Abstract
Objective
In developed countries, the societies of anesthesiologists have published reports of anesthesia quality. However, there are still no publications on anesthesia quality in Taiwan, even though the Taiwan Society of Anesthesiologists (TSA) was founded in 1956. This study was designed to evaluate the quality of anesthesia in Taiwan using databases maintained by the TSA and the Bureau of National Health Insurance-Taiwan (BNHI-T).
Methods
The TSA published annual reports in 1995–1998 and 2002–2008 (with a 3-year interval), which included a survey on anesthesia-related mortality and morbidity, the manpower and composition of anesthesia teams, and the causes of anesthesia-related complications. Since 2002, the BNHI-T has collaborated with the National Health Research Institute-Taiwan to establish a database of health care service. To understand anesthesia quality in Taiwan, we collected data from the annual TSA surveys and the BNHI-T, and analyzed trends in anesthesia-related mortality, causes of anesthesia complications, and relative manpower composition.
Results
The rate of anesthesia-related mortality was 11.9 deaths/100,000 cases. More than 50% of all anesthesia-related complications were preventable. About 1500 anesthetic procedures were performed annually by each anesthesiologist in Taiwan. The ratio of anesthesiologists to nurse anesthetists was 1:3–5.
Conclusion
Anesthesia-related mortality was about 10-fold higher in Taiwan than in the United States, Japan and the United Kingdom. Mortality related to quality of anesthesia in Taiwan must be reduced. To achieve this target, we have recommended the following six approaches: (1) decrease the workload of anesthesiologists; (2) increase reimbursement by the BNHI-T for anesthesia; (3) improve the training quality of anesthetist residents; (4) strengthen the quality of board examinations; (5) improve the training quality of nurse anesthetists; and (6) standardize monitoring procedures and equipment. Only once these measures are introduced, in combination with effective quality assurance and subjective improvement systems, can we expect an improvement in the quality of anesthesia in Taiwan.
Keywords
anesthesia-related mortality; Taiwan;
1. Introduction
Worldwide, healthcare systems are facing significant problems, namely extended life expectancies, an increased aging population and increasing healthcare expenditures. In Taiwan, the National Health Insur ance Program (NHIP) was implemented in 1995. The NHIP now covers > 99% of the population and > 94% of hospitals and clinics in Taiwan have joined the NHIP. In 1999, healthcare expenditure comprised 5.5% of the gross domestic product, and increased to 6.1% in 2007.1 With the increasing healthcare expenditures in Taiwan, the government is endeavoring to control medical expenses within a reasonable limit.
The quality of anesthesia can be assessed in many different ways.2 For example, surgeons need optimal conditions to perform surgical procedures and patients do not want to feel any discomfort or fear during the surgery. The most important objective for anesthesiologists is to ensure that their patients experience no harm during or immediately after the surgery. However, no studies have been conducted to assess the quality of anesthesia in Taiwan. Therefore, in this study, we reviewed the relevant data obtained from surveys conducted by the Taiwan Society of Anesthesiologists (TSA), which covered most of the years since the implementation of the NHIP. Anesthesia-related mortality was adopted as the most important indicator of anesthesia quality. The objective of this study was not only to reveal trends in mortality, but also to understand the underlying factors. Furthermore, we propose methods to reduce the incidence of anesthesiarelated mortality.
2. Methods
The data included in this study were retrieved from annual surveys sent to tertiary hospitals (medical centers) and secondary hospitals (regional hospitals and district hospitals) with an anesthesia department or division, and analyzed by a task force of the TSA. The TSA conducted this survey of anesthesia-related mortality, manpower and causes of anesthesia complications annually between 1995 and 1998 and between 2002 and 2008. The survey was derived from the consensus of the TSA Board and comprised: (1) the manpower in the anesthesia teams, including the number of anesthesiologists and nurse anesthetists; (2) anesthetic procedures performed; and (3) anesthesia-related mortality and the causes of the complications. The numbers of anesthesiologists and anesthesia cases documented in the annual TSA surveys were compared with data provided by the Bureau of National Health Insurance−Taiwan (BNHI-T).
Anesthesia-related mortality was also obtained from annual TSA surveys. The percentage of preventable complications of anesthesia was analyzed. Mechanical problems and human faults were categorized as preventable items. Because airway obstruction can be detected with adequate monitoring systems and constant vigilance, we considered airway obstruction as a preventable complication.
We applied descriptive statistics to our analysis and focused on the following factors: (1) trends in anesthesia-related mortality for 1995−1998 and 2002−2008; (2) percentage of preventable cases; (3) manpower composition of the anesthesia teams and anesthetic workload; and (4) comparison of anesthesia-related mortality between Taiwan, Japan, the United States and the United Kingdom.
3. Results
Anesthesia-related mortality is shown in Figure 1. The first survey conducted in 1995 revealed a mortality rate of 4.2 deaths/100,000 anesthetic cases. The lowest mortality rate was 1.5 deaths/100,000 cases in 1997. The greatest anesthesia-related mortality rate was 17.8 deaths/100,000 cases in 2003, decreasing to 7.4 deaths/100,000 cases in 2006, but increasing to 12.3 deaths/100,000 cases in 2008.
Figure 2 shows the percentage of preventable complications. Overall, > 50% of all anesthesia-related complications were preventable, reaching > 75% in 1995−1996, 1998 and 2004−2006.
Table 1 shows two series of anesthesia cases; one obtained from the BNHI-T database and the other from the TSA survey. Data from the BNHI-T were not available until 1999, and the TSA did not perform annual surveys between 1999 and 2001. In 2002, the TSA survey comprised 48,700 cases, corresponding to approximately 60% of cases recorded in the BNHI-T database in the same year. In 2008,the percentage increased to > 98% (TSA, 82,100 cases; BNHI-T, 83,500 cases). The number of anesthesiologists registered in the annual TSA survey and the average number of cases managed by each anesthesiologist are shown in Table 2. The number of cases managed by each anesthesiologist gradually decreased with increasing number of anesthesiologists within the team. Table 3 shows the manpower composition of the anesthesia teams and the ratio of anesthesiologists to nurse anesthetists for 11 years in Taiwan. The ratio of anesthesiologists to nurse anesthetists varied from 1:3.4 to 1:4.4.
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4. Discussion
Many studies have focused on anesthesia-related mortality in the past decades.3−5 Some countries have performed nationwide studies to investigate the quality of anesthesia.6 The present study is the first to assess the quality of anesthesia in Taiwan since the implementation of the NHIP-T in 1995 and there are several key findings to be discussed.
First, the annual TSA questionnaire covered a large portion of the total number of anesthetic procedures reimbursed by the BNHI-T. In 2002, 60% of all the cases were covered in this survey, increasing to > 98% in 2008. According to the preliminary data from a tertiary hospital in Taipei, about 10% of the anesthetics were self-provided, which were not included in the BNHI-T database. Apart from these self-provided anesthetics, these data from the annual TSA surveys reflect the real status of anesthesia practice in Taiwan.
Second, anesthesia-related mortality has not declined significantly over the 11 years included in this study. This implies that there have been no significant improvements in the quality of anesthesia in Taiwan since 1995. Furthermore, anesthesia-related mortality was remarkably higher in Taiwan than in other developed countries (Table 4).7−13 Of note, anesthesia-related mortality tended to decrease during the 4 years before the 3-year interval in the annual TSA surveys. The average anesthesia-related mortality in 1995−1998 was 3.2 deaths/100,000 cases, but increased to 11.9 deaths/100,000 cases in 2002−2008. The reason for this increase is unclear, but it could be related to the number of cases surveyed by the TSA. Since 1995, the population in Taiwan has increased by about 8%,14 but the number of anesthetic procedures included in the annual TSA report has increased by 100%. It is possible that fewer questionnaires were returned to the TSA during the early years of the survey because many anesthesiology departments/divisions were unwilling to report their performance results. Later, as they gained confidence in the TSA’s protection of confidential documents, they became more willing to answer the questionnaire, and the results of these surveys more closely reflected the actual clinical status in recent years.
Another important finding was that more than 50% of these complications were preventable. If these preventable complications can be eliminated, the anesthesia-related mortality and morbidity would be greatly reduced. Therefore, approaches to reduce preventable complications should be future task for the TSA. We have identified six steps that should reduce the incidence of preventable complications. First, the anesthetic teams should be given a more reasonable workload. In fact, it was reported that the workload of staff in clinical practice is the most important factor that affects the quality of anesthesia.15 Although the number of cases managed by each anesthesiologist per year has gradually decreased in Taiwan, anesthesiologists still manage a relatively large number of cases per year compared with anesthesiologists in developed countries. For example, in 2004, each anesthesiologist managed an average of 1,638 cases in Taiwan, compared with 772 in the United States. The workload is even greater in primary hospitals than in secondary hospitals. Furthermore, some anesthesiologists do not conduct clinical anesthesia but are devoted to pain management, critical care or laboratory research, meaning that the actual number of cases managed by each anesthesiologist per year is even higher. Thus, to improve the quality of anesthesia in Taiwan, it is important to decrease the workload of anesthesiologists toward a reasonable number of cases. At present, each anesthesiologist is also managing more than three or four operating rooms at the same time. This phenomenon is reflected by the ratio of anesthesiologists to nurse anesthetists in our study. Dai et al reported similar results in their study.16 In contrast, anesthesiologists in the United States manage only one or two operating rooms at the same time.
Second, the reimbursement for anesthesia in Taiwan is much lower than the expected and rational level, in terms of working stress and clinical risks. For example, the postanesthesia recovery room fee in the United States is about 120-fold higher than that reimbursed by the BNHI-T.17,18 Besides low reimbursement, the BNHI-T also adopts different anesthesia fees for different techniques, whereas a uniform anesthesia fee is provided for all anesthesia techniques in the United States. For example, the spinal anesthesia fee is one-quarter of that for general anesthesia with intubation in Taiwan. Often, surgeons will insist that their procedure be carried out under spinal anesthesia instead of general anesthesia so that the anesthesia can be fully reimbursed, even though general anesthesia is more beneficial to the patients. Because of such discrepancies, it is easy to understand why anesthesiologists in Taiwan must perform as many cases as possible to provide a reasonable income. In addition, because of the high professional risks and low pay, relatively few medical graduates select anesthesia as their specialty in Taiwan.
Third, training and certification of anesthesiologists must be improved. Currently, anesthesia residents are spread across the accredited teaching hospitals in Taiwan and most of them are included in the manpower of the anesthesia departments/divisions. Thus, clinical work often interferes with their training activities. Therefore, the accreditation council must push program directors to strictly implement the training course in accordance with the institute’s anesthesia training program. Moreover, the most important function of the anesthesia board examination is not only to evaluate the clinical performance and knowledge of anesthesia residents, but also to evaluate their competence as anesthesiologists. The Taiwan Board of Anesthesi ology has to institute appropriate certification examinations. Ironically, the passing rate for the board examination was nearly 100% in recent years, meaning greater examination quality must be implemented to test the competence of anesthesia residents.
Fourth, a standard for basic monitoring of anesthesia must be established. Previous studies have shown that improving the monitoring system improves the quality of anesthesia. For example, the safety of anesthesia has significantly improved since the introduction of end-tidal CO2 monitors and pulse oximeters.7 Unfortunately there is no such standard in Taiwan. The former presidents of the TSA (Professors Tak-Yu Lee and Shung-Tai Ho) held a series of conferences in the 1990s on patient safety and anesthesia monitoring standards, and recommended that the Department of Health develop a basic monitoring standard for anesthesia in 1995; however, there was been no response from the government.
Fifth, as described above, the quality and experience of nurse anesthetists play an important role in supporting anesthesia practice in Taiwan. Unlike the nurse anesthetist system in the United States, there are no standard training programs or official qualifications in Taiwan.16 Therefore, it is necessary to establish a standardized training program for nurse anesthetists. Finally, an efficient quality assurance and improvement system is needed for continuous quality enhancement. Such systems not only identify flaws in daily practice but also reinforce the concept of quality improvement. We should throw out the old theory of finding “bad apples”.19 Quality will only improve if faults can be discussed openly and if we look for the reasons for why they happen.2
In conclusion, the rate of anesthesia-related mortality is higher in Taiwan than in the United States, Japan and the United Kingdom, and it should be reduced by all means. To achieve this goal, we strongly recommend the following six approaches: (1) decrease the workload of anesthesiologists; (2) increase the level of reimbursement for anesthesia; (3) improve the training quality of anesthesia residents; (4) provide appropriate board examinations; (5) improve the quality of training of nurse anesthetists; and (6) establish basic monitoring standards. Only once these issues have been addressed, in combination with an effective quality assurance and continuous improvement system, can we look forward to improvements in the quality of anesthesia in Taiwan.
Acknowledgments
We wish to thank Professor Ricky Sai-Chuen Wu, President of the Taiwan Society of Anesthesiologists and Dr Tien-Hsiung Ku for their full support and generous help. We also thank Mr Te-Chun Yeh for his kind assistance.