SURGICAL PERSPECTIVE
Starting a Surgical Home Michael J. Englesbe, MD, Alisha D. Lussiez, BSE, Jeffrey F. Friedman, MSE, June A. Sullivan, MBA, and Stewart C. Wang, MD, PhD A.H. is an 84-year-old gentleman with multiple comorbidities, partially dependent functional status, and multiple previous abdominal surgical procedures who presents with a new diagnosis of colon cancer. The clinician recommends a sigmoid colectomy. The clinician discusses the risks and benefits of surgical resection with the patient and his family, explaining that the patient is at increased risk of surgical complications, but that the risk is not prohibitive. The clinician schedules the patient for surgery in 24 days.
T
he next steps are of the utmost importance. There are pressures from families, referring physicians, and institutions to operate on patients who are referred to surgical services. An aggressive surgical approach to care is good for business. In conjunction with a relatively short surgical consultation, the surgeon may not fully understand the patient’s goals of care. As a result, in the United States, many patients have major surgery in the last month of life.1 This occurs despite the observation that most patients would not choose life-sustaining treatment if they knew that the outcome would be survival with severe cognitive or functional impairment. Patients such as A.H. should receive care within a surgical home, a multidisciplinary care pathway focusing on optimal perioperative care. The focus within this surgical home is patient- and family-centered decision making, wellness, and empowerment. The potential of these programs is remarkable, but implementation is daunting. We have begun the early stages of a surgicalhomeprogramcalled the Michigan Surgical Home and Optimization Program (MSHOP). We havefocusedonthepreoperativephaseofcarethroughthestepsoutlined in Figure 1. We describe our program, detail our outcomes, discuss our strategies for managing challenges of implementation, and detail our plans to start a program across the state of Michigan.
PART 1 OF THE SURGICAL HOME: RISK ASSESSMENT AND PATIENT EMPOWERMENT The first step in this culture change is to bring empiric risk data to the bedside for the surgeon and the patient. Comorbidity, age, and functional status data can be used to detail predicted outcomes for patients, such as the one described earlier, in comparison with other patients undergoing the same procedure. Novel technologies can seamlessly incorporate risk assessment into the fast-paced workflow From the Department of Surgery and Morphomic Analysis Group, University of Michigan Health System, Ann Arbor, MI. Disclosure: Supported by Funding Opportunity No. CMS08122013 from the US Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and a grant from the Blue Cross Blue Shield of Michigan Foundation to M.J.E. and the project described. M.J.E., J.A.S., and S.C.W. are equity stakeholders in Prehab Technologies, LLC, a company formed as part of our CMS grant to deliver the technologies discussed in this article. The other authors declare no conflicts of interest. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. Reprints: Michael J. Englesbe, MD, Department of Surgery, University of Michigan Medical School, 2926A Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109. E-mail: [email protected]. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001250
Annals of Surgery Volume 262, Number 6, December 2015
of surgery. In Michigan, statewide data from the Michigan Surgical Quality Collaborative are helping surgeons improve their decision making at the bedside. Our risk assessment application, available on tablets and smartphones, requires less than 10 seconds for data entry, links to a central database, and displays the data in an intuitive manner for both surgeons and patients during the informed consent process (Fig. 1). The application generates a composite risk score of extended length of stay, complications, and mortality displayed on a scale of 0 to 100 in the design of a car speedometer. This risk score model is informed by more than 300,000 operations recorded within the Michigan Surgical Quality Collaborative database. If necessary, we use the speedometer as an example of ‘‘How fast you are traveling in your car down the highway’’ as we explain perioperative risk. Patients remember this entire story, understand their risk, and can communicate risk to others. The seriousness and anxiety associated with the need for major surgery can have a transformational effect on patient behavior. These emotions must be leveraged positively to enable patients and families to improve outcomes. Empiric risk data are a critical part of this event. In the near future, novel risk assessment approaches, such as using analytic morphomics of preoperative imaging, will improve risk assessment, informed consent, and patient-centered decision making.
PART 2 OF THE SURGICAL HOME: TRAINING FOR SURGERY AND PERIOPERATIVE OPTIMIZATION Much as athletes train for competition, all patients need to train for surgery. Unlike other factors associated with preoperative risk, such as medical comorbidities, overall physiologic status can be improved before major surgery.2 Training periods as short as 2 weeks are effective; therefore, the preoperative period is of ample length to facilitate targeted exercise intervention and physiologic adaptation.3 –5 Patients facing high-risk surgery are especially receptive to behavioral changes that can improve surgical outcomes. Success of preoperative training goes beyond physiologic improvement; it empowers patients to have control and ownership of their outcomes—an invaluable presurgical weapon.6,7 Preoperative training should not focus on single domains of risk. MSHOP patient training targets functional status, smoking, nutrition, and emotional and spiritual wellness. In our program, every patient who can walk into clinic can enroll. Patients receive e-mails, text messages, or phone calls using a voice recognition system that facilitates an interactive pedometer-based daily walking regimen with real-time data feedback. Direct contact is made with patients who are not walking. A similar strategy is used for daily incentive spirometry. A real-time nutrition risk assessment tool facilitates targeted nutrition supplementation. All smokers are educated on the benefits of smoking cessation, even short-term, and receive ample resources to aid cessation. The most important component of the program is education and care planning from the time of surgical decision making to the surgical event. This includes robust engagement from friends and family members in all aspects of perioperative care. For example, in the case of the 84-year-old gentleman detailed earlier, family and friends are assembled to facilitate his participation in all domains of www.annalsofsurgery.com | 901
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 262, Number 6, December 2015
Englesbe et al
FIGURE 1. Preoperative phase of care steps in MSHOP. the program. Such family support can also facilitate effective use of the novel technologies, which at times can be challenging, especially for older or cognitively impaired patients.
PART 3 OF THE SURGICAL HOME: PATIENT-REPORTED OUTCOMES—PRELIMINARY DATA FROM MSHOP The average time from surgical decision making to surgery is more than 30 days in our institution. Even if this duration is as short as 1 week, we offer patients the opportunity to participate. We have enrolled more than 500 patients in MSHOP, and 90% of enrolled patients have been compliant with the program. To the best of our knowledge, we have had no adverse events. Of the patients who enrolled in the program, 85% demonstrated an increase in physical activity over the preoperative period and many of those who did not were already active. Smokers comprised 12% of the cohort to date, of which 79% of these patients were ‘‘smoke free’’ at their postoperative visit as a result of our program. The primary outcomes for this clinical program have been an assessment of the patient-centered experience and financial data. Feedback from families and patients has been resoundingly positive. Patients feel engaged with the perioperative care process and in control of their outcomes. To assess the financial outcomes of the program, we matched participating patients (N ¼ 117) with historical controls based on age, sex, American Society of Anesthesiologists class, and Medicare Allowable Payments using standard propensitymatching techniques. Financial savings for payers and the hospital and the reduction in average length of stay were substantial. Hospital costs were reduced by $2308, insurance payments to the hospital were reduced by $2518, and average length of stay was reduced by 2 days (from 6 to 4 days). For any institution that runs 902 | www.annalsofsurgery.com
near capacity, reducing patient length of stay can improve institutional throughput. As the pendulum swings toward bundle and capitated pay for surgical care, reducing the cost of the surgical event is increasingly important for health systems.
PART 4 OF THE SURGICAL HOME: GOING BEYOND THE PREOPERATIVE PHASES OF CARE To date, MSHOP has only addressed the preoperative phase of care, which at outset we believed to be the easiest phase of care to affect immediate impact. No other stakeholders in postoperative outcomes engage with patients during the preoperative phase of care; thus, implementation has been reasonably simple. Our vision is to create a surgical home that engages patients and their caregivers throughout the entire surgical journey. Similar ideas have been proposed by the American Society of Anesthesiologists, and we quickly realized that our anesthesia colleagues could add to expansion efforts of MSHOP. Current efforts focus on preoperative carbohydrate loading, perioperative management plans for patients on high doses of narcotics, and collaborative efforts to improve the management of postoperative pain. As we try to build a more comprehensive surgical home, MSHOP will increase focus on the postdischarge phase of care, transitions of care, and collaboration with primary care providers.
EXPANSION AND THE FUTURE OF MSHOP Implementation efforts have thus far focused on elective, inpatient, general surgery operations. On the basis of encouraging preliminary data and financial support from our institution, our plan is to expand it to all surgical cases within our hospital. Furthermore, we plan to implement MSHOP in 40 Michigan hospitals participating in the Michigan Surgical Quality Collaborative by 2018. To do this, we ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 262, Number 6, December 2015
Starting a Surgical Home
have received generous support from the Department of Surgery at the University of Michigan, the CMS Health Care Innovation Center, and Blue Cross and Blue Shield of Michigan. Local success stems from commitment within our institution by departmental leadership. The resources we are receiving for broad expansion are a result of compelling financial data, and following financial outcomes of the program has been critical in communicating our success. The most challenging aspect of any broad-based effort to improve care is implementation. Even within a relatively uniform single institution, variation in the flow of patient care and the technologies used to support this flow is daunting. The specifics of implementation must be done locally, and the tools of the program must be flexible to facilitate implementation in a broad range of clinical environments. Bringing novel technologies to the bedside to affect clinical decision making and patient care is a challenging proposition. Clinical medicine, especially surgical care, is fast-paced and efficient. Technology solutions that reduce surgeon productivity are doomed to fail. Moreover, clinical interventions that require hiring numerous full-time equivalents are expensive. Technology should be used to minimize the personnel necessary to operate a surgical home program.
Michigan. Novel technologies at the bedside have improved surgical decision making by clinicians and patients and are key to continued success. We believe all patients should be given the opportunity to train for surgery. Even if this does not have a relevant physiologic effect, it will empower patients and engage them in their perioperative care. The challenge now is dissemination and implementation.
SUMMARY Our surgical home program in Michigan has focused narrowly on surgical decision making and preoperative optimization. We aspire to expand the breadth of the program to affect a patient’s entire surgical journey once we stably implement across the state of
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
REFERENCES 1. Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical are at the end of life: a retrospective cohort study. Lancet. 2011;378:1408– 1413. 2. Valkenet K, van de Port IG, Dronkers JJ, et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil. 2011;25:99–111. 3. Jones LW, Douglas PS, Eves ND, et al. Rationale and design of the Exercise Intensity Trial (EXCITE): a randomized trial comparing the effects of moderate versus moderate to high-intensity aerobic training in women with operable breast cancer. BMC Cancer. 2010;10:531. 4. Jones LW, Eves ND, Kraus WE, et al. The lung cancer exercise training study: a randomized trial of aerobic training, resistance training, or both in postsurgical lung cancer patients: rationale and design. BMC Cancer. 2010;10:155. 5. Jones LW, Peddle CJ, Eves ND, et al. Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer. 2007;110:590–598. 6. Chan DK, Lonsdale C, Ho PY, et al. Patient motivation and adherence to postsurgery rehabilitation exercise recommendations: the influence of physiotherapists’ autonomy-supportive behaviors. Arch Phys Med Rehabil. 2009;90:1977–1982. 7. Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Educ Couns. 2007;66:13–20.
www.annalsofsurgery.com | 903
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Starting a Surgical Home Michael J. Englesbe, MD, Alisha D. Lussiez, BSE, Jeffrey F. Friedman, MSE, June A. Sullivan, MBA, and Stewart C. Wang, MD, PhD A.H. is an 84-year-old gentleman with multiple comorbidities, partially dependent functional status, and multiple previous abdominal surgical procedures who presents with a new diagnosis of colon cancer. The clinician recommends a sigmoid colectomy. The clinician discusses the risks and benefits of surgical resection with the patient and his family, explaining that the patient is at increased risk of surgical complications, but that the risk is not prohibitive. The clinician schedules the patient for surgery in 24 days.
T
he next steps are of the utmost importance. There are pressures from families, referring physicians, and institutions to operate on patients who are referred to surgical services. An aggressive surgical approach to care is good for business. In conjunction with a relatively short surgical consultation, the surgeon may not fully understand the patient’s goals of care. As a result, in the United States, many patients have major surgery in the last month of life.1 This occurs despite the observation that most patients would not choose life-sustaining treatment if they knew that the outcome would be survival with severe cognitive or functional impairment. Patients such as A.H. should receive care within a surgical home, a multidisciplinary care pathway focusing on optimal perioperative care. The focus within this surgical home is patient- and family-centered decision making, wellness, and empowerment. The potential of these programs is remarkable, but implementation is daunting. We have begun the early stages of a surgicalhomeprogramcalled the Michigan Surgical Home and Optimization Program (MSHOP). We havefocusedonthepreoperativephaseofcarethroughthestepsoutlined in Figure 1. We describe our program, detail our outcomes, discuss our strategies for managing challenges of implementation, and detail our plans to start a program across the state of Michigan.
PART 1 OF THE SURGICAL HOME: RISK ASSESSMENT AND PATIENT EMPOWERMENT The first step in this culture change is to bring empiric risk data to the bedside for the surgeon and the patient. Comorbidity, age, and functional status data can be used to detail predicted outcomes for patients, such as the one described earlier, in comparison with other patients undergoing the same procedure. Novel technologies can seamlessly incorporate risk assessment into the fast-paced workflow From the Department of Surgery and Morphomic Analysis Group, University of Michigan Health System, Ann Arbor, MI. Disclosure: Supported by Funding Opportunity No. CMS08122013 from the US Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and a grant from the Blue Cross Blue Shield of Michigan Foundation to M.J.E. and the project described. M.J.E., J.A.S., and S.C.W. are equity stakeholders in Prehab Technologies, LLC, a company formed as part of our CMS grant to deliver the technologies discussed in this article. The other authors declare no conflicts of interest. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. Reprints: Michael J. Englesbe, MD, Department of Surgery, University of Michigan Medical School, 2926A Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109. E-mail: [email protected]. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001250
Annals of Surgery Volume 262, Number 6, December 2015
of surgery. In Michigan, statewide data from the Michigan Surgical Quality Collaborative are helping surgeons improve their decision making at the bedside. Our risk assessment application, available on tablets and smartphones, requires less than 10 seconds for data entry, links to a central database, and displays the data in an intuitive manner for both surgeons and patients during the informed consent process (Fig. 1). The application generates a composite risk score of extended length of stay, complications, and mortality displayed on a scale of 0 to 100 in the design of a car speedometer. This risk score model is informed by more than 300,000 operations recorded within the Michigan Surgical Quality Collaborative database. If necessary, we use the speedometer as an example of ‘‘How fast you are traveling in your car down the highway’’ as we explain perioperative risk. Patients remember this entire story, understand their risk, and can communicate risk to others. The seriousness and anxiety associated with the need for major surgery can have a transformational effect on patient behavior. These emotions must be leveraged positively to enable patients and families to improve outcomes. Empiric risk data are a critical part of this event. In the near future, novel risk assessment approaches, such as using analytic morphomics of preoperative imaging, will improve risk assessment, informed consent, and patient-centered decision making.
PART 2 OF THE SURGICAL HOME: TRAINING FOR SURGERY AND PERIOPERATIVE OPTIMIZATION Much as athletes train for competition, all patients need to train for surgery. Unlike other factors associated with preoperative risk, such as medical comorbidities, overall physiologic status can be improved before major surgery.2 Training periods as short as 2 weeks are effective; therefore, the preoperative period is of ample length to facilitate targeted exercise intervention and physiologic adaptation.3 –5 Patients facing high-risk surgery are especially receptive to behavioral changes that can improve surgical outcomes. Success of preoperative training goes beyond physiologic improvement; it empowers patients to have control and ownership of their outcomes—an invaluable presurgical weapon.6,7 Preoperative training should not focus on single domains of risk. MSHOP patient training targets functional status, smoking, nutrition, and emotional and spiritual wellness. In our program, every patient who can walk into clinic can enroll. Patients receive e-mails, text messages, or phone calls using a voice recognition system that facilitates an interactive pedometer-based daily walking regimen with real-time data feedback. Direct contact is made with patients who are not walking. A similar strategy is used for daily incentive spirometry. A real-time nutrition risk assessment tool facilitates targeted nutrition supplementation. All smokers are educated on the benefits of smoking cessation, even short-term, and receive ample resources to aid cessation. The most important component of the program is education and care planning from the time of surgical decision making to the surgical event. This includes robust engagement from friends and family members in all aspects of perioperative care. For example, in the case of the 84-year-old gentleman detailed earlier, family and friends are assembled to facilitate his participation in all domains of www.annalsofsurgery.com | 901
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 262, Number 6, December 2015
Englesbe et al
FIGURE 1. Preoperative phase of care steps in MSHOP. the program. Such family support can also facilitate effective use of the novel technologies, which at times can be challenging, especially for older or cognitively impaired patients.
PART 3 OF THE SURGICAL HOME: PATIENT-REPORTED OUTCOMES—PRELIMINARY DATA FROM MSHOP The average time from surgical decision making to surgery is more than 30 days in our institution. Even if this duration is as short as 1 week, we offer patients the opportunity to participate. We have enrolled more than 500 patients in MSHOP, and 90% of enrolled patients have been compliant with the program. To the best of our knowledge, we have had no adverse events. Of the patients who enrolled in the program, 85% demonstrated an increase in physical activity over the preoperative period and many of those who did not were already active. Smokers comprised 12% of the cohort to date, of which 79% of these patients were ‘‘smoke free’’ at their postoperative visit as a result of our program. The primary outcomes for this clinical program have been an assessment of the patient-centered experience and financial data. Feedback from families and patients has been resoundingly positive. Patients feel engaged with the perioperative care process and in control of their outcomes. To assess the financial outcomes of the program, we matched participating patients (N ¼ 117) with historical controls based on age, sex, American Society of Anesthesiologists class, and Medicare Allowable Payments using standard propensitymatching techniques. Financial savings for payers and the hospital and the reduction in average length of stay were substantial. Hospital costs were reduced by $2308, insurance payments to the hospital were reduced by $2518, and average length of stay was reduced by 2 days (from 6 to 4 days). For any institution that runs 902 | www.annalsofsurgery.com
near capacity, reducing patient length of stay can improve institutional throughput. As the pendulum swings toward bundle and capitated pay for surgical care, reducing the cost of the surgical event is increasingly important for health systems.
PART 4 OF THE SURGICAL HOME: GOING BEYOND THE PREOPERATIVE PHASES OF CARE To date, MSHOP has only addressed the preoperative phase of care, which at outset we believed to be the easiest phase of care to affect immediate impact. No other stakeholders in postoperative outcomes engage with patients during the preoperative phase of care; thus, implementation has been reasonably simple. Our vision is to create a surgical home that engages patients and their caregivers throughout the entire surgical journey. Similar ideas have been proposed by the American Society of Anesthesiologists, and we quickly realized that our anesthesia colleagues could add to expansion efforts of MSHOP. Current efforts focus on preoperative carbohydrate loading, perioperative management plans for patients on high doses of narcotics, and collaborative efforts to improve the management of postoperative pain. As we try to build a more comprehensive surgical home, MSHOP will increase focus on the postdischarge phase of care, transitions of care, and collaboration with primary care providers.
EXPANSION AND THE FUTURE OF MSHOP Implementation efforts have thus far focused on elective, inpatient, general surgery operations. On the basis of encouraging preliminary data and financial support from our institution, our plan is to expand it to all surgical cases within our hospital. Furthermore, we plan to implement MSHOP in 40 Michigan hospitals participating in the Michigan Surgical Quality Collaborative by 2018. To do this, we ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 262, Number 6, December 2015
Starting a Surgical Home
have received generous support from the Department of Surgery at the University of Michigan, the CMS Health Care Innovation Center, and Blue Cross and Blue Shield of Michigan. Local success stems from commitment within our institution by departmental leadership. The resources we are receiving for broad expansion are a result of compelling financial data, and following financial outcomes of the program has been critical in communicating our success. The most challenging aspect of any broad-based effort to improve care is implementation. Even within a relatively uniform single institution, variation in the flow of patient care and the technologies used to support this flow is daunting. The specifics of implementation must be done locally, and the tools of the program must be flexible to facilitate implementation in a broad range of clinical environments. Bringing novel technologies to the bedside to affect clinical decision making and patient care is a challenging proposition. Clinical medicine, especially surgical care, is fast-paced and efficient. Technology solutions that reduce surgeon productivity are doomed to fail. Moreover, clinical interventions that require hiring numerous full-time equivalents are expensive. Technology should be used to minimize the personnel necessary to operate a surgical home program.
Michigan. Novel technologies at the bedside have improved surgical decision making by clinicians and patients and are key to continued success. We believe all patients should be given the opportunity to train for surgery. Even if this does not have a relevant physiologic effect, it will empower patients and engage them in their perioperative care. The challenge now is dissemination and implementation.
SUMMARY Our surgical home program in Michigan has focused narrowly on surgical decision making and preoperative optimization. We aspire to expand the breadth of the program to affect a patient’s entire surgical journey once we stably implement across the state of
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
REFERENCES 1. Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical are at the end of life: a retrospective cohort study. Lancet. 2011;378:1408– 1413. 2. Valkenet K, van de Port IG, Dronkers JJ, et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil. 2011;25:99–111. 3. Jones LW, Douglas PS, Eves ND, et al. Rationale and design of the Exercise Intensity Trial (EXCITE): a randomized trial comparing the effects of moderate versus moderate to high-intensity aerobic training in women with operable breast cancer. BMC Cancer. 2010;10:531. 4. Jones LW, Eves ND, Kraus WE, et al. The lung cancer exercise training study: a randomized trial of aerobic training, resistance training, or both in postsurgical lung cancer patients: rationale and design. BMC Cancer. 2010;10:155. 5. Jones LW, Peddle CJ, Eves ND, et al. Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer. 2007;110:590–598. 6. Chan DK, Lonsdale C, Ho PY, et al. Patient motivation and adherence to postsurgery rehabilitation exercise recommendations: the influence of physiotherapists’ autonomy-supportive behaviors. Arch Phys Med Rehabil. 2009;90:1977–1982. 7. Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Educ Couns. 2007;66:13–20.
www.annalsofsurgery.com | 903
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
