THE PERIOPERATIVE
SURGICAL HOME:
WHY EVERYONE WINS
Thomas R. Vetter, MD, MPH
Maurice S. Albin Professor of Anesthesiology and Perioperative Medicine
Professor of Gerontology, Geriatrics and Palliative Care
Professor of Pediatrics
Professor of Health Care Organization and Policy
University of Alabama at Birmingham
© Thomas R. Vetter 2015
MY PRESENTATION OBJECTIVES
 Describe the details of a prototypic
Perioperative Surgical Home model
 Foster the conversation about the
various topics central to the rationale,
implementation, and validation of a
Perioperative Surgical Home model
My Conflicts of Interest: I have nothing to disclose.
WHAT IS VALUE IN HEALTH CARE?
HEALTH CARE VALUE EQUATION
QUALITY SAFETY
SATISFACTION
VALUE
$ TOTAL COSTS OF CARE
“Burning Platform” of Changing Reimbursement Models
Goal of the Department of Health and Human Services is to increase the proportion of federal payments related to value to 30% by the end of 2016 and to 50% by the end 2018.
Porter ME. What is Value in Health Care? N Engl J Med 2010;363:2477-81.
Vetter TR, Jones KA: Perioperative Surgical Home: Perspective II. In Value-Based Care, Anesthesiology Clinics
(Fleisher LA, Guest Editor) 2015 [In press].
1
THE DRIVERS OF VALUE-BASED
HEALTHCARE
Centers for Medicare & Medicaid Services (CMS) Accountable Care Organizations (ACOs)
Pay‐for‐Performance and Quality Incentives
Population Health Management Commercial Insurers
Regional Care Organizations (RCOs) Specialty Care Programs
Large Employers
Centers of Excellence
Medicaid Opt‐Out States Increased Value
Patients
Greater Out‐of‐
Pocket Expenses
Vetter TR, Jones KA: Perioperative Surgical Home: Perspective II. In Value-Based Care, Anesthesiology Clinics
(Fleisher LA, Guest Editor) 2015 [In press].
MEDICARE ACCESS AND CHIP
REAUTHORIZATION ACT OF 2015 (MACRA)
• Eliminated the Sustainable Growth Rate (SGR) formula
• Consolidates and expands pay-for-performance (P4P)
incentives within the fee-for-service system, creating the
new Merit-Based Incentive Payment System (MIPS) that
combines the current:
– Physician Quality Reporting System (PQRS)
– Value-Based Modifier (VBM)
– Electronic Health Record (EHR) Meaningful Use (MU)
• Applies to physicians, nurse practitioners, clinical nurse
specialists, physician assistants, and certified registered
nurse anesthetists
MERIT-BASED INCENTIVE PAYMENT SYSTEM
(MIPS) FEE-FOR-SERVICE ADJUSTMENTS
• Adjusts Medicare payments based on performance on a
single budget-neutral payment beginning in 2019
• Losers  Negative Adjustments to Payments
– 2019: Up to ‒ 4%
– 2020: Up to ‒ 5%
– 2021: Up to ‒ 7%
– 2022: Up to ‒ 9%
• Winners  Positive Adjustments to Payments
– 2019: Up to + 12%
– 2020: Up to + 15%
– 2021: Up to + 21%
– 2022: Up to + 27%
2
THE IOM’S CEO CHECKLIST FOR HIGHVALUE HEALTH CARE: 5 SELECTED ITEMS
• Infrastructure Fundamentals
 Information technology best practices: automated,
reliable information to and from the point of care
 Evidence protocols: effective, efficient, and consistent care
• Care Delivery Priorities
 Integrated care: right care, right setting, right providers,
right teamwork
 Shared decision making: patient–clinician collaboration
on care plans
 Targeted services: tailored community and clinic
interventions for resource-intensive patients
Cosgrove D, Fisher M, Gabow P, Gottlieb G, Halvorson G, James B, Kaplan G, Perlin J, Petzel R, Steele G, Toussaint J.
A CEO Checklist for High-Value Health Care. Washington, DC: Institute of Medicine, 2012.
INCREASING THE VALUE OF SURGICAL CARE
Perioperative Surgical Home must translate, implement,
sustain, and document quality, safety, and satisfaction
improvement and cost reduction strategies:
– Decrease practice variability – including unit of service cost
for anesthesia services
– Increase practice efficiency – including the maximum use of
advanced practice nurses
– Patient risk stratification and mitigation – including open
dialogue about futile surgery
– Perioperative optimization of patient co-morbidities –
including optimal timing of surgery
– Patient education and counseling – including “What can I do
to improve the outcomes that are most important to me?”
Vetter TR, Jones KA: Perioperative Surgical Home: Perspective II. In Value-Based Care, Anesthesiology Clinics 2015 [In press].
ONE DEFINITION OF THE
PERIOPERATIVE SURGICAL HOME
 Patient-centered, institution-led, interdisciplinary,
team-based, coordinated, standardized care model
 Guides the patient through the entire surgical
continuum, from the decision for surgery to posthospital discharge care
 Seeks to enhance surgical experience and outcomes
and to add measurable value to the highest cost
segment of healthcare
 Multiple effective variants based upon institutional
infrastructure, resources, and internal/external forces
Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: How Can It Make the Case
so Everyone Wins? BMC Anesthesiol 2013 Mar 14;13:6.
3
IDEALLY, A HIGHLY COLLABORATIVE
AND THUS SYMBIOTIC RELATIONSHIP…
American Society of Anesthesiologists
American College of Surgeons
Society of Hospital Medicine
American College of Physicians American Academy of Family Physicians
Anesthesiologist
and CRNA
Surgeon
Hospitalist
THE
PATIENT
Can we all play nice
in the sandbox?
and
Intensivist
Let’s hope so…
For everyone‘s sake
Primary Care Physician and Medical Specialists
American Association of Nurse Practitioners American Association of Nurse Anesthetists
ROBUST INTEGRATION OF THE
ENTIRE PERIOPERATIVE
CONTINUUM OF CARE
Preoperative
Phase
Intraoperative
Phase
Postoperative
Phase
PostDischarge
Phase
Three Key Design Elements
1. Strong Patient and Family Centeredness and Shared Decision-Making
2. Robust Team Member Collaboration Across the Continuum
3. Seamless Health Information Exchange and Shared Care Plans
Service Line or Procedure‐Specific Integrated Care Pathways
Enhanced Recovery after Surgery (ERAS®) Protocols
Perioperative Risk Optimization and Management Planning Tools
Reduce Practice Variation, Optimize Patient Outcomes, Maximize Value
4
INTEGRATED CARE PATHWAY (ICP)
• ICP = Task-orientated care plan that details all the
essential steps or elements in the care of all
patients undergoing a specific surgical procedure
• Toyota Production System (TPS) approach to
making cars and LEAN Six Sigma methodology
are rigorously applied to surgical patient care.
• Collect and analyze data to highlight and address
any lack of process standardization and resulting
inefficiencies, rework, and waste
Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The Perioperative Surgical Home as a Future
Perioperative Practice Model. Anesth Analg 2014 May;118(5):1126-30.
EXAMPLES OF INTEGRATED CARE PATHWAYS
Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated Care Pathways. BMJ. 1998 Jan 10;316(7125):133-7.
PERIOPERATIVE RISK OPTIMIZATION
AND MANAGEMENT PLANNING TOOL
• Conventional national clinical practice guidelines can have
limited local clinician buy-in and adoption
• PROMPT™  local clinician-designed/driven approach:
– Accommodates patients' individual differences
– Respects and seeks local providers' clinical acumen
– Keeps pace with the rapid growth of medical knowledge
• PROMPT™ is not prescriptive “cook-book” medicine but
a local best practices-based decision support tool
• Some examples of PROMPTs (55+ in pipeline at UAB):
– PONV, postoperative delirium; patient-centered blood
management; perioperative anticoagulant therapy
Vetter TR, Jones KA: Perioperative Surgical Home: Perspective II. In Value-Based Care, Anesthesiology Clinics (Fleisher LA, Guest Editor) 2015 [In press].
Vetter TR, Barman J, Boudreaux AM, Jones KA: Developing, Prioritizing and Implementing the Use of the Perioperative Risk Optimization and Management
Planning Tool (PROMPT™). Anesth Analg Case Management Report 2015 [In preparation].
5
PERIOPERATIVE PERSONALIZED PATIENT CARE MATRIX
PROMPT 1
PROMPT 2
PROMPT 3
• ICP Element 1
• ICP Element 2
• ICP Element 3
• ICP Element 4
Preoperative Phase
PROMPT 1
PROMPT 2
PROMPT 3
Intraoperative Phase
• ICP Element 5
• ICP Element 6
• ICP Element 7
• ICP Element 8
• ICP Element 9 • ICP Element 10
• ICP Element 11
• ICP Element 12
Postoperative Phase
Post‐Discharge Phase
• ICP Element 13
• ICP Element 14
• ICP Element 15
• ICP Element 16
PROMPT 1
PROMPT 2
PROMPT 3
PROMPT 1
PROMPT 2
PROMPT 3
In this example, the Integrated Care Pathway (ICP) (e.g., for pancreatectomy) contains
16 specific, standardized elements, and the patient’s co-morbidities warrant 3 Perioperative Risk
Optimization and Management Planning Tools (PROMPT 1, PROMPT 2, PROMPT 3)
(e.g., for preoperative anemia, diabetes mellitus, and postoperative cognitive dysfunction/delirium)
Vetter TR, Boudreaux AM, Jones KA, Hunter JM Jr, Pittet JF. The Perioperative Surgical Home: How Anesthesiology Can
Collaboratively Achieve and Leverage the Triple Aim in Health Care. Anesth Analg. 2014 May;118(5):1131-6.
WHAT PROBLEMS ARE WE TRYING TO FIX?
• Incomplete & inconsistent patient preparation for surgery
• Incomplete documentation of patient co-morbidities
• Incomplete & inaccurate medication reconciliation
• Irregular & inefficient patient scheduling and throughput
• Persistent case delays and cancellations
• Continued failure to rescue and never events
• Greater than desired morbidity and mortality
• Higher than desired hospital readmission rates
• Difficulty with compliance with key performance measures
• Lower than desired patient and family satisfaction
• Excessive and variable cost per episode of surgical care
BY THE WAY, DOCTOR…WHAT IS
YOUR RISK-ADJUSTED MORTALITY?
• Observed-to-expected (O:E) mortality ratio is an
increasingly important health care quality metric.
• Allows quantification/comparison of survival
outcomes among different providers/institutions
• Hospital revenue will be directly affected by its
risk-adjusted mortality rate.
• As hospital performance data circulate ever
more widely to the public, the O:E ratio is quite
prominent.
Shine D. Risk-Adjusted Mortality: Problems and Possibilities. Computational and Mathematical Methods in Medicine 2012, 2012:5.
6
UHC TOP PERFORMERS (123 MEMBERS)
Rank
October 2014 UHC Quality Leadership Awards
October 2013 UHC Quality Leadership Awards
1
NYU Langone Medical Center
NYU Langone Medical Center
2
Emory University Hospital
Mayo Clinic – Rochester
3
Emory Hospital Midtown
Ohio State University Wexner Medical Center
4
Mayo Clinic – Rochester
Beaumont Health System, Royal Oak, MI
5
Rush University Medical Center
Rush University Medical Center
6
Beaumont Health System, Royal Oak, MI
University of Utah Health Care
7
Fletcher Allen Health Center, Vermont
Emory University Hospital
8
Ohio State University Wexner Medical Center
University of Kansas Medical Center, Kansas City, KS
9
University of Utah Health Care
University of Missouri Health Care
10
University of Colorado Hospital
Cleveland Clinic
11
Houston Methodist Hospital
12
Memorial Hermann-Texas Medical Center
https://www.uhc.edu/news/Twelve-academic-medical-centers-receive
THE AGING UNITED STATES POPULATION
“THE SILVER TSUNAMI”
Number of Americans > 65 years (millions)
80
70
60
50
54.8
25% of all Medicare spending occurs in the
last year of life
40
25.5
30
31.2
40.3
35
16.6
20
10
72.1
An estimated 32% of older Americans undergo
surgery in the year before their death…and
9
4.9
3.1
0
1900 1920 1940 1960 1980 1990 2000 2010 2020 2030
4.1%
13.1%
19.3%
Administration on Aging: A Profile of Older Americans: 2011. Washington, DC: U.S. Department of Health and Human Services; 2011: 1-16.
Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, Jha AK. The Intensity and Variation of Surgical Care at the End of
Life: A Retrospective Cohort Study. The Lancet 2011;378:1408-13.
PROJECTED RISE IN CHRONIC DISEASE
BURDEN BETWEEN 2003 AND 2023
Percentage Increase in Prevalence
70%
62%
54%
60%
56%
50%
By 2020, 157 million Americans will
have one chronic disease, and 81 million
will have multiple such conditions.
41%
39%
40%
31%
29%
30%
20%
10%
0%
Cancers
Mental
Disorders
Diabetes
Heart
Disease
Hypertension
Pulmonary
Conditions
Stroke
Versus a Projected 19% Population Growth
DeVol R., Bedroussian A. An Unhealthy America: The Economic Burden of Chronic Disease. Santa Monica, CA: Miliken Institute; 2007: 1-38.
7
ANESTHESIA-RELATED SAFETY
• Modern death rate from complications/adverse events
associated with anesthesia has decreased by 97%:
– 64 deaths per 100,000 anesthetics in late 1940’s
– By 2005, only 0.82 deaths per 100,000 anesthetics
• Both increased age and prevalence of chronic diseases have
been independently associated with increased surgical mortality.
 Maintaining or improving on the 20th century gains in
anesthesia-related mortality will be challenging.
• The Perioperative Surgical Home offers the needed
more comprehensive and coordinated approach to the
management of our older and sicker surgical patients.
Li G, Warner M, Lang BH, Huang L, Sun LS. Epidemiology of Anesthesia-Related Mortality in the United States, 1999–2005.
Anesthesiology 2009, 110(4):759-765.
Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical Risk Factors, Morbidity, and Mortality in Elderly Patients. J Am Coll Surg
2006, 203(6):865-877.
WHEREVER YOU GO – THERE YOU ARE
Surgical death rates vary widely across US hospitals ─ from 3.5% in
very-low-mortality hospitals to 6.9% in very-high-mortality hospitals.
• Despite similar rates of
overall complications
and of major
complications ─
• MORTALITY in patients
with major complications
was significantly greater
in hospitals with very
high overall mortality
compared with those
with very low overall
mortality.
BUT WHY?
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in Hospital Mortality Associated with Inpatient Surgery.
N Engl J Med 2009, 361(14):1368-1375.
FAILURE-TO-RESCUE (FTR)
• Silber et al. (1992) = Hospital deaths after adverse occurrences
such as postsurgical complications
• Contributors to FTR have been broadly categorized:
1) Lack of a timely response  prompt recognition of the
complication
2) Lack of an appropriate response  correct management
and treatment
• An abundance of retrospective data supports that adverse events
in general ward (non-ICU) patients are preceded by a significant
period — on the order of hours — of physiologic deterioration
• Most common causes in the surgical population
1) Respiratory complications (38%)
2) Infection complications (28%)
3) Cardiovascular complications (23%)
Taenzer, AH, Pyke JB, McGrath SP. A Review of Current and Emerging Approaches to Address Failure-to-Rescue. Anesthesiology
2011 Aug,115(2):421-431.
Helling TS, Martin LC, Martin M, et al. Failure Events in Transition of Care for Surgical Patients. J Am Coll Surg 2014 Apr;218(4):723-31.
8
COMPLICATIONS, FAILURE TO RESCUE
AND MORTALITY RATES
Michigan Surgical Collaborative for Outcomes Research and Evaluation (M-SCORE)
• Medicare Provider Analysis and Review (MEDPAR) data
from 2005 and 2006 for pancreatectomy, esophagectomy,
AAA repair, CABG, AVR, and MVR
• 8 major postoperative complications: pulmonary failure,
pneumonia, myocardial infarction, deep venous thrombosis/
pulmonary embolism, acute renal failure, hemorrhage,
surgical site infection, and gastrointestinal bleeding
• Failure to rescue (FTR) was defined as death in a patient
with one or more of these 8 defined complications.
Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, Failure to Rescue, and Mortality with Major Inpatient Surgery in Medicare Patients.
Ann Surg 2009 Jun, 250(6):1029-1034.
Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital Volume and Failure to Rescue with High-Risk Surgery. Med Care 2011 Dec;49(12):1076-81.
COMPLICATIONS, FAILURE TO RESCUE
AND MORTALITY RATES
40%
35%
36.4%
32.7%
30%
Failure to Rescue Rates (subgroups)
5.7% versus 56.9% for esophagectomy
4.0% versus 50.8% for pancreatectomy
25%
20%
16.7%
15%
10%
6.8%
5%
8.0%
3.0%
0%
Complications
Failure to
Rescue
Mortality
Best Hospital
Mortality
Worst Hospital
Mortality
NNH = 20 for
MORTALITY at
worst versus best
hospitals
Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, Failure to Rescue, and Mortality with Major Inpatient Surgery in Medicare Patients.
Ann Surg 2009, 250(6):1029-1034.
Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital Volume and Failure to Rescue with High-Risk Surgery. Med Care 2011 Dec;49(12):1076-81.
PREOPERATIVE TARGETS TO PREVENT
FTR AND IMPROVE SURGICAL MORTALITY
• “Failure to rescue is an emerging quality metric.”
• 2007 to 2011 Nationwide Inpatient Sample
• Lowest mortality quintile: N = 282 hospitals; 56,893 patients
• Highest mortality quintile: N = 282 hospitals; 45,784 patients
• Small bowel resection, pancreatectomy, colorectal
resection, open abdominal aortic aneurysm repair, lower
extremity arterial bypass, and nephrectomy
• FTR population  (+) Qualifying postoperative complication
• High-mortality risk population  High risk predicted via
logistic regression model based upon age & co-morbidities
Hyder JA, Wakeam E, Adler JT, DeBord Smith A, Lipsitz SR, Nguyen LL. Comparing Preoperative Targets to Failure-to-Rescue
for Surgical Mortality Improvement. J Am Coll Surg 2015 Jun;220(6):1096-106.
9
PREOPERATIVE TARGETS TO PREVENT FTR
AND IMPROVE SURGICAL MORTALITY
FTR: 20.2% vs 22.4% p = 0.002
Variation in mortality rates across lowest-mortality hospitals (gray bars)
and highest-mortality hospitals (black bars)
1) FTR population  18.9% vs 7.8%, p < 0.0001, NNH = 9
2) High-risk  20.2% vs 7.5%, p < 0.0001, NNH = 8
3) Emergency surgery  11.1% vs 4.1%, p < 0.0001, NNH = 14
4) Elderly (> 75 years)  10.7% vs 3.7%, p < 0.0001, NNH = 14
Postoperative FTR = A potential way to reduce mortality
Hyder JA, Wakeam E, Adler JT, DeBord Smith A, Lipsitz SR, Nguyen LL. Comparing Preoperative Targets to Failure-to-Rescue
for Surgical Mortality Improvement. J Am Coll Surg 2015 Jun;220(6):1096-106.
ASSOCIATION BETWEEN POSTOPERATIVE
TROPONIN LEVELS AND 30-DAY MORTALITY AMONG
PATIENTS UNDERGOING NONCARDIAC SURGERY
• 15,133 patients; sequential 4th generation troponin T levels at
6-12 hours postoperatively, POD 1, 2, 3  peak value of…
• TnT of 0.02 ng/mL:
– 4% mortality with adjusted hazard ratio [aHR] = 2.41
• TnT of 0.03 to 0.29 ng/mL:
– 9.3% mortality & aHR = 5.00
• TnT of 0.30 ng/mL or greater:
– 16.9% mortality & aHR = 10.48
Myocardial Injury after
Non-Cardiac Surgery (MINS)
How do we risk stratify
patients and prevent MINS?
Kaplan-Meier Estimates of
30-Day Mortality Based on
Peak Troponin T Values
Association between Postoperative Troponin Levels and 30-day Mortality among Patients Undergoing Noncardiac Surgery. Vascular
Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators. JAMA. 2012 Jun 6;307(21):2295-304.
PYRAMID OF PRACTICE CHANGE
Practice Change
3 BUILDING BLOCKS
Decision Support
Analytics
Informatics (Data)
Vetter TR, Jones KA: Perioperative Surgical Home: Perspective II. In Value-Based Care, Anesthesiology Clinics 2015 [In press].
10
PERIOPERATIVE MEDICAL INFORMATICS
Perioperative epidemiology is an area of growth – ultimately enabling the perioperative care team to translate precise real‐time information into improved outcomes.
Proposed Model of the Flow of Data Throughout the Perioperative Period
Outcomes
Decision Support
Bartels K, Barbeito A, Mackensen GB. The Anesthesia Team of the Future. Curr Opin Anaesthesiol 2011, 24(6):687-692.
MEMORIAL SLOAN KETTERING CANCER
CENTER DIRECTOR OF PERIOPERATIVE
INFORMATICS AND INNOVATION
• The Director of Perioperative Informatics and Innovation
(“Director”) will be a key leader in the transformation of care
across the pre-operative, intra-operative, and post-operative
care, leading a team in the implementation of systems across
the new 14 story Josie Robertson Surgery Center.
• The Director will be a leader in the development of system-wide
analytics initiatives that will transform care for MSK patients.
• The qualified candidate will have experience overseeing the
design, build and implementation of clinical systems combining
informatics and clinical process, data analytics and the
ability to optimize the interoperability of clinical information
systems to enhance patient safety and clinical outcomes.
www.wittkieffer.com/position/memorial-sloankettering-cancer-center/director-of-perioperative-informatics-and-innovation/12005
WHAT’S IN IT FOR THE SURGEON?
• The Perioperative Surgical Home is not intended to
replace the surgeon’s primary patient care responsibility…
• Rather aligns and leverages the talents and abilities of the
entire perioperative care team in the service of the patient
• From a surgeon’s perspective, the Perioperative Surgical
Home model can create value in four primary ways:
1) Takes advantage of the well-established relationships among
the surgeon/anesthesiologist/intensivist/hospitalist
2) Expands upon the existing pre-, intra-, and post-operative
relationship between the anesthesiologist and the patient
3) Increases the quality of surgical care by increasing the
scope and depth of the perioperative team
4) Improves the surgeon’s efficiency and productivity
Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: How Can It Make the Case
so Everyone Wins? BMC Anesthesiol 2013 Mar 14;13:6.
11
ENHANCED RECOVERY AFTER
SURGERY (ERAS)
• Pioneered in Scandinavia and UK by surgeons
• Evidence-based “fast-track” approach to surgery
• Multifaceted perioperative care pathway designed
to attenuate the stress response during all three
phases of the perioperative period and the
patient’s surgical journey
• Facilitate the maintenance of bodily composition
and organ function and to achieve early recovery
Varadhan KK, Lobo DN, Ljungqvist O. Enhanced Recovery After Surgery: The Future of Improving Surgical Care. Crit Care Clin
2010;26(3):527-47.
Ljungqvist O. ERAS-Enhanced Recovery After Surgery: Moving Evidence-Based Perioperative Care to Practice.
J Parenter Enteral Nutr 2014;38(5):559-66.
ENHANCED RECOVERY AFTER SURGERY (ERAS)
• Preadmission patient counseling and education, including anxiety reduction techniques
• Prehabilitation of nutritional (protein) status, cardiopulmonary reserve, and muscle strength • No prolonged fasting
• No or selective bowel preparation
• Oral fluid and carbohydrate loading immediately prior to surgery
• Antibiotic and thromboembolism prophylaxis
• Oral adjuvant analgesics but no sedative premedication
• Single subarachnoid dose of a moderately hydrophilic opioid for laparoscopic surgery
• Short‐acting anesthetic agents and medications • No surgical drains
• Avoidance of salt and water overload
• Goal‐directed fluid therapy
• Restrictive blood transfusion triggers
• Maintenance of normothermia via body warmer and intravenous fluid warmer
• Anesthetic depth monitoring in patients at risk for delirium and cognitive dysfunction
• Mid‐thoracic epidural analgesia with local anesthetic but no opioid for open laparotomy
• No nasogastric tube
• Prevention of postoperative nausea and vomiting
• Avoidance of salt and water overload
• Restrictive blood transfusion triggers
• Early oral nutrition
• Early mobilization
• Non‐opioid intravenous and oral analgesics
Hunter JM, Vetter TR: Major General Surgery in the Elderly Patient. In Barnett SR (Ed). Perioperative Care of the
Elderly Patient. Cambridge, UK: Cambridge University Press, 2015/2016 [In press]; www.erassociety.org/
PREOPERATIVE PREHABILITATION
• “Prehabilitation” is an intervention to
enhance functional capacity in anticipation
of a forthcoming physiological stressor.
• Preoperative prehabilitation aims to enhance
functional capacity preoperatively for better
tolerance of surgery and to facilitate recovery.
• Also accurately predict and then reduce need
for prolonged postoperative, post-discharge
institutional rehabilitation and convalescence
Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ et al. Randomized Clinical Trial of Prehabilitation in Colorectal Surgery.
Br J Surg 2010;97(8):1187-97.
Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS et al. Impact of a Trimodal Prehabilitation Program on Functional Recovery After
Colorectal Cancer Surgery: A Pilot Study. Surg Endosc 2013;27(4):1072-82.
Biffl WL, Biffl SE. Rehabilitation of the Geriatric Surgical Patient: Predicting Needs and Optimizing Outcomes. Surg Clin North Am
2015;95(1):173-90.
12
PREOPERATIVE TRIMODAL PREHABILITATION
• Home-based, approximately one month program:
1) Moderate aerobic and resistance exercises
2) Nutritional counseling + whey protein supplementation
3) Relaxation exercises (anxiety reduction)
P = 0.016
But no changes were observed in
SF-36 or Hospital Anxiety and
Depression Scale (HADS) scores
and post-operative complication
rates and the hospital length of stay
were similar in the prehabilitation
versus the postoperative
rehabilitation patients.
Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS et al. Impact of a Trimodal Prehabilitation Program on Functional Recovery
After Colorectal Cancer Surgery: A Pilot Study. Surg Endosc 2013;27(4):1072-82.
Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A et al. Prehabilitation Versus Rehabilitation: A Randomized Control Trial in
Patients Undergoing Colorectal Resection for Cancer. Anesthesiology 2014 May;121(5):937-47.
ANESTHESIOLOGY AND OUR NEEDED
MORE COMPETITIVE STRATEGY
• Anesthesiology is facing strong economic pressures
that require a broader competitive strategy.
• Looming austere, constrained economic landscape and
need to provide a more effective and efficient product
• To strengthen the future viability of our specialty:
Urgent need for anesthesiologists to challenge our
current, historically successful business model and
our assumptions about the market forces, mission,
and core competencies of our specialty
Gross WL, Gold B. Anesthesiology and Competitive Strategy. Anesth Clin 2009, 27(1):167-174.
Seim AR, Sandberg WS. Shaping the Operating Room and Perioperative Systems of the Future: Innovating for Improved
Competitiveness. Curr Opin Anaesth 2010, 23(6):765-771.
Martin J, Cheng D. Role of the Anesthesiologist in the Wider Governance of Healthcare and Health Economics. Can J Anaesth
2013;60:918-28
THE ANESTHESIOLOGIST AND
PERIOPERATIVE MEDICINE
• Necessary to expand the core knowledge, skills, and
experience expected of the anesthesiologist
• Need to view the “Perioperative Medicine” as an
expansion of the specialty, rather than an abdication of
the traditional and still vital intraoperative role
• Not all anesthesiologists will be able or willing to play a
role in this new activity.
• But just as with the seminal development within
anesthesia of the subspecialties of critical care medicine
and pain medicine, a subset will need to do so and be
supported by colleagues in their efforts
Van Aken H, Thomson D., Smith G, Zorab J. 150 Years of Anaesthesia -- A Long Way to Perioperative Medicine: The Modern
Role of the Anaesthesiologist. Eur J Anaesthesiol 1998, 15(5):520-523.
Grocott MPW, Pearse RM. Perioperative Medicine: The Future of Anaesthesia? Br J of Anaesth 2012, 108(5):723-726.
13
UAB PREOPERATIVE ASSESSMENT,
CONSULTATION, AND TREATMENT CLINIC
• Semantic and clinical evolution has occurred at UAB
– PAT = Pre-Admission Testing (1990)
– PAC = Pre-Anesthesia Assessment Clinic (1995)
– PACT Clinic = Preoperative Assessment, Consultation, and
Treatment Clinic (2010)
• Road trips to Johns Hopkins, Brigham and Women’s,
Cleveland Clinic (Cleveland), and Mayo Clinic (Rochester)
• PACT Clinic moniker intentionally chosen to communicate
our comprehensive scope of practice and services
• Frankly, we continue to grow into its full potential…
VALUE STREAM MAPPING:
PSH PREOPERATIVE
PROCESS ACTIVITY
MAPPING
• Preoperative patient
risk screening tool
• Formal E&M code-based
preoperative consultation
• Robust patient-centered
shared decision-making
• Therapeutic interventions
• Post-discharge care
planning before surgery
• Preoperative clearance
Vetter TR, Jones KA: Perioperative Surgical Home: Perspective II. In Value-Based Care, Anesthesiology Clinics 2015 [In press].
A COMPREHENSIVE REVIEW OF
THE PERIOPERATIVE SURGICAL
HOME LITERATURE
“The PSH model may have significant
implications for policymakers, payers,
administrators, clinicians, and patients. The
potential for policy-relevant cost savings and
quality improvement is apparent across the
perioperative continuum of care, especially
for integrated care organizations, bundled
payment, and value-based purchasing.”
Kash BA, Zhang Y, Cline KM, Menser T, Miller TR. The Perioperative Surgical Home (PSH): A Comprehensive Review of
US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes. Milbank Q 2014 Dec;92(4):796-821.
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A COMPREHENSIVE REVIEW OF
THE PERIOPERATIVE SURGICAL
HOME LITERATURE
• 152 peer-reviewed articles between 1980 and 2013
• History and evolution of PSH and PSH-like models
• Summary of the results of studies of PSH elements in
the United States and in other countries
Phase of Perioperative Care
Significantly Positive Cost & Efficiency
Significantly Positive Clinical Outcomes
Preoperative Initiatives
82%
82%
Intraoperative Initiatives
77%
86%
Postoperative Initiatives
75%
87%
Kash BA, Zhang Y, Cline KM, Menser T, Miller TR. The Perioperative Surgical Home (PSH): A Comprehensive Review of
US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes. Milbank Q 2014 Dec;92(4):796-821.
INTEGRATED CARE PATHWAYS
• Task-orientated care plans that detail the essential steps or
elements in the care of all patients on a specific service line
or undergoing a specific surgical procedure
• Lean or Six Sigma: Collect data to highlight and address
any lack of process standardization and resulting
inefficiencies, rework, and waste
• UC Irvine Health “Total Joint Perioperative Surgical Home”
Outcome
LOS
30 Day RA
Transfusion
Complications
Mortality
SCIP
UCI Health
3 days
0.7%
6.2% 0% 0%
100%
Group
Benchmark THA
UCI THA
Benchmark TKA
UCI TKA
Per Diem Cost
$16,267 $9,952 $17,588 $10,042 Implementation of a Total Joint Replacement-Focused Perioperative Surgical Home: A Management Case Report. Garson L,
Schwarzkopf R, Vakharia S, Alexander B, Stead S, Cannesson M, Kain Z. Anesth Analg. 2014 May;118(5):1081-9.
Total joint Perioperative Surgical Home: An Observational Financial Review. Raphael DR, Cannesson M, Schwarzkopf R, Garson LM,
Vakharia SB, Gupta R, Kain ZN. Perioper Med (Lond). 2014 Aug 27;3:6.
FEW FINAL OBSERVATIONS…
There is no limit to what can be
accomplished if it doesn't matter
who gets the credit.
Ralph Waldo Emerson
(1803 – 1882)
Health care must be a business —
But medicine remains an art and a science, and the successful practice of medicine is all about strong relationships with one’s patients and one’s colleagues.
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