The Perioperative Surgical Home (PSH): Evidence-based International Research and Models of Practice
in the US
Presenters: Dr. Bita Kash & Kayla Cline, Texas A&M University
Recorded on: December 18, 2013
All right, well, good afternoon to those of you on the east coast, and good morning to the rest. This is
Nick Edwardson. I'm the Assistant Director at the Center for Health Organization Transformation. Thank
you for joining us today for our final chat, Deep Dive Webinar of 2013. Today's webinar is titled The
Perioperative Surgical Home, Evidence-based International Research and Models of Practice in the U.S.
led by doctor Bita Kash and Kayla Cline from Texas A&M University.
Before we begin the webinar, I have two quick announcements. The first, our next webinar will take
place on Wednesday, January 29th, at the same time. This webinar will be hosted by Dr. Chris DeFlitch
from Penn State University, and the topic will be on emergency department flow optimization. He had
some interesting results from a project he began about 18 months ago.
Second, the dates and location of CHOT's spring IAD meeting have been set. The meeting will take place
in Austin, Texas, on Thursday, April 24th and Friday, April 25th. If you've attended our meetings before,
we'll follow the same format where we begin early on Thursday morning, run a full day, and then only a
half day on Friday to where you could be flying back home by Friday afternoon.
Again, those dates were April 24th and 25th. More information about both of those events along with
additional webinars that we have planned, slated for 2014 can be found on CHOT's website, which, of
course, www.chotnsf.org. Now on to today's webinar, Dr. Kash.
>> All right, thank you Nick. I'm sitting here with Kayla Cline, the PhD student in charge of this project
that we are engaged in with the American Society of Anesthesiologist, and we have some good results
to share with you today.
And the title of the presentation as Nick mentioned is the Perioperative Surgical Home. We will cover
two things, evidence-based international research from a comprehensive literature review, and Kayla
will then follow-up with models of practice in the US. So I will make sure I don't spend too much time on
the lit review.
The lit review is available online as well comprehensive. But most people here would like to probably
hear from Kayla about the survey, specific perioperative surgical home programs that we have done in
the US. I will refer to the perioperative surgical home as the PSH sometimes and so, just to keep us all on
the same page.
As we all know, and this is kind of an estimate, in the US, we spend about $180 billion per year on
inpatient surgical procedures just for non-federal hospitals. And the average cost of surgery is
increasing. It continues to climb and always, as we know, patient safety outcomes and readmissions are
still ongoing concerns.
So the overarching research question here for this project was, is this new concept, evolving concept of
the perioperative surgical home a part of the answer for us here in the US? And we're looking at it as a
concept of better coordinated, integrated perioperative surgical management system, and these type of
programs have been implemented or parts of these type of programs have been implemented primarily
in North America, in Europe, in Australia within the last 40 years or so.
And really the evolution of the PSH concept in the US seems to be even more recent. So when we look
at these type of developments within the US, we can associate them mostly with three general trends.
And these three trends have to do with surgical specialties moving more and more towards same day
scheduling And the second trend would be just market expectation.
We're expected to try to perform better, have higher quality surgical outcomes are expected in the
market, while controlling cost and being competitive in the price of surgery. And then number three is
the trend of this move towards value-based payment programs, mostly being launched as the result of
the patient's protection and Affordable Care Act.
So the market seems to be moving us towards really having to pay attention to improving patient
outcomes, reducing cost of surgery care by doing a better job in coordination. Now the latest definition
of a PSH, I think would be best described with a definition that that was a model adopted by the
University at Alabama at Birmingham.
The UAB definition is the PSH model is an innovative, patient centered surgical continuing of care model
that incorporates shared decision making. So a lot of patient involvement in and a development of a
team around surgical procedures. As we've developed the purpose for this study, you can see the first
bullet identifying the key elements of the PSH has to do with the comprehensive lit review.
So we have seen emerging evidence appearing in the literature that supports care coordination models,
including the well-established patient-centered medical home, for example. The patient-centered
medical home and the PSH share a vision of improved quality and lower cost of care while incorporating
kind of similar elements of also patient engagement and care coordination.
Unfortunately though, this type of standardization and coordination in surgery has often been lacking,
and there was room for improvement. And so we were interested to see what the literature tells us
about these types of initiatives that are part of the PSH model. And the last two bullets then describe
that we would then engage in identifying certain PSH programs around the nation.
And then hopefully be able to then describe and define a conceptual model of a perioperative surgical
care, which takes us to the next slide explaining our research approach in defining that model We
decided it's a good idea to maybe look into a framework of thinking that has to do with clinical
microsystems.
And this is work that has been established and also been tested in the healthcare field in a recent
technical report by the IOM. They're a committee on quality of healthcare in America. And what they
have done is it was a study of 43 microsystems, mostly primary and specialty care providers.
Engaged in disease management. Also emergency medicine, critical care, and then also it included
hospice programs. But what they took is they analyzed, they had qualities of interview with these
programs and they analyzed this data using applied microsystem theory. We also thought that the
concept of the PSH would be a good candidate for applying microsystems theory because it includes the
necessary elements of microsystems as defined by Nelson.
So, we are as you see we have incorporated the phases of the PSH into the micro system framework and
we know the PSH would include a core team of healthcare professionals working as a team towards a
common aim and that's one of the requirements or the definitions of the microsystem.
A common aim, a certain service line or one unifying clinical purpose. Also the microsystem would have
a defined patient population with similar disease profiles. Also we would be looking at information
systems and environments that supports the work of these professionals and patients as a team. And
then also we are interested in identifying and understanding the support staff, the equipment, the
culture and the work environment that enable this type of shared performance towards a unified clinical
outcome or goal.
So that's why we followed micro-systems theory in our research design. As part of our literature review I
thought it would be helpful to quickly just show the result of our initial comprehensive literature review
in identifying those key elements of what a surgical home might look like and we have learned that
throughout the U.S. when you talked to quite developed PSH programs, they might employ not all but
some of these elements.
Some programs might be mostly engaged in preoperative type initiatives and some are mostly engaged
in post-operative initiatives. But when we are studying and categorizing these articles and studies and
looking at them in terms of their results. Were they positive results or negative results of this type of
initiative?
We categorize them as initiatives around preoperative and the preoperative stage, versus the inter
operative stage, versus the post operative stage. These are the elements we identified looking at the
literature. So preoperative has a lot to do with some programs might have a centralized preoperative
area or clinic where pretesting and triaging might be performed.
Or some might be doing that without a clinic. There is early preadmission assessment. There is often
programs called prehabilitation program, getting the patient ready for surgery. Over time, patient
education and use of really multi-disciplinary teams, many different professionals engaged in prepping
the patient before surgery. In the intra-operative initiative, we found a lot around integrated pay
management.
A focus on fast track surgeries and discharged home that results in reductions in length of stay. Fluid
management is a big one. And also, a lot of initiatives are around just making scheduling more effective
and efficient with using delays and allowing better efficiencies and a lower flow. So scheduling initiatives
and reducing cancellations were big initiatives in that phase.
In the post-operative key element study we found a large in pay management. Also a post-operative
early discharge initiative. So mobilization, getting physical therapy integrated, acute care. And improving
that coordination so a lot of initiatives having to do with post-discharge phone calls and adjust better
transition home or transition to the next level of care.
So let's just look at what we have with the comprehensive literature as I have said you can access the
full report on the ASA website. And what we did is we started in August and we have, no we started, I'm
sorry we finished in August, we started in May or June.
I believe, right Kayla? And we finalized the report in August. So that's the report you see online. And we
are right now going through an update with the comprehensive literature review. And so there'll be an
updated one available mid-January. And will go through another update in April and make that available
to everyone.
With the literature review, the way we went about that, we looked at the search process in seven
overall categories so that we can capture the concept of the surgical home in general, as well as really
focused on initiatives that are very specific to a perioperative stage, whether it's preoperative, interoperative, or post-operative.
And those search terms are defined in the report and approach is described there as well. Also, what we
thought was useful maybe to share as a manuscript and there's a manuscript in preparation right now
and being finalized for submission is comparing US studies to other countries. There seem to be some
trends in what we see.
The studies we found from other countries versus what we find in the US and really what we see in the
US is the concept of the perioperative surgical home as a comprehensive program.
>> Is something that's evolving and researchers are trying to understand and define it better and the
real goal is in improving the quality and reducing cost of surgical care.
What we see in the international literature is very focused programs, focused initiatives often times
around what we call enhanced recovery after surgery, the ERAS protocols. Which basically employs
some key elements of the more comprehensive PSH models within the US. Those type of programs are
more common in other countries and very well studied specific to reductions and costs.
And better outcomes again. There may also be some subtle differences between the US and the non-US
research cosign. When we did our lit review, the literature in the non-US settings seems to focus on
strict comparisons. Real comparisons of outcomes from changing certain practices, from changing
certain policies. In the US on the other hand research seems to be more focused on discovery.
Discovery of innovation, innovative practices, and really developing that model of a PSH. And less on
direct changes. So that's the overall difference in research for FoSi as well. That was interesting. Next,
we will go through the key findings from this comprehensive literature review. And the way we'll go
about it, we will organize it into three phases, and see what we found in the pre-operative phase and
the intra-operative phase and in the post-operative phase, and what those initiatives, what type of
results those initiatives reported.
So in the US studies, and these are studies we looked at, these don't include review articles. These are
actual empirical studies. In the pre-operative phase, we see that there is a lot of focus on factors that
contribute to excessive pre-operative testing, so those are opportunities for cost reduction.
And in the non U.S. studies, there is a lot of focus on the feasibility of eliminating specific preoperative
tests. Even among high risk patient pools. So an overall look in the next graphic, you will see the key
findings quantified in terms of, did we find mostly significant positive results of these type of preoperative initiatives?
Or did we find non-significant results or mostly negative results? And as you can see, there is a trend
towards very positive results. And the numbers and the graph show you the number of studies that
focused on cost and efficiency so reductions in cost and then on the right hand side the clinical outcome
study for specific pre-operative initiative.
Next, you will see, we'll go through the intra-operative phase. And those type of initiatives within the
intra-operative space. And what we find is both in the US and outside the US studies have highlighted
that the effectiveness of both PSH programs and initiatives and Aras programs in terms of mostly
reduced delays, surgery delays, reduced waiting time, and the availability of surgeons increasing for
more urgent surgeries.
So, we see a lot of efficiencies and cost savings in these type of studies, as well as reduction in errors. So
clinical outcomes were shown as well as we can see in the next graphic. And this is a summary of all the
studies that included intra-operative initiatives. And as we can see we coded these mostly as we were
looking at them.
Most studies seem to show significant, positive results as a part of the coding process. Finally, the key
findings from the literature review on post-operative initiatives, we definitely see a focus on heiress
programs and heiress protocols both in the U.S. and elsewhere. And we see that these type of practices
reviews length of stay and they improve patient recovery.
So what we have also discovered is that these Aras programs are very prevalent in Europe, especially in
the United Kingdom. Supports for these type of initiatives has increased. And, the enhanced recovery
partnership program in the United Kingdom also highlights the necessity of consistently tracking these
measures of patient outcomes and really pushing the standardized heiress programs.
In the U.S. we see these type of protocols adopted by two insurance collaboratives- The Michigan
Surgical Quality Collaborative and then the Blue Cross Blue Shield Cardiovascular Consortium of efforts.
So again, a quick snapshot of all the studies that included post-operative initiatives. And the way we
went about coding them.
And these results, again, are going to be submitted as a manuscript to be published. And we see mostly
positive results, so significant positive results both on the cost and efficiency side and the political
outcome side. And we see the same type of trend among the US studies as well as the non-US studies.
Now just a quick note that we make note of that as a limitation. When we looked at these studies and
coded them as positive significant positive results versus non-significant or negative results. We need to
keep in mind of two potential limitations. One having to do with publication bias.
We all like to publish really positive results. And those non-positive results might not be published. Also,
one thing that we did not take into consideration is study design criteria. We basically, if a study was
published in a peer review journal, we consider that study to be included in this count and it was coded.
So, at this point now we will Have Kayla talk to you about all the programs that were selected to be
interviewed in order to understand this PSH initiative in the US. And she's the one who talked to all the
leaders in 15 PSH programs in the US, and she's become quite the content, subject expert in this.
Kayla?
>> Hi, everybody. In case you missed the introduction at the beginning, my name is Kayla Cline, and I am
a PhD student here at Texas A&M, and I've been working on this project. So what I'll be discussing in the
webinar today is the interview process. How we conducted the interviews, and then some preliminary
findings from those interviews.
We are still analyzing those results, so these results that we're presenting are very preliminary. But
hopefully, they'll be informative. So our second phase, as we mentioned earlier, were interviews with
key informants at 15 PSH programs around the country. We ended up speaking to a total of 24 people,
either anesthesiologists or clinic administrators involved in the PSH program.
So we got into these 15 PSH sites through a process of elimination. A previously conducted survey of
anesthesiologists conducted by the American Society of Anesthesiologists yielded 55 potential interview
sites, and the ASA sent those sites to us. We took a look at those sites, and based on willingness to
participate in this research and the practice's affiliation with one hospital, we selected 35 programs that
could possibly fit our criteria.
And from there we took those 35 programs, we put them on a survey, and we sent that survey to ASA
committee members who voted on those organizations. And then we additionally assessed their
willingness to participate, their progress in implementing the PSH, and we tried to obtain broad
geographic representation.
And after looking at that, we identified our final 15 sites that we'll look at in just a second. When we
interviewed anesthesiologists and practice administrators at these sites, we asked a total of 54
questions that fell into 9 over our 10 categories. The first one we covered which is practice
demographics, what type of practice tends to develop a PSH.
We also asked for details about the program, what types of patients and pairs they're working with,
financial relationships with healthcare systems. We also looked at quality reporting, and then we looked
at organizational aspects like barriers, enablers of PSH implementation success and program
performance. And we wrapped up the interview with an assessment of the future of anesthesiology
related to PSH programs.
So on the next slide, you can see the list of the programs that we studied. As you see there were 15, and
they are all over the country from Alabama, to Minnesota, to Tennessee, to Washington. We pretty
much covered most of all the corners of the country. And you can also see that at some of these
organizations we spoke to more people, and at some of these organizations we only spoke to one.
And that was based on, essentially, do you speak with one person and ask for suggestions, if we should
speak with anyone else to get a more full picture of the program. And so that's how we ended up
interviewing multiple people at several of the organizations. So now we'll jump into our preliminary
results, our findings, starting with demographic information about these practices.
As you can see from this chart, most of the PSH programs, the practices affiliated with these programs,
were fully integrated processes. Which means that the anesthesiologists were employed by the hospital
or the health care system. The remainder were primarily independent physician practices, either leased
to a hospital or with hospital contracts.
And what's interesting about this is that several of the physicians in the fully integrated practice
indicated that, that was one of the things that helped the PSH be successful. They indicated that by
being employed by the hospital system, they had easier access to resources and to higher up support on
higher levels.
Which were really important in getting the PSH up and running, and getting people on board, so that
was then. Obviously it's not impossible to run a PSH without being fully integrated as we keep you here,
but it did seem to be helpful. We also saw that most of the practices affiliated or running PSH programs
covered academic medical centers and ambulatory surgery centers.
Some also covered community hospitals or physician owned specialty hospitals, but for the most part
the PSH programs were being run at the academic medical centers, for the most part. Ambulatory
surgery centers were not as common of a target for the PSH, although several places indicated they
would like to develop the PSH at their primary hospital.
And perhaps expand some or part of it to maybe a community hospital or ambulatory surgery center
later on, after the PSH gets to be more developed. The average size of the practice was 62
anesthesiologists and 61 non-anesthesiologists, for the most part they were CRNAs. The practice size
varied considerably, but that was the average.
In about two thirds of the program, all of the anesthesiologists were associated with the PSH. So they
worked with the PSH, they were familiar with the PSH, they provided perioperative services. In the other
third, 40% or fewer were affiliated with the PSH. So basically, the pattern that we saw was either the
whole practice runs the PSH and is involved, or it's only a very small subset, for the most part.
And so, in those practices where only a small subset runs the PSH, it seemed that other practitioners
perhaps didn't even know that the PSH existed. And those were generally the smaller programs that
were just getting started. In addition, about 87% of the practices interviewed conducted some form of
student training, either anesthesia residence or CRNA training.
For the PSH programs that we interviewed, the average number of cases was about 46,000, and about
80% or so was in the OR. Again, that varied widely because we interviewed practices of very different
sizes, so there was a lot of variety in that number. And as you can see from the graph on the right, they
primarily provided regional anesthetics, about 75%.
But also provided general anesthetics and monitored anesthesia care. The number of ORs, excuse me,
ranged from 12 to 120. And about half of the programs were involved in providing critical care, so they
worked in the ICU routinely. As you can see from this graph, most of these organizations participated in
some sort of external benchmarking.
Very few of them were involved in benchmarking with all of these groups, but most of them did some
sort of benchmarking. And as you can see, PQRI was the most popular, it was the favorite. Now this is
kind of an interesting Testing results. As you can see most of these, the healthcare system affiliated with
PSHs, did use electronic healthcare records for the most part.
And many of the anesthesiologists that I interviewed indicated that this is key for the success of a
perioperative surgical home largely because, to coordinate the care of a patient across a complex
surgical process, a lot of people have a lot of information and need a lot of information.
And so, without an electronic health care record, it seems that it was very, very difficult to make that
happen, to make sure everyone has the information that they need at any given time. So EHR's were
very common, as were anesthesia information management systems. Anesthesia quality outcomes
capture programs weren't as common, but several organizations indicating that they had a department
that worked on the quality outcome capture they just didn't have a program that did it.
In terms of the patient profile, this is another interesting finding as you can see here. Only 32% of the
programs reported taking patient profile into account when they were enrolling patients into PSH but
50% of the programs reported that they disproportionately third at risk patient population. So those two
results seem to be at odds.
And what I think is really happening here, I think people were a little unsure of what the question was
asking. But from the narrative responses I received, my understanding is that most programs take a look
initially at all surgical patients. And then they triage them and low risk patient either don't go through
the PSH process or they go through a very limited version of the PSH process.
For example, perhaps the CRNA will call them and ask them a pre-surgical questionnaire to check for any
abnormalities or anything like that. I think most programs seem to take an initial look at everyone, triage
them and then spend most of their time, resources, efforts on the high risk patient, which makes sense.
So I think that's what's going on here, it seems. This phase of implementation, we also had some
interesting results here. From the looks of this graph, it would seem that of the four phases we asked
about, the planning phase, which is really just idea development, understanding what a PSH is, and
figuring out how to put it into practice.
Early implementation which is that next step where you start getting things up and running,
sustainability would be you've implemented all the elements and now you're just getting everything up
to full speed, and then late implementation would be smooth sailing, you're good to go. And you're
looking to maybe expand your program to a new area or maintain what you're doing or whatever.
So from the looks of this, it kind of looks to me about even between the four phases. Approximately
25%. But, in speaking with a certain anesthesiologist who were very involved, in the development of the
PSH program, one of these anesthesiologists said, if somebody said they're late implantation they're
lying, and I quote.
And I think what's happening here is that they're not necessarily lying, that's probably a bit of an
overstatement. I think what's happening here is that most of these PSH programs, started with a pre-op
clinic, or something along those lines. And that element that they started with is very well developed.
So that pre-op clinic, for example, may actually be in the late implementation phase, because they've
been doing it for 15 years and they have that down. But, what I think perhaps what people weren't
considering was that a perioperative surgical home is more than just that one element that happens to
be more developed.
It's all of these elements that we talked about. So I think people said they were late implementation
because the most important aspect to them was late implementation. So I think it was perhaps just a
different take on the question. From my understanding if you were to look at PSH implementation as a
whole, it seems that most people are in fact in the early implementation phase.
Some may be in the sustainability phase, but this concept hasn't been, this idea as it stands hasn't been
around for a very long time, and so it'd be really difficult for anyone to have developed this into a late
implementation phase. Although some places have been doing PSH, but not calling it a PSH for a very
long time.
So it's possible that some locations are in fact in the late implementation phase. What is the, the next
session we'll talk about are services provided. We'll talk about the pre-operative, intra-operative and
post operative element that we talked about earlier. And we'll also talk about pain management
because that's a important part of many peri-operative surgical homes, almost all of the programs that
we interviewed offered acute and chronic pain services, 94% and 81%.
Chronic pain services were generally a smaller subset. So on average six practitioners were in involved.
And if you remember the average practice size is about 60 anesthesiologists, so that's about 10% of the
workforce involved in providing chronic pain services. Acute pain services were a little more popular.
About 21 practitioners on average, which is about a third of the average practice size, providing care to
an average of 2,154 patients per year.
Now we're gonna move on and start talking about how many of these programs have implemented
these elements of pre-operative, inter-operative, and post-operative care that we've been discussing,
starting with the pre-operative care element. So you can see here that early patient education and
engagement and coordinated pre-op testing were very common.
I think this is largely because pre-op clinics were generally developed before the PSH and a lot of these
programs, and so these aspects were developed first in most of the programs from my understanding.
You can see that patient nutrition and lifestyle counseling and patient physical fitness and prep were not
quite as common.
And in fact, in a few of the organizations that I spoke with, they hadn't even considered these elements
to be a part of the PSH until we'd spoken. And most of those organizations were in the planning phase
and still figuring out what they were going to do. But this is not as common as the other testing type
elements of pre operative care.
Now on the inter operative side you see that all of the implementation percentages are very very high.
Scheduling initiatives, reduced delay initiatives, facilities optimization initiatives and so on. Participation
was very very high for the most part. And I think part of that is probably because hospitals and
anesthesiologists have been working on several of these things for a long time, and the PSH incorporates
those.
And so perhaps the PSH wasn't necessarily the one and only catalyst for the development of these
initiatives. But it's certainly incorporating these initiatives and perhaps formalizing them. That was the
understanding that I got was that the PSH formalizing processes that had already been in place but it's
putting them under a new umbrella especially on the intra operative side.
Moving on to the post operative side, this phase seemed to be the least developed of the three for most
peri operative surgeries. So if you look, nausea and vomiting protocols and post operative pain
management were relatively common, and also reducing length of stay. I think these sort of fall under
the umbrella that I was talking about in the inter operative stage.
I think these were things that hospitals and anesthesiologist were working on beforehand and then the
PSH was developed and the was moved under the PSH. Again the PSH may not have been the catalyst
necessarily for developing these elements. If you look at the other three categories, patient mobility,
coordinated discharge planning and discharge phone calls.
These elements were not as commonly implemented. And again I kind of got some surprise from some
people. Some people had not really thought about these elements as being part of the PSH. But it really
did seem to me that the post operative phase was a little bit under considered for a lot of the
anesthesiologists that we spoke with, a lot of the programs that we spoke with.
The discharge planning and discharge phone calls weren't a huge consideration from us PSH's. So the
next question or the next kind of topic that we discussed was implementation enablers. So essentially
we asked the anesthesiologist that we were speaking with. Of this list, and the list was the categories
you see under the columns here, which were most important for implementing a perioperative surgical
home?
And there were a few that were highlighted as most important. The first two that you see, culture of
patient safety or accountability and focus on patient experience. To me both of those sort of speak to a
culture of patient centeredness. And from my understanding, the PSH looks like a lot of money up front.
And so to sell the PSH to hospital administrators and people that are going to have to help fund it. You
really have to sell the side that it's going to improve patient care. It's going to improve outcomes. It's
going to improve efficiency and so on. And I, I think that cultures that focus on patient centeredness are
more likely to buy into that argument and more likely to be supportive of a PSH.
That kind of rolls into the organizational leadership and support. Most organizations indicated that if
they didn't have support at the top it was almost impossible to even get the space to have a pre op
clinic. Or, to get the resources, the people that they need to coordinate care.
So that was a huge implementation enabler and if you look at the test at the bottom, 94 percent of
practitioners said that they did have institutional departmental and colleague support when
implementing the PSH. So it was very important and as you can see of these PSH's that we interviewed.
We interviewed these programs because they were developing a PSH, and I think without the support it
doesn't seem like they would be in this interview pool at all because they wouldn't be able to implement
a PSH at all. And then lastly the other sort of outlier is information technology capabilities.
And I think we touched on this before with the electronic healthcare record. If there is not the IT
capability to track patients and collect the information needed to assess outcome and provide good
care, the PSH is very difficult to make work. I think information technology capabilities is also key for
several of the people that we interviewed.
Furthermore, 100% of the programs interviewed had access to professional quality personnel, either in
their practice or in their health care. Quality management was something they were familiar with and
had access to, and in addition most groups reported using either Lean or Sigma as well as a few other
change management methodologies.
And in fact some of the anesthesiologists were interviewed were 6 Sigma black belts and they lead
several initiatives for a very long time. Which indicates that many of these programs, these practices
affiliated with PSH programs, are familiar with change and implementing strategic change. This
information was interesting. We asked the question, so we posed this question to the anesthesiologist.
We said, on a scale of one to ten. How much of a priority is the PSH concept and practice too? And then
we asked that question of each of these groups. So we asked, how important is it to the anesthesiologist
in charge? And as you can see there, it was most important to the anesthesiologist in charge, which I
think makes sense because they're in charge of the PSH.
Then we asked the anesthesiologist in charge, how important is PSH to be to other anesthesiologists in
practice? As you can see that was a little bit lower. I think in some groups, other anesthesiologists
weren't around it or they just weren't as much on board. When we asked that same question about the
healthcare organization the response was a little bit higher, it seemed that most hospitals and
healthcare organizations were very interested in the PSH and what it promised and what it could deliver.
So for the most part most hospitals were supportive of the PSH. And then we asked how important it
was to the surgeons that the anesthesiologists were working with. The findings here were very
interesting. Essentially it was a ten or two something along those lines. Some surgeons really loves the
PSH because it reduced day of cancellations.
They were more confident that the patient had had the appropriate workup. And it took some workload
off of them, and so some surgeons really appreciated it. Some surgeons, however, saw it as
anesthesiologists encroaching on their territory, and so taking away something they did, taking away
some of their market share and they didn't appreciate that.
And that seemed to vary both by organization and by surgical specialty. So some surgical specialties
were more okay with handing over this perioperative management side than others, and so that was
kind of an interesting finding. We closed the interview by asking the anesthesiologist how important the
PSH was to the future of anesthesiology.
And the general consensus was that it was pretty important. 71% of the anesthesiologists indicated, ten
out of ten, most important, very important. When asked why, most of them said something along the
lines of, the traditional practice of anesthesia has kind of been threatened to be taken over by cost
providers.
And so there's that threat there and if an anesthesiologist wants to defend their market share and sort
of defend themselves as specialty, they've got to expand their skill set and they are opposed to do that
by managing perioperative care because they're already sort of involved in all three of those phases.
They have the knowledge to be involved and care for their patients in all three of those phases. And for
the PSH it's a great way for them to add value to the healthcare system and sort of maintain their
autonomy and value as a speciality. So in some kind of the key take aways from the interviews that I got.
Most of the PSH programs started small. So they either started with one stage, maybe just the pre-op
stage, and they developed a Pre-op clinic. Or they started with one surgical line, so, just urology, and
they demonstrated value in that small way. Once they had demonstrated value, they were able to get
more support from the higher ups in terms of personnel, financial resources, space.
But they had to demonstrate value in a small way to get those resources. And on that same note, the
most frequently cited barrier to the implementation or expansion of the PSH was, where are the funds
gonna come from? Who's going to pay for this? Is this going to have to come out of the pocket of the
practice or is the hospital gonna pay for this?
Who's gonna foot the bill, essentially? Because as it stands now, there is no, no insurers pay for care
coordination. There's just not a payment for that and so, not an explicit payment anyway. And so that
was the most cited barrier. And then finally, the interviewees from the most developed PSH programs
generally emphasize that, to reap the benefits of a PSH you need to implement it fully.
You cant piecemeal it. You can't just pick and choose what you like. You've gotta coordinate care across
the whole spectrum. You gotta plan discharge. You've got to manage prehabilitation and do the whole
nine yards to reap the benefits that a PSH promises. So that was kind of the key takeaways from our
interviews, and with that we will open the floor for questions.
>> I don't think we. Somebody spoke, we definitely did not hear it. There was a technical problem with
that, something happened.
>> SSS
>> That's not really working out.
>> Yeah, that phone connection is not working out. Maybe somebody else has a question for us?
>> Or feel free to use the chat function.
I've sent out notes. Sorry, I'm trying to figure out which microphone is giving us the feedback, but we'll
figure it out here shortly. So feel free to use the chat function. Any other questions? I've unmuted the
majority of people.
>> All right, well, any other final comments or questions?
I'm not getting any other chat messages here. You must have answered every question, Vita and Kayla.
>> Right, so we would be glad to answer questions after the webinar. So if you have a question email me
and Kayla or Kayla, and we will definitely be glad to talk about our study results and share with you any
more information that you might need.
>> We have one question here. Is it a misnomer to call it a surgical home as opposed to something
associated with coordinated perioperative surgical care? Thoughts? We did. In some of the interviews,
some of the anesthesiologists discussed that there was kind of some push back to the surgical home
name.
And there's even been. It's more of a surgical hotel than a home because it's not a long thing necessarily.
So, several of the organizations that we talked about did call it something more like their perioperative
services or care rather than surgical home. We saw a wide variety of names.
>> And again, based on the literature review also,we know the concept is evolving in the U.S., so really
everybody's trying to figure out what it is. I'm sure there is room for improving the name, making it
something that leaders in this area are most comfortable with and would encourage and support.
Most of the programs, as Kayla said, did not use a specific name. They did not call their program a
perioperative surgical home necessarily.
>> Thank you for that. Any other questions from the panel? Okay, well I appreciate the time. Thank you
Dr. Cash. Thank you Kayla. As a reminder this meeting-
>> Thank you.
>> Has been recorded, and we will be hosting this on chotnsf.org to be watched asynchronously at a
later time. If you have any questions feel free to reach out to either Dr. Cash, Kayla, or myself. We will
talk to you again in January. Happy holidays.
>> Great, thank you. Happy holidays.
>> Bye.