To the Editor:--Correspondence from Ready examined the use of patient-controlled analgesia (PCA) in the United States. [1]As an extension to his useful work, it would be helpful to have additional data regarding PCA management in elderly postoperative patients, who are at greater risk for perioperative problems than the general population.* In Florida, we find little management of postoperative PCA by anesthesiologists. Perhaps this is because of the relatively large percentage of Medicare patients in our state and because of the decision of the Health Care Financing Administration (HCFA) to halt further Medicare reimbursement to Florida anesthesiologists for this service, effective June 1, 1992. The HCFA's position is that surgeons have historically managed patients' postoperative pain and that they should continue to do so "except under special circumstances," with pain management reimbursement thus part of the surgeon's global fee.** Our opinion is that this conclusion by HCFA is erroneous, because no one managed postoperative pain until anesthesiologists recently defined a new standard and began to focus their attention upon it. [2].

PCA is commonly thought of as an "autopilot" process, and thus there is no need for specialized acute pain service management. However, is this true? We have believed that PCA was just as management-intensive as epidural analgesia and that anesthesiologists were the ideal providers of PCA because of their knowledge of pain physiology and their command of the analgesic armamentarium, including the utilization of parenteral opioids and the treatment of their side effects and complications. [3]Our impression of PCA management intensity was confirmed by a pilot study: We noted that PCA has just as many side effects and requires just as many ward nurse and acute pain service interventions as does epidural analgesia.*** In addition, the common assumption that PCA possesses less risk than epidural analgesia is unwarranted: There is no evidence that respiratory depression, the most dangerous side effect of opioid administration, occurs less often with PCA relative to epidural administration. [4].

No one questions the need for anesthesiologists to manage epidural analgesia, but if PCA is equally problematic and equally management-intensive, anesthesiologists should likewise be reimbursed for this service. And in the case of postoperative epidural analgesia, how much of the overall benefit is derived exclusively from the epidural infusion per se, and how much is the result of other undefined aspects of twice-a-day acute pain service rounds? We do not believe that we are unnecessarily fixated on dollars: The decision of the HCFA not to reimburse anesthesiologists for postoperative PCA pain management has impeded optimal postoperative pain management--anesthesiologists are the optimal providers of PCA, and yet it is realistic to assume that, if they are not reimbursed for this service, they are unlikely to assume its burden. Our department has decided to continue to manage all PCA, including postoperative, because we are convinced that this is what is best for our patients and because our group practice situation allows us to do so with minimal individual financial repercussion. For a variety of reasons, however, many other anesthesiology departments have not been so inclined. For optimal postoperative PCA management, HCFA Medicare reimbursement policies should support the recently published U.S. Department of Health and Human Services acute pain management guidelines, which state that, "in all cases, responsibility for [acute pain management] should be assigned to those most knowledgeable, experienced, interested, and available to deal with the patients' needs in a timely fashion."****

David C. Mackey, M.D., Consultant in Anesthesiology and Medicine, Department of Anesthesiology and Critical Care Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, Florida 32224-1865.

M. Kathleen Ebener, R.N., M.S.N., Clinical Research Nurse, St. Luke's Hospital, 4205 Belford Road, Jacksonville, Florida 32216-5898.

Bonnie L. Howe, R.N., B.S.N., Acute Pain Service, Department of Anesthesiology and Critical Care Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, Florida 32224-1865.

(Accepted for publication May 12, 1995.)

* Jones RL: Anesthesia risk in the geriatric patient. Probl Anesth 3:527-550, 1989.

** Letters from Carrier Medical Directors' Meetings, dated May 29, 1992, and September 29, 1992; Health Care Financing Administration.

*** Ebener MK, Howe BL, Mackey DC, Atkinson EJ: Intensity of postoperative pain management: Patient-controlled analgesia (PCA) is equivalent to epidural analgesia. American Pain Society 13th Annual Scientific Meeting, 1994.

**** AHCPR Pub. No. 92-0032: Acute pain management: Operative or medical procedures and trauma, Clinical Practice Guideline. Rockville, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, 1992, p 71.

Ready LB: How many acute pain services are there in the United States, and who is managing patient-controlled analgesia? (letter). ANESTHESIOLOGY 82:322, 1995.
Ready LB, Oden R, Chadwick HS, Benedetti C, Rooke GA, Caplan R, Wild LM: Development of an anesthesiology-based postoperative pain management service. ANESTHESIOLOGY 68:100-106, 1988.
Saidman L: The anesthesiologist outside the operating room: A new and exciting opportunity (editorial). ANESTHESIOLOGY 68:1-2, 1988.
Etches RC: Respiratory depression associated with patient-controlled analgesia: a review of eight cases. Can J Anaesth 41:125-132, 1994.