道分娩时分娩镇痛的平均持续时间差异尚不清楚。医院之间的这种均值差异会影响美国麻醉团队合理的公平按服务付费。公平付费是相对价值单位付费的基本原则，在美国，这意味着使用美国麻醉医师协会的相对价值指南。
我们分析了美国麻醉医师协会麻醉质量研究所的数据，以测试美国各医院阴道分娩时分娩镇痛的平均持续时间是否存在显著差异。我们使用来自两家医院的详细数据选择该分析的统计方法。对报告了至少200次持续时间的172家医院进行了均值分析；持续时间为1.0小时或更短的比例不超过5.0%；并且至少有5个四周时间段，每个时间段平均每两天至少有一次硬膜外麻醉。这172家医院提供了n = 5671个医院与四周时间段的组合以及551,707次分娩硬膜外麻醉，总体平均持续时间为6.12小时（标准误，0.001小时）。
172家医院中有55.2%的医院阴道分娩时分娩镇痛的平均持续时间与总体均值存在差异（P < 0.001）。在这55.2%的医院中，有9.9%的医院均值≤5.12小时。这些低端均值范围为2.68（标准误，0.17）至5.10（标准误，0.07）小时。此外，在这55.2%的医院中，有12.2%的医院均值≥7.12小时。这些高端均值范围为7.13（标准误，0.08）至12.03（标准误，0.23）小时。若未应用纳入标准，医院间平均持续时间的异质性会更大。
我们的结果表明，仅分娩硬膜外麻醉的次数并非量化产科麻醉生产力的有效指标。此外，仅基于开始的分娩硬膜外麻醉次数向美国麻醉团队支付分娩镇痛费用是不公平的。先前的研究表明，基于与患者面对面的时间（即类似于外科麻醉）进行付费缺乏有效性和平等性。使用基础单位和时间单位，每小时一个时间单位，是一种合适的付费系统。
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