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In this issue of Anesthesia & Analgesia, Zuegge et al1 describe a performance improvement initiative led by their multidisciplinary OR Green Team that combined provider education with cognitive aids in the operating room to drive practice improvement. What was unique about this initiative was the primary objective—to reduce greenhouse gas emissions stemming from anesthesia care. Education centered on inhaled drug global warming potentials, and how pollution emissions vary at different fresh gas flow rates (see Table). Labels were also fixed onto the vaporizers to encourage environmentally preferable practice choices at the point of decision making. The authors then tracked inhaled anesthetic usage, using purchasing records, before and after implementation of their initiative. Comparing 2015 to 2012 (with 31,779 and 28,957 cases, respectively), they demonstrated an annual procurement reduction of desflurane from 72.5 to 32.5 L, an increase in sevoflurane from 78.6 to 91.6 L, and no significant change in isoflurane purchase (4.2 from 4.1 L). They also noted a reduction in nitrous oxide procurement from 6160 to 1468 kg. They assumed that frequency of total intravenous anesthesia and regional techniques did not change. The authors estimated an impressive annual savings of 2,865,430 kg of carbon dioxide equivalent emissions (equivalent to removing 613 passenger vehicles from the road for 1 year) and also approximately $300,000 in inhaled drug purchase costs.
The climate change crisis has been named the number 1 public health issue of the 21st century, leading to a global call for action in the health community.3 Health care pollution itself harms public health4 and can indirectly increase the cost of health care by increasing the demand for services.5 Inhaled anesthetics are an obvious target for mitigation because they can comprise 50% of operating room total greenhouse gas emissions,6 and simple practice changes could reduce emissions.7 Reducing waste by decreasing excess fresh gas flows is one of the simplest ways to reduce pollution and facility costs, without affecting care quality.
Physicians are generally unaware of the costs of drugs, tests, supplies, and procedures.8 Displaying radiology and laboratory test results to motivate change has demonstrated mixed results.9 Displaying anesthesia drug prices—particularly when combined with educational initiatives—can lead to practice change that reduces costs without reducing quality of care.10 Prior drug studies largely focused on encouraging substitution of cheaper drugs for more expensive ones and not on physical waste reduction. In the study by Zuegge et al,1 staff suggested that the strongest motivation for change was information about the environmental impact of practice choices, not cost. Coincidentally, the acquisition cost of desflurane is the highest of the inhaled drugs and it also has the highest global warming potential.1,7 Because educational efforts did not focus on prices, it is unclear if estimated cost savings were a byproduct of pollution prevention or if savings were indeed a primary motivator for practice change. It helps to consider how nitrous oxide usage changed in the study by Zuegge et al.1 In clinically relevant doses, the carbon footprint of nitrous oxide is similar in magnitude to that of desflurane (Table). Nitrous oxide is the cheapest of the inhaled drugs studied, yet its procurement was also dramatically reduced in this study. This suggests that anesthesia providers can be motivated by environmental emissions information to reduce waste and prevent pollution, which is a novel and important finding.
Providing enduring motivation to health professionals for resource conservation is a long-standing challenge. A Cochrane review found that audit and feedback efforts generally lead to small but potentially important improvements in professional practice. Effectiveness depends on baseline performance and how the feedback is provided.11 A promising strategy with potentially long-term effectiveness includes real-time decision support. Nair et al12 developed a tool using the Anesthesia Information Management System that alerts users if fresh gas flows exceed 1 L/min. If sevoflurane reaches 2 minimum alveolar concentration hours at low flow (between 1 and 2 L/min), then the alert notifies providers to increase the rate to 2 L/min. These authors demonstrated a mean reduction of maintenance fresh gas flows from 2.10 L/min (±1.12 L/min) to 1.59 L/min (±1.02 L/min), saving a total of $105,000 in 2010.12 Anesthesia machine tools exist, such as Low Flow Wizard (Drager, Lubeck, Germany) and EcoFlow (GE Healthcare, Madison, WI), which can also provide real-time cost feedback, but their effectiveness is not well documented. One potentially important opportunity for implementation of a feedback tool for anesthetic fresh gas flow management is through the Multicenter Perioperative Outcomes Group Anesthesia Performance Improvement and Reporting Exchange. Of the 50 hospital members of Multicenter Perioperative Outcomes Group, 15 already interface with Anesthesia Performance Improvement and Reporting Exchange. Anesthesia Performance Improvement and Reporting Exchange collects anesthetic management and outcomes data. Provider feedback, both in the form of real-time decision support as well as performance reports, can be used to reduce complications and cost. Based on findings by Zuegge et al,1 in addition to fresh gas flow rates, information on greenhouse gas emissions in terms of carbon dioxide equivalent and equivalent miles driven could also motivate resource conservation.
To further scale motivation, sustainability metrics should be integrated into the Quality Payment Program established by the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015.13 Medicare Access and Children’s Health Insurance Program Reauthorization Act is transforming Medicare from a fee-for-service payment system to a Merit-based Incentive Payment System and other Alternative Payment Models. Physicians are financially rewarded for clinical practice improvement activities, cost, promoting interoperability, and quality. Qualified Clinical Data Registries develop performance metrics for the Merit-based Incentive Payment System quality component and offer a unique opportunity to incorporate environmental performance as a determinant of physician reimbursement for health care services. Environmental costs, such as greenhouse gas emissions associated with clinical resource consumption, need to be incorporated into the cost component of Merit-based Incentive Payment System, as well, to reward waste reduction.
Given findings by Zuegge et al,1 a potentially important and novel strategy would be for Choosing Wisely to promote pollution prevention as a dimension of waste reduction and improved safety to public health. The Choosing Wisely initiative of the American Board of Internal Medicine Foundation seeks to reduce inappropriate use of health care resources and prevent unintended harm due to overtreatment and overtesting. Areas of waste have been identified, and evidence-based prevention practices have been promoted by multiple specialties. The American Society of Anesthesiologists should add inhaled anesthetic management to its Choosing Wisely top recommendations list.14
Priority should always be given to patient safety. Waste reduction is one of the simplest means to both save money and prevent pollution, without impacting patient outcomes. It is conceivable that cost and pollution metrics could be at odds. For example, if the drug with the highest cost also has the lowest carbon footprint, decision makers must weigh the cost–benefit ratio. Some argue that reduced anesthetic emergence times partially offset the higher costs of desflurane, but this does not take into account the environmental costs. Economic losses in the United States are estimated at $240 billion annually from weather-related events influenced by human-induced climate change, and subsequent health damages, due to air pollution caused by fossil fuel energy production.15 Such externalized costs must be accounted for when performing cost–benefit analyses. Indirect savings from prevention of health care-related pollution damages may be small in study by Zuegge et al,1 however, could be meaningful when extrapolated over the entire industry. Finally, in an expanded view of patient safety that includes protection of public health, the duty to first, do no harm would further prioritize pollution prevention.
Zuegge et al1 is to be commended for implementing an inhaled anesthetic practice improvement program that resulted in both significant pollution prevention and cost savings. Importantly, this is the first demonstration of the utility of pollution metrics to inspire practice improvement. Incorporation of sustainability metrics into real-time decision support tools and provider feedback could result in more rapid adoption of best fresh gas flow and selection of environmentally preferable drugs where safe choices exist. Adding sustainability metrics into the Merit-based Incentive Payment System could further incentivize pollution prevention. The Choosing Wisely initiative could similarly use sustainability metrics to add motivation for waste reduction. Taken together, such efforts could rapidly scale up practice improvement and make an enduring impact.
Jodi D. Sherman, MD.
Contribution: This author contributed to the conceptualization and writing of this manuscript.
Name: Lauren Berkow, MD, FASA.
Contribution: This author contributed to the conceptualization and writing of this manuscript.
This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.
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