New health care measures: emphasis on better management of postsurgical pain and postoperative nausea and vomiting.

Hospital Practice

ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20

New Health Care Measures: Emphasis on Better Management of Postsurgical Pain and Postoperative Nausea and Vomiting Joseph V. Pergolizzi Jr MD, Marco Pappagallo MD, JoAnn LeQuang BA, Sumedha Labhsetwar MD & Robert Taylor Jr PhD To cite this article: Joseph V. Pergolizzi Jr MD, Marco Pappagallo MD, JoAnn LeQuang BA, Sumedha Labhsetwar MD & Robert Taylor Jr PhD (2014) New Health Care Measures: Emphasis on Better Management of Postsurgical Pain and Postoperative Nausea and Vomiting, Hospital Practice, 42:1, 65-74 To link to this article: http://dx.doi.org/10.3810/hp.2014.02.1093

Published online: 13 Mar 2015.

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Date: 22 September 2015, At: 17:35

C l i n i c a l F o c u s : H o s p i ta l A d m i s s i o n s , L at e s t P r o t o c o l s , P e r i o p e r at i v e M e d i c i n e , a n d T r a n s i t i o n s o f C a r e

New Health Care Measures: Emphasis on Better Management of Postsurgical Pain and Postoperative Nausea and Vomiting

Downloaded by [Central Michigan University] at 17:35 22 September 2015

DOI: 10.3810/hp.2014.02.1093

Joseph V. Pergolizzi Jr, MD 1,2 Marco Pappagallo, MD 3 JoAnn LeQuang, BA 2 Sumedha Labhsetwar, MD 2 Robert Taylor Jr, PhD 2 1 Adjunct Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Associate Professor of Pharmacology, Temple University School of Medicine, Philadelphia, PA; 2NEMA Research, Inc, Naples, FL; Association of Chronic Pain Patients, Houston, TX; 3Director of Pain Management, New Medical Home for Chronic Pain, New York, NY; Professor, University of Rome, La Sapienza, Italy

Abstract: Value-based purchasing and the Hospital Consumer Assessment of Healthcare Providers and Systems are tying patient-centric measures to reimbursements. Hospitals should be particularly concerned about management of postoperative pain and control of postoperative nausea and vomiting (PONV), known to adversely impact overall patient satisfaction. Anesthesiologists are likely to be on the frontlines of these transitions. Although postoperative pain is not always effectively managed, clinicians have the pharmacological tools and guidelines for better pain control. Considerable work has been done in PONV to better identify high-risk patients and effective prophylactic agents. Postoperative pain control and preventing PONV are two relatively straightforward ways to respond to new quality metrics. The aim of this review is to raise practitioner awareness of these new quality metrics and provide an overview of the current tools and methods used to improve postoperative pain control and PONV. Keywords: value-based purchasing; HCAHPS; postoperative; nausea; vomiting; analgesia; opioids

Introduction

The United States pays more for health care than other nations but does not have better health outcomes.1 Current health care reform aims to contain costs while simultaneously expanding services by evaluating what health care dollars actually buy. Paradoxically, lower quality can be associated with higher costs,2 because lower quality care may be associated with complications, which, in turn, are associated with hospital readmissions, prolonged lengths of stay, additional physician services, and postdischarge care.3 Because about one third of all health care expenditures go to hospitals and hospital-related services, quantifying hospital quality emerges as an urgent objective in containing high hospital costs. Tying quality metrics to payments has led to the concept of value-based purchasing (VBP), which holds hospitals accountable for both cost and quality. As diagnosis-related group reimbursements decline, the role of VBP gains importance. Navigating the new VBP paradigm requires strategies to mitigate risk, provide top-quality care, develop a collaborative culture, and promote accountability with transparency. All of this depends on data. Correspondence: Robert Taylor Jr, MD, NEMA Research, Inc, 840–111th Ave N, Suite 9, Naples, FL 34108. Tel: 239-597-3662 Fax: 239-597-7566 E-mail: [email protected]

Defining Quality Data

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) multiple-choice survey composes about 30% of a hospital’s VBP score and is tied to reimbursements as of fiscal year 2013.4 Outstanding results are required, because

© Hospital Practice, Volume 42, Issue 1, February 2014, ISSN – 2154-8331 65 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.

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only the best answer counts (for example, “excellent” counts but “good” is the same as “poor”).5 The HCAHPS survey evaluates the patient’s experience in the hospital by assessing 8 main areas: nursing communication, physician communication, responsiveness of staff, pain management, communication about medications, discharge information, cleanliness, and quietness of the hospital environment; an overall score is also calculated. In the VBP model, a hospital’s operating room and surgical/anesthesia staff must achieve and consistently maintain high-quality standards. It may be argued that anesthesiologists are already on the frontlines in gathering relevant quality-related data. The American Society of Anesthesiology has created the Anesthesia Quality Institute (AQI) and the National Anesthesia Clinical Outcomes Registry (NACOR) to create a database system for benchmarking and evaluating changes in clinical outcomes.6 The NACOR was designed to collect data from all anesthetic and pain clinic procedures performed each year by anesthesiologists in the United States.7 The desired data that are captured fall into 4 broad categories: patient d emographics, case specific data (eg, Current Procedural Terminology [CPT] codes, anesthesia type, duration of surgery), outcome data (eg, mortality, major morbidities, infections), and risk adjustment data (eg, International Classification of Diseases [ICD-9] codes, preoperative medication use). Information is processed by the AQI and practice reports are sent to anesthesiologists and practices throughout the country in order to help improve patient care and outcomes. However, NACOR is not the only data stream available to anesthesiology. Some large hospitals and teaching hospitals may operate an anesthesia information management system (AIMS), which is a proprietary electronic database system that collects important anesthesiology information. The AIMS reports often include intraoperative events (eg, vital signs, medications, fluids) and perioperative events (eg, induction, intubation, emergence). In some hospitals, AIMS data can flow into NACOR to create consolidated data.8 Although AIMS reports are often limited to a hospital or hospital system, AQI and NACOR data should be regarded as a collective system from a network of sources. Nationallevel anesthesiology data can be valuable, but data input via multiple systems are vulnerable to compromise if the individuals responsible for submitting data supply incorrect, incomplete, or haphazard data. Therefore, it is important for the hospital’s responsible staff to follow the standardized data sets and report accurately in order to protect the integrity of NACOR data.

Defining Relevant Clinical and Financial Data

Although the HCAHPS survey focuses on patient experience, health care data systems focus on outcomes, and these are not necessarily the same thing. The Institute of Medicine defines quality in terms of outcomes: quality is “the degree to which health services for individuals and populations increase the likelihood of the desired health outcomes and are consistent with current professional knowledge.”9 As a metric, outcomes make intuitive good sense to clinicians, but outcomes are rarely the exclusive result of health care q uality. For example, the simple metric of in-hospital m ortality might seem a reasonable measure of quality, but it is not a fair quality metric for emergency acute myocardial infarction patients without allowing for risk adjustment, a regression model that accounts for patient risk factors. Using mortality alone as a quality metric would incentivize hospitals to avoid high-risk patients and, in so doing, ultimately compromise health care. Thus, risk adjustment must accompany many seemingly straightforward pieces of hospital data. In the case of perioperative mortality, the mortality rates for specific surgeries would help adjust for surgical risk. Mortality rates for certain surgeries are published in some states,10 but not all of the information required for accurate risk adjustment is available. Work is ongoing to determine which quality metrics are most clinically and financially meaningful; for example, in 2012, the National Quality Forum endorsed 9 quality metrics related to surgical care.11 The Medicare Physician Fee Schedule plans to update quality reporting initiatives, including the Physician Quality Reporting System, an incentive program tied to electronic prescribing, and the Physician Quality Reporting System Medicare Electronic Health Record Incentive Pilot program.12 The value modifier required by the Affordable Care Act will impact payments to groups based on both the quality and the cost of care to patients.13 Another metric for assessing the value of quality of care lies within the quality of the practitioner. The Joint Commission, a certifying body for many American hospitals, has required surveyed hospitals to participate in the Focused Professional Practice Evaluation and the Ongoing Professional Practice Evaluation, evaluations used to assess the quality and capability of the practitioner.14,15 Specifically for anesthesiologists, new certification requirements are rolling out; the Maintenance of Certification in Anesthesiology now involves a multiyear process of ongoing continuing medical education and personal practice assessment.16 Reports indicate that anesthesiologists believe that improving com-

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© Hospital Practice, Volume 42, Issue 1, February 2014, ISSN – 2154-8331 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.

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Health Care Measures for Postsurgical Pain and PONV

petence and quality of care are important; however, current implementation of certification requirements, especially Maintenance of Certification in Anesthesiology, may hinder anesthesiologists from continuing education due to the length of time, the cost, and the complexity of the certification.17 If these certifications are improved and eventually become an indicator for improved patient outcomes, then this may provide an opportunity to increase efficiencies, reduce complication, and increase cost-effective care in the health care system, ultimately becoming a main driver in VBP.8


Quality Improvement in Anesthesia

There is no doubt that quality improvement programs in health care can be effective in improving care while reducing costs.18 Anesthesiologists are seldom experts in quality improvement or quality performance metrics and may feel that the bar is set too high.19,20 There is inherent difficulty in developing quality metrics for anesthesia because anesthesia care does not “cure” disease. Surgery may provide long-range benefit for patients, but at the cost of short-term pain and discomfort; quality metrics focus on the immediate hospital experience. Although modern anesthesia can be described as very safe, there is no clear consensus on how to define anesthesia-related death with respect to timing (perioperative, # 48 hours, or # 30 days) and which anesthesia-related metrics should be evaluated.21 Thus, although we know that the anesthesia-related mortality rate is low, it is measured in different ways at different hospitals.

Postoperative Pain Control

Postoperative pain continues to be undertreated despite the advances in pain medication, our greater understanding of the pathophysiology of pain, and improvement in treatment guidelines. For example, 82% of patients continue to experience pain after surgery, with approximately 75% of patients experiencing pain after discharge from the h ospital.22 Undertreatment of pain can have negative effects on patient satisfaction, which is important for improving the quality of pain management and is an important factor in the HCAHPS survey. In 2010, the national average score for pain management was 69/100 (with 3827 hospitals reporting),23 suggesting that many patients are dissatisfied with their postoperative pain treatment. Postsurgical pain is typically reported by patients as moderate to severe, as most intense immediately after surgery, and decreasing over the course of $ 1 day.24 This pain trajectory may vary with type of procedure and patient condition. Inadequately controlled pain has been associated with postoperative morbidity, increased

costs, prolonged hospital stays, and slower rehabilitation; uncontrolled or under-controlled postoperative pain is a risk factor for the development of chronic pain syndromes.25,26 Despite these known poor outcomes, postsurgical pain control is often inadequate.22 There are safe and effective ways to manage pain in the postoperative setting.

Opioids

Opioid use is often appropriate for controlling postoperative pain but should be limited to the lowest effective doses for the shortest duration of time. Where opioid consumption may be required over several days, doses should be tapered as therapy concludes. Concerns over addiction, tolerance, and misuse are valid, but it has been shown that in previously addicted patients, inadequate analgesia is more likely to provoke a relapse to addiction than medically supervised pain management using opioids.27 An important concern for the postoperative use of opioids are their well-known side effects, which may occur more frequently in geriatric and obese patients and in those with specific comorbidities, such as respiratory dysfunction.28 A common opioid side effect is nausea, which may exacerbate rates of PONV. Many side effects of opioid analgesics can be managed in the short-term setting, such as with the use of antiemetics or laxatives. The Joint Commission issued a new Sentinel Event Alert in August 2012 regarding the safe in-hospital use of opioids.29 Among its recommendations were ongoing monitoring of opioid patients, including tracking of opioid-associated incidents, use of technology to create alerts for limit dosing, training and education for all clinical staff and patients about opioid use, and standardization of tools and systems to screen patients at risk for oversedation or respiratory depression.

Multimodal Pain Therapy

Multimodal pain therapy combines $ 2 agents with complementary mechanisms of action to treat the components of multimechanistic pain. A multimodal regimen may offer additive (the benefits of the agents are summed together) or synergistic benefits (the benefits of the agents in combinations exceeds their sum).30,31 Multimodal regimens may consist of opioids and nonopioids such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthetics, or regional anesthesia.32 A particularly useful combination therapy includes a nonopioid analgesic agent (acetaminophen or an NSAID) plus an opioid, which are combined in such a way that adequate analgesia is achieved with a lower dose of opioid versus opioid monotherapy. Such fixed-dose combination


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products have been shown to be equianalgesic to opioid monotherapy for control of postsurgical pain,33–35 and result in lower cumulative morphine consumption. This so-called opioid-sparing effect36,37 sometimes translates into lower rates of opioid-associated side effects (nausea, dizziness, somnolence, constipation, and so on),38–40 but these findings are inconsistent.40,41 This may be due in part to the fact that postsurgical pain control with opioids typically lasts only a few days. Adjuvant agents that are primarily used for neuropathic pain are also used effectively in multimodal pain therapy such as gabapentin,42 pregabalin,43 and others.44,45 Anticonvulsants may also exert an opioid-sparing effect without compromising analgesic effect.46

Analgesics With Dual Modes of Action

Tramadol and tapentadol are analgesic agents with dual modes of action. Tramadol is a centrally acting analgesic with weak µ-opioid receptor agonist effects combined with nonopioid effects in the form of being a serotonin and norepinephrine reuptake inhibitor.47 Tramadol may be particularly effective in treating pain with a neuropathic component, but caution and dosage adjustments may be necessary in special populations, such as elderly patients and those with renal impairment.34,48 Tapentadol also has a dual mode of action (µ-opioid receptor agonist and norepinephrine reuptake inhibitor), but it is analgesically distinct from tramadol.49 Tapentadol may be an effective agent for relieving postsurgical pain.50

Familiar Agents With New Routes of Administration

In managing postoperative pain, it is important to consider the management of analgesic gaps and breakthrough pain. Analgesic gaps occur when analgesics are administered on a time schedule and serum concentrations of the agents drop before the next dose is administered. With analgesic gaps, patients experience “spikes” of pain with no overt precipitating action (such as movement). Patient-controlled analgesia can help smooth out analgesic gaps. Analgesic gaps are distinct from breakthrough pain, although both may manifest as sudden, unexpected, and intense pain. Breakthrough pain refers to paroxysmal severe pain of relatively short duration that occurs against a background of lower level ambient pain. Although breakthrough pain is often thought of as cancer-related pain, it can occur in postoperative patients without cancer. Breakthrough pain requires prompt administration of a powerful but short-acting analgesic, such as fentanyl (eg, injectable). Immediate-

release and fast-acting oral formulations of analgesics are not always effective in treating breakthrough pain, which has resulted in the development of intranasal and transmucosal formulations,51 specifically of fentanyl.52 On the other hand, transdermal formulations of fentanyl and buprenorphine are commercially available to provide around-the-clock pain relief for an extended period of time.53 Transdermal patches may be appropriate for more protracted periods of postsurgical pain, such as that associated with major orthopedic surgery. Clinical decisions as to the appropriate agent and route of administration have always depended on the individual patient’s condition, comorbidities, other medications, and other factors; in the new patient-centric VBP paradigm, patient preferences for specific products or routes of administration play an increasingly large role.

Empowering Patients

Effective pain control must include patient education to inform, empower, and encourage patients to report pain and seek pain relief. Patients may be inhibited from asking for pain medications or erroneously believe that severe postoperative pain must be tolerated. Cultural, familial, and personal attitudes about pain can make patients reluctant to bring up the subject of pain relief with clinicians. For that reason, the clinical team must regularly ask patients about pain and encourage patients to describe their pain. Although pain is a subjective experience, many validated tools for pain measurement exist, including a visual analog scale or numeric and categorical scales.54 The Wong-Baker FACES pain scale (smiling and frowning faces) is useful for pediatric patients.55 Reporting pain on a verbal descriptive scale (pain is “very bad” or “much better” or “not too bad”) may be a useful supplement to a visual analog scale, particularly in geriatric postsurgical patients.56 The percentage of pain reduction appears to correlate with the patient’s subjective impression of pain relief.57 Clinicians should carefully explain the available pain medication options to patients and patients should be instructed that it is not abnormal to need pain medications following surgery, but patient expectations must be managed insofar as complete pain relief may not be possible. Patients concerned about opiates should be informed that if they need these drugs following surgery, they will be used only for as short a time as possible and at the lowest effective doses, all under close medical supervision. Clinicians should also explain to patients how long pain medications will be given and how they will be discontinued, for example, tapering off of opioids.

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Postoperative Nausea and Vomiting

Postoperative nausea and vomiting (PONV) occurs in approximately 20% to 30% of all surgical patients58; postoperative nausea occurs more frequently than PONV, with rates ranging from 14% to 47%.59 In specific patient populations, the rate of PONV can exceed 60%.60–62 There are known risk factors for PONV: female sex, nonsmoker, history of PONV or motion sickness, and the use of postoperative opioids.63 Anesthetic risk factors also come into play, with PONV associated more with the use of volatile anesthetics, nitrous oxide, and intraoperative opioids.58 Patients undergoing general anesthesia were 11 times more likely to experience PONV compared with those patients undergoing regional, monitored anesthesia care, or chronic pain block.64 It is not entirely clear if the type of surgery is a risk factor for PONV,65 but surgeries generally associated with high rates of PONV include dental, orthopedic, and plastic surgeries.64 The duration of surgery has also been associated with PONV rates.58,64 For example, for surgical durations of # 30 minutes, the PONV rate was 2.8%, but this rate increases to 27.7% for those undergoing surgery of 2.5 to 3 hours in duration. A direct association between surgical duration in minutes and PONV rate can be made for surgical procedures lasting 1.5 to 3 hours. Although imperfect, risk stratification tools for PONV can help identify high-risk patients. In 1991, when Dr Patricia Kapur famously described PONV as the “big little problem,”66 physicians tended to downplay PONV, but PONV has been associated with potentially serious negative clinical consequences. Nausea and vomiting can increase tension on suture lines,67 emesis can be aspirated by patients,68 and vomiting may cause hematomas to form beneath surgical flaps.64 Also, PONV has been linked to delayed discharge from the postanesthesia care unit (PACU),68 increased hospital costs,69 and unintended

hospital admissions.68 In connection with the new health care measures, PONV can affect the patient’s overall satisfaction following surgery as captured on the HCAHPS survey. Postoperative nausea and vomiting is so distressing that it has been identified as one of the single greatest concerns of surgical patients (Figure 1).69,70 Physicians may trivialize this concern and underestimate how adversely it impacts patient satisfaction.70 Postoperative nausea and vomiting is sometimes falsely believed to occur only in the short window of time the patient spends in the PACU. The incidence of PONV is actually higher 48 hours after surgery than in the PACU, and PONV rates up to 5 days following surgery are higher than PACU rates.71 The US Food and Drug Administration (FDA) has approved multiple medications for PONV prophylaxis including, but not limited to, transdermal scopolamine, ondansetron, droperidol, and promethazine; the Society for Ambulatory Anesthesia guidelines recommend dexamethasone as well, although this is not an FDA-approved indication.58 These treatments, like all drugs, are not without risk; boxed warnings conveying safety risks are stated for droperidol and promethazine. Optimal PONV management is multidisciplinary, including the anesthesia provider (eg, anesthesiologist, certified registered nurse anesthetist), the surgical team, pharmacists, and nursing staff. Although effective prophylaxis is available, resource availability, cost-containment initiatives, and other factors, including institutional protocols, make it impractical to provide all surgical patients with PONV prophylaxis. Thus, risk must be assessed and at-risk patients provided with prophylactic drug therapy, chosen by the physician to be best suited to the individual patient. The risk factors for PONV are well described in the literature. Apfel and colleagues72 proposed an original risk factor model, which was later simplified, so that 4 factors are considered: female sex, nonsmoking status, h istory

Figure 1. When patients were asked how much they would pay out of $100 to avoid 10 surgical outcomes, vomiting was allocated the most money, more than pain or gagging on an endotracheal (ET) tube.70


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of PONV or motion sickness, and the use of postoperative opioids.63 The risk of PONV is 10% for patients with no risk factors, 20% for those with 1, 40% for 2, 60% for 3, and 80% for all 4.63 Although simple and practical, this is a “rule of thumb” and should not override clinical judgment. A more complex model has recently been proposed by Sarin and colleagues73 that employs both modifiable physician specific anesthetic practices and nonmodifiable factors (eg, sex, smoking history, history of PONV) in a logistic regression model. In this model, patient history, outcome factors (ie, maximum pain score postoperatively), surgical factors, and anesthesia-related factors were considered with good predictive results. The pathophysiology of PONV involves several known pathways and systems, including the central nervous system, the gastrointestinal tract, the cardiac system, the chemoreceptor trigger zone (including dopamine type 2 receptors), and the vestibular system—all interacting with the vomiting center in the brain (nucleus of tractus solitarius).74 Guidelines recommend the use of different antiemetics, including antagonists for the 5-hydroxytryptamine (5-HT3), histamine, muscarinic, dopamine, and neurokinin-1 (NK1) receptors (ie, ondansetron, promethazine, scopolamine, droperidol, and aprepitant, respectively).75,76 Although all these antiemetics have shown efficacy and safety, transdermal scopolamine may be of special interest to anesthesiologists and patients

because it is the only PONV agent currently available for transdermal delivery, which may increase patient compliance and patient satisfaction, and offer a number of other significant advantages over non-transdermal products.77 Although its greatest affinity is for muscarinic receptors, the anticholinergic drug scopolamine also has an affinity for dopaminergic and histaminic receptors. A transdermal scopolamine patch offers clinical convenience, in that it may be applied behind the ear preoperatively (the night before surgery, for example). The patch contains 1.5 mg of scopolamine in a matrix designed to release approximately 1 mg of the agent over a 3-day period. When the patch is applied, a priming dose is delivered from the adhesive layer to saturate skin binding sites (Figure 2).78 Rates of PONV in placebo-controlled trials using transdermal scopolamine range from 35% (general, plastic, orthopedic surgery) to 21% (gynecologic laparoscopy) to 42% (cesarean section) for the patch, versus 65%, 63%, and 70%, respectively, for placebo (P = 0.05, P = 0.003, and P # 0.05, respectively).79–81 In a meta-analysis of 25 randomized, placebo-controlled clinical trials (N = 3298), use of the transdermal scopolamine patch was associated with a relative risk reduction of 41% for postoperative nausea, a 32% risk reduction for postoperative vomiting, and a 27% risk reduction for PONV in the first 24 hours after anesthesia (Figure 3).82

Figure 2. The transdermal scopolamine patch (Transderm Scop) has an adhesive layer with a priming dose and a rate-controlling membrane to allow for a dose of about 1 mg of scopolamine during a 3-day period.

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Figure 3. Results from a meta-analysis of 25 randomized, placebo-controlled studies evaluating the rates of postoperative nausea, postoperative vomiting, and PONV 24 hours after induction of anesthesia (N = 3298).82

Transdermal scopolamine has been associated with certain adverse events, the most common of which are dry mouth and dizziness, and patients should be advised on possible blurred vision, particularly if the patch is applied the day before surgery. Caution is advised with geriatric patients or patients with liver or kidney dysfunction, as well as in patients with pyloric obstruction, urinary bladder neck obstruction, or any patient suspected of having an intestinal obstruction. It should be used only with clinical caution in patients with a history of seizures or psychosis or in patients taking other central nervous system drugs, such as sedatives or tranquilizers.78 In addition, patients who are discharged to home should be taught how to remove the patch according to its instructions.

Discussion

On the surface, health care rating systems and surveys appear to be laudable ideas. But as health care providers start to monitor their care systems, “our patients” soon become “health care consumers.” Although a health care organization may rightly view hospital inpatients as its customers, this phraseology makes clinicians uncomfortable. Doctors and nurses treat patients, not wait on customers. The doctor– patient relationship is unique and complex, and it is unclear to what degree it can be simplified into the transactional relationship of provider to consumer. The sudden proliferation of data produced by these paradigm shifts poses another problem. Data can be very easily distorted, whether by design, reporting processes, or deliberate events. For example, hospital A may transfer a patient experiencing an acute myocardial infarction to hospital B,

hoping that the mortality will be credited to hospital B, although the events at hospital A may have been contributing factors. Besides, not all negative data reflect poor quality but may reflect poor hospital systems. For instance, hospital A has intensive diagnostic routines that report more comorbid conditions, resulting in a higher adjusted mortality rate; this hospital will seem superior to similar hospitals that do not report sufficient comorbidities to adjust their mortality rate, even if all other factors are the same. Although quality advocates argue this will incentivize hospitals to be more diligent with diagnostics and reporting of comorbidities, it may produce misleading data in the short term. Anesthesiologists will be at the forefront of the transition to a VBP system. Early efforts in defining, measuring, monitoring, and reporting quality will be fraught with problems, which we can expect to resolve eventually into a transparent data-driven system. Problems with data collection can surely be sorted out. The literature provides much encouragement that quality-reporting systems can be both functional and effective. A German model for capturing and measuring perioperative events and complications during and after anesthesia and mapping them onto overall patient satisfaction scores demonstrates that there is a viable means for recording perioperative adverse events.83 In 1994, the publication of pediatric cardiology surgery data from a hospital in the United Kingdom resulted in a decrease in its mortality rate from 30% in 1994 to 4% in 1996.21,84 In California, the government Office of the Patient Advocate reports online about physician groups by county using a 4-star quality report card.85 The Maine Health Management Coalition, a private nonprofit


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organization, publishes Pathways to Excellence, a public reporting initiative to share quality data on primary care practices and hospitals through its website GetBetterMaine. com.86 The Leapfrog Group, an organization of employers and agencies that purchase health care, describes its mission as informing Americans about hospital safety and quality.87 Implementing the Leapfrog intensive care unit (ICU) physician staffing standard at a 15-bed mixed medical-surgical community ICU was found to decrease the ICU length of stay, lower the prevalence of ventilator-associated pneumonia and central venous access device infection, and provided a 1-year return-on-investment to the hospital of 105%.88 Thus, there is much to be gained from the VBP model, provided we approach this change realistically.

Conclusion

The transition of the US health care system to a VBP paradigm is monumental. On the frontlines of this transition are anesthesiologists and surgeons, who find themselves in an important position to affect quality rankings by patients, yet are also in a field where objective quality metrics are difficult to establish. Because patient satisfaction and postoperative pain control are highly relevant in the value-based paradigm, anesthesiologists can leverage their specific knowledge of PONV prophylaxis and postoperative pain control to advance the quality scores of their hospitals. Patients find PONV particularly distressing; it can be safely and effectively managed using drug therapy, such as transdermal scopolamine or a multimodal regimen. Postoperative pain control requires accurate and frequent pain assessments, patient education, and drug therapy, which may include parenteral agents, patient-controlled analgesia systems, oral agents, novel transmucosal agents (particularly useful for breakthrough pain), and transdermal buprenorphine or transdermal fentanyl for round-the-clock pain relief for an extended time period. Multimodal pain regimens have been shown to be particularly effective in treating postoperative pain. We must begin to deploy the tools at our disposal to reduce PONV, better manage postoperative pain, and provide high-quality care to our patients, knowing that this improved care will translate into meaningful gains in the VBP model.

Conflict of Interest Statement

Joseph V. Pergolizzi, MD, is employed by Purdue Pharma as a consultant and is a member of the speaker’s bureau and the advisory committee; is a consultant and a member of the speaker’s bureau for Baxter International, Inc; is a member of the speaker’s bureau and has received research funding

from Endo Pharmaceuticals, Inc; and is a consultant for and patent holder with Kirax Corporation. Marco Pappagallo, MD, is employed by Grünethal-USA. Jo Ann LeQuang, BA, and Sumedha Labhsetwar, MD, have no conflicts of interest to declare. Robert Taylor Jr, PhD, is employed by NEMA Research, Inc, in the areas of focus pain and therapy.

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Current management of postoperative nausea and vomiting.

New modalities in postoperative nausea and vomiting.

Postoperative nausea and vomiting.

Consensus guidelines for the management of postoperative nausea and vomiting.

Preventing postoperative nausea and vomiting.

The study of postoperative nausea and vomiting.

Postoperative nausea and vomiting in pediatric anesthesia.

Does previous chemotherapy-induced nausea and vomiting predict postoperative nausea and vomiting?

Prevention of postoperative nausea and vomiting: a thought on ondansetron.

Postoperative pain, nausea and vomiting among pre- and postmenopausal women undergoing cystocele and rectocele repair surgery.

Pathophysiological and neurochemical mechanisms of postoperative nausea and vomiting.

Guidelines and use of dexamethasone for postoperative nausea and vomiting.

Surgical and patient factors involved in postoperative nausea and vomiting.

Erratum to: 'Prophylaxis and management of postoperative nausea and vomiting in enhanced recovery protocols'.

Alternative Therapies for the Prevention of Postoperative Nausea and Vomiting.

Caffeine for the prevention of postoperative nausea and vomiting - Reply.

[Prevention of postoperative nausea and vomiting by ondansetron].

Caffeine for the prevention of postoperative nausea and vomiting.

The role of 5-HT in postoperative nausea and vomiting.

The use of midazolam for persistent postoperative nausea and vomiting.

Postoperative nausea and vomiting. Its etiology, treatment, and prevention.

The Effect of Administration of Ketamine and Paracetamol Versus Paracetamol Singly on Postoperative Pain, Nausea and Vomiting After Pediatric Adenotonsillectomy.

Is postoperative nausea and vomiting still the big "little" problem?

Gastric Decompression Decreases Postoperative Nausea and Vomiting in ENT Surgery.