E The Open Mind
Residency Board Certification Requirements and Preoperative Surgical Home Activities in the United States: Comparing Anesthesiology, Family Medicine, Internal Medicine, and Surgery Kayla M. Cline, MS,* Rahil Roopani, BA,† Bita A. Kash, PhD, MBA,* and Thomas R. Vetter, MD, MPH‡ THE STATE OF THE PERIOPERATIVE SURGICAL HOME IN THE UNITED STATES
Surgical care is not often standardized or coordinated, resulting in duplicated or unnecessary care that costs an estimated $18 billion annually in the United States.1 The Perioperative Surgical Home (PSH) is a new model to address the well-documented high cost, low quality, and suboptimal outcomes of surgical care.2,3 While other models of perioperative care, such as Enhanced Recovery After Surgery, have been used in other countries, the PSH is gaining traction in the United States. The impact of the PSH on clinical outcomes and cost of care has recently been evaluated.4 PSH programs are being developed largely independently across the United States and thus vary in their focus on preoperative, intraoperative, and/or postoperative care initiatives.5 However, generally, these PSH programs involve an anesthesiologist-intensivist as primarily overseeing care across the perioperative continuum, including postdischarge planning.6–10 Other specialists, including surgeons, internal medicine hospitalists, and primary care physicians, have also From the *Health Policy and Management, School of Public Health, Texas A&M University Health Science Center, College Station, Texas; †University of Texas Medical School at Houston, Houston, Texas; and ‡Department of Anesthesiology, University of Alabama at Birmingham Medical Center, Birmingham, Alabama. Accepted for publication February 23, 2015. Funding: The preparation of this article is based upon work supported by the National Science Foundation (NSF) under Grant No. IIP-0832439. Further, this project was cofunded by NSF Center for Health Organization Transformation industry members, including the American Society of Anesthesiologists. Conflict of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). This report was previously presented, in part, at the Spring 2014 Center for Health Transformation Semiannual Meeting, held on April 24–25, 2014, in Austin, TX. Reprints will not be available from the authors. Address correspondence to Thomas Vetter, MD, MPH, Department of Anesthesiology, University of Alabama at Birmingham School of Medicine, 619 19th St. South, Jefferson Tower 862, Birmingham, AL 35249. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000772
1420 www.anesthesia-analgesia.org
recognized the need for improved surgical care coordination and embraced this role and its responsibilities.11–13 Surgeons are clearly involved in the pre-/intra-/postoperative phases of surgery, and their clinical efficiency and productivity are adversely affected by delays, cancellations, and complications when patients are not adequately prepared for surgery.14–16 Internal medicine hospitalists can care for patients pre- and postoperatively.17–19 Anesthesiologists have expanded their scope of practice to include preoperative management and more extensive postoperative care.17 Thus, any of these specialties could take the lead in providing perioperative care. However, the 2014 Institute of Medicine report on graduate medical education in the United States noted that there is “a gap between new physicians’ knowledge and skills and the competencies required for current medical practice.”20 Activities central to the PSH may be one of these gaps in medical education. The emerging demand to meet this need is unchartered ground for many, if not all, of the specialties. The primary purpose of this study was to identify gaps in education present across 4 specialties to guide future curriculum development to meet the demands of PSH program activities.
RESEARCH APPROACH
This study was reviewed and approved by the Texas A&M University IRB, and written informed consent was obtained from all interview subjects. The first stage in the gap analysis identified PSH program activities because there is currently no widely accepted definition of a PSH. To create a comprehensive list of activities, we performed a literature review to identify salient pre/intra/postoperative care elements. These salient PSH elements from the literature were then validated by interviews within 15 PSH programs in the United States. In the second stage of the gap analysis, these PSH elements were mapped to residency training requirements in anesthesiology, internal medicine, surgery, and family medicine to ascertain which elements are covered on the 4 selected specialty board certification examinations.
Initial Literature Review
A literature review was conducted in the summer of 2013 and updated in December 2013 and May 2014. Researchers June 2015 • Volume 120 • Number 6
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Residency Training Requirements in Perioperative Care
Records identified through database searching (n = 227)
Additional records identified through other sources (n = 34)
Records after duplicates removed (n = 261)
Full-text articles assessed for eligibility (n = 261)
Full-text articles excluded, with reasons (n = 152)
Figure 1. Diagram of literature review approach. Adapted from: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Med 6(6): e1000097.
Studies included in listing of activities (n = 152)
Table 1. Interview Sites Interview site Allentown Anesthesia Services Matrix Anesthesia University of Alabama at Birmingham Medical Center Anesthesia of Boise Boston Children’s Hospital Brigham & Women’s Hospital Dartmouth Hitchcock Aurora Medical Group Vanderbilt University Medical Center Anesthesia Services, P.A. Kaiser Permanente University of California Irvine Medical Center Oregon Health & Science University Medical Group Mayo Clinic Physicians Anesthesia Service
Location Allentown, PA Bellevue, WA Birmingham, AL Boise, ID Boston, MA Boston, MA Lebanon, NH Milwaukee, WI Nashville, TN Newcastle, DE Oakland, CA Orange, CA Portland, OR Rochester, MN Seattle, WA
Number of anesthesiologists interviewed 1 1 2 2 1 1 2 2 1 1 1 1 2 2 1
Number of administrators interviewed 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0
searched PubMed and Google Scholar using keywords related to the PSH concept: patient engagement, preoperative testing, intraoperative efficiency and quality improvement, postoperative pain management and early mobilization, postoperative complications, care coordination, transition planning, and Enhanced Recovery After Surgery. These searches yielded 118 articles published after 1975. Exclusion criteria were lenient to cast the broadest net possible for PSH-relevant activities and concepts. The American Society of Anesthesiologists (ASA) recommended 34 additional relevant peer-reviewed articles, resulting in 152 articles (Fig. 1).
by members of the ASA Committee on Future Models of Anesthesia Practice and to obtain broad geographic representation. The final 15 PSH programs ranged in size from 21 to 120 physicians and were located in 12 states across the United States (Table 1). A total of 24 anesthesiologists and administrators were interviewed by telephone at the 15 sites. Interviews lasted between 60 and 90 minutes and were primarily conducted by the first author, with supervision by a senior author for the first 3 interviews. Interviews were audio-recorded and transcribed by a professional transcription service. Transcripts were reviewed for accuracy by the first author.
Selection of Interview Sites
Interview Approach and Analysis
Selection of PSH programs to be interviewed by the research team was based upon a prior ASA survey of anesthesiologists that assessed interest of anesthesia practices in participating in an ASA PSH-leaning collaborative project. This yielded 55 potential interview sites, of which 35 met the required inclusion criteria of agreeing to participate and affiliation with 1 hospital. Our project funding required only 15 site interviews, which were selected based on a vote
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The interview instrument was driven by questions suggested by ASA leadership and a comprehensive review of the perioperative care and organizational change literature. These sources yielded 54 questions subcategorized into 9 themes: practice demographics, PSH program profile, PSH patient and payer profile, PSH relationship to the health care organization, quality reporting systems (practice-level), quality reporting systems (hospital-level), barriers and
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E THE OPEN MIND Table 2. Elements of Preoperative Care Percent of 15 interviewed PSH programs reporting activitya
American Board of Family Medicine requirements
American Board of Internal Medicine requirements
American Board of Anesthesiology requirements
American Board of Surgery requirements
100% 93% 73% 53%
Xb X X X
X
X
X X
X
X X
Key perioperative care activity Preoperative phase Early patient engagement Coordinated preoperative testing Lifestyle counseling Anemia management Triaging to identify high-risk patients Preoperative protocols (e.g., ERAS) Intraoperative phase OR scheduling initiatives Reduced delay initiatives Quality improvement initiatives Facilities optimization Patient throughput initiatives Surgical error reduction Blood utilization Integrated pain management Intraoperative protocols (e.g., ERAS) Precise fluid management Use of Lean or Six Sigma methodologies Postoperative phase Postoperative pain management Reducing length of stay Nausea and vomiting protocols Coordinated discharge planning Discharge phone calls Early mobility therapy and rehabilitation Postoperative protocols (e.g., ERAS) Postdischarge patient education
100% 100% 100% 93% 93% 87% 87%
100% 87% 80% 60% 60% 40%
X
X
X
X
X
X
X
PSH = perioperative surgical home; ERAS = enhanced recovery after surgery. a If no percentage given, this element was identified from a review of the literature rather than key informant interviews. b X: A mark is placed in the table whenever a match between the PSH criteria (a key element or activity of the PSH care model) and the content for the respective residency program examination content was noted.
enablers of PSH success, PSH program performance, and future of PSH programs. The interview script is available as an online supplemental content (Supplemental Digital Content 1, http://links.lww.com/AA/B128). Interview data were used to verify the PSH activities generated by the literature review. Interviewees were asked whether their program participated in each PSH activity identified in the literature review and were asked whether their PSH program performed any additional pre/intra/postoperative activities (Table 2).
Mapping Approach
A 2-phase mapping effort followed this verification of perioperative care activities identified in the literature review (Fig. 2). During the summer of 2014, the second author studied the curricular content of the board certification examinations of 4 specialty boards (Supplemental Digital Content 2, http:// links.lww.com/AA/B129; Supplemental Digital Content 3, http://links.lww.com/AA/B130; Supplemental Digital Content 4, http://links.lww.com/AA/B131; Supplemental Digital Content 5, http://links.lww.com/AA/B132): American Board of Anesthesiology (ABA) (updated 2011), American Board of Family Medicine (ABFM) (updated 2010), American Board of Internal Medicine (ABIM) (updated 2014), and American Board of Surgery (ABS) (updated 2013). The salient PSH activities were mapped to board certification
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Figure 2. Stage 2 gap analysis approach: 2 phases of mapping of key Perioperative Surgical Home activities to residency board certification requirements.
requirements of these 4 specialties that could potentially contribute to a PSH-type program, using keywords such as “preoperative testing” or “anemia management,” to evaluate specialties via their board examinations about knowledge of that activity. This mapping process was then edited and refined by a PhD candidate. The second phase of the mapping exercise involved review by the third and fourth author,
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Residency Training Requirements in Perioperative Care
an experienced health services researcher and a senior anesthesiologist, to further confirm the mapping logic. These findings were finally further confirmed by interviews with 2 anesthesiology residency program directors in the United States, who are developing perioperative medicine residency curricula.
RESULTS
In evaluating which medical specialties are currently best prepared to manage the various aspects of a PSH, we studied the curricula content for the board certification examinations of the ABA, ABFM, ABIM, and ABS. Table 2 presents the findings. Across all phases of surgical care, the tallies of “matches” for the PSH and specialty board certification requirements were: ABA, 7 matches; ABS, 5 matches; ABIM, 3 matches; and ABFM, 2 matches. The first keyword mapped was “Coordinated Preoperative Testing.” Residents in each of the 4 specialties were assessed on their ability to evaluate a surgical patient. This preoperative testing includes electrocardiogram or echocardiography, chest radiogram or pulmonary function testing, coagulation testing, etc. Additionally, the ABA, ABIM, and ABS examination contents contain the topic of “Triaging to Identify High Risk Patients” and the ability to recognize patients at increased risk of major morbidity and mortality intraoperatively and postoperatively. “Lifestyle Counseling,” related to “Prehabilitation” in the PSH model, was only present in the ABFM and ABIM curricula. Family medicine and internal medicine residents are tested on their ability to undertake a focused discussion about patients’ activities of daily living and social routines. These discussions address modifiable behaviors (e.g., diet, alcohol intake, hours spent exercising) to recommend changes that will benefit the patient. “Anemia Management” was found in all 4 residency curricula, indicating the importance of the subject. Residents in all 4 specialties are examined on the pathophysiology of anemia so that they can presumably correct it preoperatively. However, an intraoperative extension of this topic, “Blood Utilization,” was only present in the ABA curriculum. This topic includes, but is not only limited to, the proper transfusion of blood products in an acutely anemic and thus hypovolemic patient. In the curricula of the 4 specialties, only the ABA and ABS examination contents contain topics beyond the preoperative phase of perioperative care coordination. The aforementioned topic of “Blood Utilization” is only present in the examination content of the ABA. However, “Fluid Management” is covered in the curricula of the ABA and ABS. Residents of these specialties are tested on their ability to accurately monitor fluid input/output and to recognize the intraoperative need for fluids in order to maintain cardiac output and thus adequate vital organ perfusion. “Postoperative Pain Management” is another topic of perioperative care that is addressed in the curricula of the ABA and ABS. Physicians of both these specialties must understand the extent of the procedure and continue proper care to alleviate pain from the surgery. Furthermore, only the ABA examination curriculum covers postoperative “Nausea and Vomiting Protocols.”
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Lastly, only the ABA examination content contains the topic of “Postdischarge Patient Education” such that its residents are tested on educating patients regarding the basics of postoperative rehabilitation and the expected timeline to recovery as well as what to do for pain control. Notably, however, there are several gaps in postoperative care across all 4 specialties, particularly related to early rehabilitation therapies and postdischarge planning. This gap is supported by only 60% of the interviewed PSH program directors indicating any involvement in postdischarge planning or telephone calls and only 40% involvement in postoperative rehabilitation.
IMPLICATIONS FOR RESIDENCY PROGRAM TRAINING IN THE UNITED STATES
The results of this exploratory study indicate that residents in all 4 specialties are generally prepared to undertake the preoperative activities involved in a PSH. At least 1 of the 4 specialties, and for many care elements, more than 1 specialty, expects residents to master the coordination of preoperative testing, lifestyle counseling, anemia management, and triaging of high risk patients. However, early patient engagement and development of preoperative protocols are not included in any specialty training, which suggests that such knowledge is expected to be learned on the job. Interestingly, 100% of the 15 PSH program directors interviewed stressed the importance of early patient engagement, which includes the discussion about preparation for surgery, risks and benefits of the operation, other treatment alternatives, and expectations for recovery. The intraoperative phase is clearly the most sparsely populated section of Table 2; only 2 of the 11 activities (blood utilization and fluid management) appeared in any of the 4 residency training requirements. This may be because many of the key intraoperative PSH activities are less clinical and more organizational in nature: at least 6 of the 11 activities are more administrative than clinical (operating room scheduling, reduced delays, quality improvement, facilities optimization, patient throughput, and use of Lean or Six Sigma methodologies). Thus, it is not surprising that these activities are not currently included in residency training and board certification requirements. The postoperative section of Table 2 was slightly less sparse, with at least 1 specialty requiring education in 3 of the 8 activities (pain management, nausea and vomiting prevention and treatment, and postdischarge patient education). Several gaps are again largely administrative or organizational, (e.g., reducing length of stay and development of postdischarge protocols). However, other postoperative gaps are more clinical (e.g., early rehabilitation and therapy and postdischarge planning). These elements are also lacking in perioperative practice, so it is possible that a lack of emphasis in residency training is related to the lack of emphasis in practice. Consequently, it is possible that an increased emphasis during residency on postdischarge planning could increase its emphasis in practice. Based on specialty board certification requirements, anesthesiology has the most matches, followed by surgery and then by internal medicine hospitalists. However, anesthesiology curricula matched on only 7 of the 25 activities involved in the PSH. Thus, all specialties have room to improve training to include key PSH activities.21–23
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E THE OPEN MIND STUDY LIMITATIONS
The list of key PSH elements was confirmed by interviews with anesthesiologists identified via an informal survey process by the ASA. Internal medicine hospitalists, family practitioners, and surgeons were not consulted in this confirmation process. This may have contributed to the high number of matches between anesthesiology board certification requirements and PSH elements and may have limited the generalizability of these results beyond this sample. In addition, requirements for board certification in a given specialty may not be a comprehensive depiction of that specialty’s skill set; there may be unmeasured factors that contribute to a specialty’s ability to manage the perioperative process. Thus, our approach is inherently simplistic and potentially biased in favor of anesthesiology. In addition, all anesthesiologists surveyed practiced in the United States and only American residency board certification requirements were studied, limiting generalizability of these results to an international setting. However, these study limitations provide future research opportunities. It is important to understand the perspective of the other specialties studied here. Future studies could perform a similar interview exercise to identify perioperative care elements perceived as important to all 4 specialties. In addition, a more sophisticated approach and/or an international sample could better identify gaps in perioperative education and facilitate the development of specific solutions.
CONCLUSIONS
Better management of the perioperative process has come unto the spotlight in recent years as a way to possibly reduce costs while improving the quality of care.11 However, perioperative care is not a subject traditionally comprehensively covered in any 1 medical specialty. Various elements of perioperative care are included in each of the 4 residencies studied (anesthesiology, family medicine, internal medicine, and surgery), but many of the activities inherent to the PSH are not required for board certification in any of the specialties, particularly in the intraoperative and postoperative phases. All 4 specialties appear to have room for improvement by expanding perioperative care education. E DISCLOSURES
Name: Kayla M. Cline, MS. Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript. Attestation: Kayla M. Cline has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files. Conflicts of Interest: Kayla M. Cline received research funding from American Society of Anesthesiologists. Name: Rahil Roopani, BA. Contribution: This author helped analyze the data and write the manuscript. Attestation: Rahil Roopani has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare.
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Name: Bita A. Kash, PhD, MBA. Contribution: This author helped design the study, conduct the study, and write the manuscript. Attestation: Bita A. Kash has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Conflicts of Interest: Bita A. Kash received research funding from American Society of Anesthesiologists as is a member of the NSF Center for Health Organization Transformation (CHOT) at Texas A&M University. Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write the manuscript. Attestation: Thomas R. Vetter reviewed the analysis of the data and approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. This manuscript was handled by: Franklin Dexter, MD, PhD. REFERENCES 1. Pasternak LR. Preoperative testing: moving from individual testing to risk management. Anesth Analg 2009;108:393–4 2. Cannesson M, Kain Z. Enhanced recovery after surgery versus perioperative surgical home: is it all in the name? Anesth Analg 2014;118:901–2 3. Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The perioperative surgical home as a future perioperative practice model. Anesth Analg 2014;118:1126–30 4. Kash BA, Zhang Y, Cline KM, Menser T, Miller TR. The perioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes. Milbank Q 2014;92:796–821 5. Lee A, Kerridge RK, Chui PT, Chiu CH, Gin T. Perioperative Systems as a quality model of perioperative medicine and surgical care. Health Policy 2011;102:214–22 6. Dexter F, Wachtel RE. Strategies for net cost reductions with the expanded role and expertise of anesthesiologists in the perioperative surgical home. Anesth Analg 2014;118:1062–71 7. Garson L, Schwarzkopf R, Vakharia S, Alexander B, Stead S, Cannesson M, Kain Z. Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg 2014;118:1081–9 8. Graham JB, Thomas R, Strohecker KA, Irgit K, Smith WR. Reducing mortality in hip fracture patients using a perioperative approach and “patient-centered medical home” model: a prospective cohort study. Patient Saf Surg 2014;8:7 9. Hooper VD. Who staffs the perioperative surgical home? Anesth Analg 2013;116:754–5 10. Vetter TR, Boudreaux AM, Jones KA, Hunter JM Jr, Pittet JF. The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg 2014;118:1131–6 11. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The perioperative surgical home: how can it make the case so everyone wins? BMC Anesthesiol 2014;13:6 12. Batsis JA, Phy MP, Melton LJ 3rd, Schleck CD, Larson DR, Huddleston PM, Huddleston JM. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med 2007;2:219–25 13. Kash BA, Cline KM, Timmons S, Roopani R, Miller TR. International comparison of preoperative testing and assessment protocols and best practices to reduce surgical care costs: a systematic literature review. In: Buttigieg SC, Rathert C, Von Eiff W, eds. Advances in Health Care Management, Volume 17. Emerald Group Publishing Limited, 2015:161–94 14. Masursky D, Dexter F, Isaacson SA, Nussmeier NA. Surgeons’ and anesthesiologists’ perceptions of turnover times. Anesth Analg 2011;112:440–4 15. Wright JG, Roche A, Khoury AE. Improving on-time surgical starts in an operating room. Can J Surg 2010;53:167–70
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Residency Training Requirements in Perioperative Care
16. Wachtel RE, Dexter F. Influence of the operating room schedule on tardiness from scheduled start times. Anesth Analg 2009;108:1189–901 17. Adesanya AO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: Are their roles complementary? Proc (Bayl Univ Med Cent) 2007;20:140–2 18. Whinney C, Michota F. Surgical comanagement: a natural evolution of hospitalist practice. J Hosp Med 2008;3:394–7 19. White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Med 2011;9:58
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20. Eden J, Berwick D, Wilensky G. Graduate Medical Education That Meets the Nation’s Health Needs. Report of the Institute of Medicine. Washington, DC: The National Academies Press, 2014 21. Butterworth JF 4th, Green JA. The anesthesiologist-directed perioperative surgical home: a great idea that will succeed only if it is embraced by hospital administrators and surgeons. Anesth Analg 2014;118:896–7 22. Grocott MP, Pearse RM. Perioperative medicine: the future of anaesthesia? Br J Anaesth 2012;108:723–6 23. Huang J, Schweitzer M. The perioperative surgical home: what anesthesiologists need to do. J Med Pract Manage 2014;29:235–7
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Residency Board Certification Requirements and Preoperative Surgical Home Activities in the United States: Comparing Anesthesiology, Family Medicine, Internal Medicine, and Surgery Kayla M. Cline, MS,* Rahil Roopani, BA,† Bita A. Kash, PhD, MBA,* and Thomas R. Vetter, MD, MPH‡ THE STATE OF THE PERIOPERATIVE SURGICAL HOME IN THE UNITED STATES
Surgical care is not often standardized or coordinated, resulting in duplicated or unnecessary care that costs an estimated $18 billion annually in the United States.1 The Perioperative Surgical Home (PSH) is a new model to address the well-documented high cost, low quality, and suboptimal outcomes of surgical care.2,3 While other models of perioperative care, such as Enhanced Recovery After Surgery, have been used in other countries, the PSH is gaining traction in the United States. The impact of the PSH on clinical outcomes and cost of care has recently been evaluated.4 PSH programs are being developed largely independently across the United States and thus vary in their focus on preoperative, intraoperative, and/or postoperative care initiatives.5 However, generally, these PSH programs involve an anesthesiologist-intensivist as primarily overseeing care across the perioperative continuum, including postdischarge planning.6–10 Other specialists, including surgeons, internal medicine hospitalists, and primary care physicians, have also From the *Health Policy and Management, School of Public Health, Texas A&M University Health Science Center, College Station, Texas; †University of Texas Medical School at Houston, Houston, Texas; and ‡Department of Anesthesiology, University of Alabama at Birmingham Medical Center, Birmingham, Alabama. Accepted for publication February 23, 2015. Funding: The preparation of this article is based upon work supported by the National Science Foundation (NSF) under Grant No. IIP-0832439. Further, this project was cofunded by NSF Center for Health Organization Transformation industry members, including the American Society of Anesthesiologists. Conflict of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). This report was previously presented, in part, at the Spring 2014 Center for Health Transformation Semiannual Meeting, held on April 24–25, 2014, in Austin, TX. Reprints will not be available from the authors. Address correspondence to Thomas Vetter, MD, MPH, Department of Anesthesiology, University of Alabama at Birmingham School of Medicine, 619 19th St. South, Jefferson Tower 862, Birmingham, AL 35249. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000772
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recognized the need for improved surgical care coordination and embraced this role and its responsibilities.11–13 Surgeons are clearly involved in the pre-/intra-/postoperative phases of surgery, and their clinical efficiency and productivity are adversely affected by delays, cancellations, and complications when patients are not adequately prepared for surgery.14–16 Internal medicine hospitalists can care for patients pre- and postoperatively.17–19 Anesthesiologists have expanded their scope of practice to include preoperative management and more extensive postoperative care.17 Thus, any of these specialties could take the lead in providing perioperative care. However, the 2014 Institute of Medicine report on graduate medical education in the United States noted that there is “a gap between new physicians’ knowledge and skills and the competencies required for current medical practice.”20 Activities central to the PSH may be one of these gaps in medical education. The emerging demand to meet this need is unchartered ground for many, if not all, of the specialties. The primary purpose of this study was to identify gaps in education present across 4 specialties to guide future curriculum development to meet the demands of PSH program activities.
RESEARCH APPROACH
This study was reviewed and approved by the Texas A&M University IRB, and written informed consent was obtained from all interview subjects. The first stage in the gap analysis identified PSH program activities because there is currently no widely accepted definition of a PSH. To create a comprehensive list of activities, we performed a literature review to identify salient pre/intra/postoperative care elements. These salient PSH elements from the literature were then validated by interviews within 15 PSH programs in the United States. In the second stage of the gap analysis, these PSH elements were mapped to residency training requirements in anesthesiology, internal medicine, surgery, and family medicine to ascertain which elements are covered on the 4 selected specialty board certification examinations.
Initial Literature Review
A literature review was conducted in the summer of 2013 and updated in December 2013 and May 2014. Researchers June 2015 • Volume 120 • Number 6
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Residency Training Requirements in Perioperative Care
Records identified through database searching (n = 227)
Additional records identified through other sources (n = 34)
Records after duplicates removed (n = 261)
Full-text articles assessed for eligibility (n = 261)
Full-text articles excluded, with reasons (n = 152)
Figure 1. Diagram of literature review approach. Adapted from: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Med 6(6): e1000097.
Studies included in listing of activities (n = 152)
Table 1. Interview Sites Interview site Allentown Anesthesia Services Matrix Anesthesia University of Alabama at Birmingham Medical Center Anesthesia of Boise Boston Children’s Hospital Brigham & Women’s Hospital Dartmouth Hitchcock Aurora Medical Group Vanderbilt University Medical Center Anesthesia Services, P.A. Kaiser Permanente University of California Irvine Medical Center Oregon Health & Science University Medical Group Mayo Clinic Physicians Anesthesia Service
Location Allentown, PA Bellevue, WA Birmingham, AL Boise, ID Boston, MA Boston, MA Lebanon, NH Milwaukee, WI Nashville, TN Newcastle, DE Oakland, CA Orange, CA Portland, OR Rochester, MN Seattle, WA
Number of anesthesiologists interviewed 1 1 2 2 1 1 2 2 1 1 1 1 2 2 1
Number of administrators interviewed 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0
searched PubMed and Google Scholar using keywords related to the PSH concept: patient engagement, preoperative testing, intraoperative efficiency and quality improvement, postoperative pain management and early mobilization, postoperative complications, care coordination, transition planning, and Enhanced Recovery After Surgery. These searches yielded 118 articles published after 1975. Exclusion criteria were lenient to cast the broadest net possible for PSH-relevant activities and concepts. The American Society of Anesthesiologists (ASA) recommended 34 additional relevant peer-reviewed articles, resulting in 152 articles (Fig. 1).
by members of the ASA Committee on Future Models of Anesthesia Practice and to obtain broad geographic representation. The final 15 PSH programs ranged in size from 21 to 120 physicians and were located in 12 states across the United States (Table 1). A total of 24 anesthesiologists and administrators were interviewed by telephone at the 15 sites. Interviews lasted between 60 and 90 minutes and were primarily conducted by the first author, with supervision by a senior author for the first 3 interviews. Interviews were audio-recorded and transcribed by a professional transcription service. Transcripts were reviewed for accuracy by the first author.
Selection of Interview Sites
Interview Approach and Analysis
Selection of PSH programs to be interviewed by the research team was based upon a prior ASA survey of anesthesiologists that assessed interest of anesthesia practices in participating in an ASA PSH-leaning collaborative project. This yielded 55 potential interview sites, of which 35 met the required inclusion criteria of agreeing to participate and affiliation with 1 hospital. Our project funding required only 15 site interviews, which were selected based on a vote
June 2015 • Volume 120 • Number 6
The interview instrument was driven by questions suggested by ASA leadership and a comprehensive review of the perioperative care and organizational change literature. These sources yielded 54 questions subcategorized into 9 themes: practice demographics, PSH program profile, PSH patient and payer profile, PSH relationship to the health care organization, quality reporting systems (practice-level), quality reporting systems (hospital-level), barriers and
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Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
E THE OPEN MIND Table 2. Elements of Preoperative Care Percent of 15 interviewed PSH programs reporting activitya
American Board of Family Medicine requirements
American Board of Internal Medicine requirements
American Board of Anesthesiology requirements
American Board of Surgery requirements
100% 93% 73% 53%
Xb X X X
X
X
X X
X
X X
Key perioperative care activity Preoperative phase Early patient engagement Coordinated preoperative testing Lifestyle counseling Anemia management Triaging to identify high-risk patients Preoperative protocols (e.g., ERAS) Intraoperative phase OR scheduling initiatives Reduced delay initiatives Quality improvement initiatives Facilities optimization Patient throughput initiatives Surgical error reduction Blood utilization Integrated pain management Intraoperative protocols (e.g., ERAS) Precise fluid management Use of Lean or Six Sigma methodologies Postoperative phase Postoperative pain management Reducing length of stay Nausea and vomiting protocols Coordinated discharge planning Discharge phone calls Early mobility therapy and rehabilitation Postoperative protocols (e.g., ERAS) Postdischarge patient education
100% 100% 100% 93% 93% 87% 87%
100% 87% 80% 60% 60% 40%
X
X
X
X
X
X
X
PSH = perioperative surgical home; ERAS = enhanced recovery after surgery. a If no percentage given, this element was identified from a review of the literature rather than key informant interviews. b X: A mark is placed in the table whenever a match between the PSH criteria (a key element or activity of the PSH care model) and the content for the respective residency program examination content was noted.
enablers of PSH success, PSH program performance, and future of PSH programs. The interview script is available as an online supplemental content (Supplemental Digital Content 1, http://links.lww.com/AA/B128). Interview data were used to verify the PSH activities generated by the literature review. Interviewees were asked whether their program participated in each PSH activity identified in the literature review and were asked whether their PSH program performed any additional pre/intra/postoperative activities (Table 2).
Mapping Approach
A 2-phase mapping effort followed this verification of perioperative care activities identified in the literature review (Fig. 2). During the summer of 2014, the second author studied the curricular content of the board certification examinations of 4 specialty boards (Supplemental Digital Content 2, http:// links.lww.com/AA/B129; Supplemental Digital Content 3, http://links.lww.com/AA/B130; Supplemental Digital Content 4, http://links.lww.com/AA/B131; Supplemental Digital Content 5, http://links.lww.com/AA/B132): American Board of Anesthesiology (ABA) (updated 2011), American Board of Family Medicine (ABFM) (updated 2010), American Board of Internal Medicine (ABIM) (updated 2014), and American Board of Surgery (ABS) (updated 2013). The salient PSH activities were mapped to board certification
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Figure 2. Stage 2 gap analysis approach: 2 phases of mapping of key Perioperative Surgical Home activities to residency board certification requirements.
requirements of these 4 specialties that could potentially contribute to a PSH-type program, using keywords such as “preoperative testing” or “anemia management,” to evaluate specialties via their board examinations about knowledge of that activity. This mapping process was then edited and refined by a PhD candidate. The second phase of the mapping exercise involved review by the third and fourth author,
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Residency Training Requirements in Perioperative Care
an experienced health services researcher and a senior anesthesiologist, to further confirm the mapping logic. These findings were finally further confirmed by interviews with 2 anesthesiology residency program directors in the United States, who are developing perioperative medicine residency curricula.
RESULTS
In evaluating which medical specialties are currently best prepared to manage the various aspects of a PSH, we studied the curricula content for the board certification examinations of the ABA, ABFM, ABIM, and ABS. Table 2 presents the findings. Across all phases of surgical care, the tallies of “matches” for the PSH and specialty board certification requirements were: ABA, 7 matches; ABS, 5 matches; ABIM, 3 matches; and ABFM, 2 matches. The first keyword mapped was “Coordinated Preoperative Testing.” Residents in each of the 4 specialties were assessed on their ability to evaluate a surgical patient. This preoperative testing includes electrocardiogram or echocardiography, chest radiogram or pulmonary function testing, coagulation testing, etc. Additionally, the ABA, ABIM, and ABS examination contents contain the topic of “Triaging to Identify High Risk Patients” and the ability to recognize patients at increased risk of major morbidity and mortality intraoperatively and postoperatively. “Lifestyle Counseling,” related to “Prehabilitation” in the PSH model, was only present in the ABFM and ABIM curricula. Family medicine and internal medicine residents are tested on their ability to undertake a focused discussion about patients’ activities of daily living and social routines. These discussions address modifiable behaviors (e.g., diet, alcohol intake, hours spent exercising) to recommend changes that will benefit the patient. “Anemia Management” was found in all 4 residency curricula, indicating the importance of the subject. Residents in all 4 specialties are examined on the pathophysiology of anemia so that they can presumably correct it preoperatively. However, an intraoperative extension of this topic, “Blood Utilization,” was only present in the ABA curriculum. This topic includes, but is not only limited to, the proper transfusion of blood products in an acutely anemic and thus hypovolemic patient. In the curricula of the 4 specialties, only the ABA and ABS examination contents contain topics beyond the preoperative phase of perioperative care coordination. The aforementioned topic of “Blood Utilization” is only present in the examination content of the ABA. However, “Fluid Management” is covered in the curricula of the ABA and ABS. Residents of these specialties are tested on their ability to accurately monitor fluid input/output and to recognize the intraoperative need for fluids in order to maintain cardiac output and thus adequate vital organ perfusion. “Postoperative Pain Management” is another topic of perioperative care that is addressed in the curricula of the ABA and ABS. Physicians of both these specialties must understand the extent of the procedure and continue proper care to alleviate pain from the surgery. Furthermore, only the ABA examination curriculum covers postoperative “Nausea and Vomiting Protocols.”
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Lastly, only the ABA examination content contains the topic of “Postdischarge Patient Education” such that its residents are tested on educating patients regarding the basics of postoperative rehabilitation and the expected timeline to recovery as well as what to do for pain control. Notably, however, there are several gaps in postoperative care across all 4 specialties, particularly related to early rehabilitation therapies and postdischarge planning. This gap is supported by only 60% of the interviewed PSH program directors indicating any involvement in postdischarge planning or telephone calls and only 40% involvement in postoperative rehabilitation.
IMPLICATIONS FOR RESIDENCY PROGRAM TRAINING IN THE UNITED STATES
The results of this exploratory study indicate that residents in all 4 specialties are generally prepared to undertake the preoperative activities involved in a PSH. At least 1 of the 4 specialties, and for many care elements, more than 1 specialty, expects residents to master the coordination of preoperative testing, lifestyle counseling, anemia management, and triaging of high risk patients. However, early patient engagement and development of preoperative protocols are not included in any specialty training, which suggests that such knowledge is expected to be learned on the job. Interestingly, 100% of the 15 PSH program directors interviewed stressed the importance of early patient engagement, which includes the discussion about preparation for surgery, risks and benefits of the operation, other treatment alternatives, and expectations for recovery. The intraoperative phase is clearly the most sparsely populated section of Table 2; only 2 of the 11 activities (blood utilization and fluid management) appeared in any of the 4 residency training requirements. This may be because many of the key intraoperative PSH activities are less clinical and more organizational in nature: at least 6 of the 11 activities are more administrative than clinical (operating room scheduling, reduced delays, quality improvement, facilities optimization, patient throughput, and use of Lean or Six Sigma methodologies). Thus, it is not surprising that these activities are not currently included in residency training and board certification requirements. The postoperative section of Table 2 was slightly less sparse, with at least 1 specialty requiring education in 3 of the 8 activities (pain management, nausea and vomiting prevention and treatment, and postdischarge patient education). Several gaps are again largely administrative or organizational, (e.g., reducing length of stay and development of postdischarge protocols). However, other postoperative gaps are more clinical (e.g., early rehabilitation and therapy and postdischarge planning). These elements are also lacking in perioperative practice, so it is possible that a lack of emphasis in residency training is related to the lack of emphasis in practice. Consequently, it is possible that an increased emphasis during residency on postdischarge planning could increase its emphasis in practice. Based on specialty board certification requirements, anesthesiology has the most matches, followed by surgery and then by internal medicine hospitalists. However, anesthesiology curricula matched on only 7 of the 25 activities involved in the PSH. Thus, all specialties have room to improve training to include key PSH activities.21–23
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E THE OPEN MIND STUDY LIMITATIONS
The list of key PSH elements was confirmed by interviews with anesthesiologists identified via an informal survey process by the ASA. Internal medicine hospitalists, family practitioners, and surgeons were not consulted in this confirmation process. This may have contributed to the high number of matches between anesthesiology board certification requirements and PSH elements and may have limited the generalizability of these results beyond this sample. In addition, requirements for board certification in a given specialty may not be a comprehensive depiction of that specialty’s skill set; there may be unmeasured factors that contribute to a specialty’s ability to manage the perioperative process. Thus, our approach is inherently simplistic and potentially biased in favor of anesthesiology. In addition, all anesthesiologists surveyed practiced in the United States and only American residency board certification requirements were studied, limiting generalizability of these results to an international setting. However, these study limitations provide future research opportunities. It is important to understand the perspective of the other specialties studied here. Future studies could perform a similar interview exercise to identify perioperative care elements perceived as important to all 4 specialties. In addition, a more sophisticated approach and/or an international sample could better identify gaps in perioperative education and facilitate the development of specific solutions.
CONCLUSIONS
Better management of the perioperative process has come unto the spotlight in recent years as a way to possibly reduce costs while improving the quality of care.11 However, perioperative care is not a subject traditionally comprehensively covered in any 1 medical specialty. Various elements of perioperative care are included in each of the 4 residencies studied (anesthesiology, family medicine, internal medicine, and surgery), but many of the activities inherent to the PSH are not required for board certification in any of the specialties, particularly in the intraoperative and postoperative phases. All 4 specialties appear to have room for improvement by expanding perioperative care education. E DISCLOSURES
Name: Kayla M. Cline, MS. Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript. Attestation: Kayla M. Cline has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files. Conflicts of Interest: Kayla M. Cline received research funding from American Society of Anesthesiologists. Name: Rahil Roopani, BA. Contribution: This author helped analyze the data and write the manuscript. Attestation: Rahil Roopani has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare.
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Name: Bita A. Kash, PhD, MBA. Contribution: This author helped design the study, conduct the study, and write the manuscript. Attestation: Bita A. Kash has seen the original study data, reviewed the analysis of the data, and approved the final manuscript. Conflicts of Interest: Bita A. Kash received research funding from American Society of Anesthesiologists as is a member of the NSF Center for Health Organization Transformation (CHOT) at Texas A&M University. Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write the manuscript. Attestation: Thomas R. Vetter reviewed the analysis of the data and approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. This manuscript was handled by: Franklin Dexter, MD, PhD. REFERENCES 1. Pasternak LR. Preoperative testing: moving from individual testing to risk management. Anesth Analg 2009;108:393–4 2. Cannesson M, Kain Z. Enhanced recovery after surgery versus perioperative surgical home: is it all in the name? Anesth Analg 2014;118:901–2 3. Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The perioperative surgical home as a future perioperative practice model. Anesth Analg 2014;118:1126–30 4. Kash BA, Zhang Y, Cline KM, Menser T, Miller TR. The perioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes. Milbank Q 2014;92:796–821 5. Lee A, Kerridge RK, Chui PT, Chiu CH, Gin T. Perioperative Systems as a quality model of perioperative medicine and surgical care. Health Policy 2011;102:214–22 6. Dexter F, Wachtel RE. Strategies for net cost reductions with the expanded role and expertise of anesthesiologists in the perioperative surgical home. Anesth Analg 2014;118:1062–71 7. Garson L, Schwarzkopf R, Vakharia S, Alexander B, Stead S, Cannesson M, Kain Z. Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg 2014;118:1081–9 8. Graham JB, Thomas R, Strohecker KA, Irgit K, Smith WR. Reducing mortality in hip fracture patients using a perioperative approach and “patient-centered medical home” model: a prospective cohort study. Patient Saf Surg 2014;8:7 9. Hooper VD. Who staffs the perioperative surgical home? Anesth Analg 2013;116:754–5 10. Vetter TR, Boudreaux AM, Jones KA, Hunter JM Jr, Pittet JF. The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg 2014;118:1131–6 11. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The perioperative surgical home: how can it make the case so everyone wins? BMC Anesthesiol 2014;13:6 12. Batsis JA, Phy MP, Melton LJ 3rd, Schleck CD, Larson DR, Huddleston PM, Huddleston JM. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med 2007;2:219–25 13. Kash BA, Cline KM, Timmons S, Roopani R, Miller TR. International comparison of preoperative testing and assessment protocols and best practices to reduce surgical care costs: a systematic literature review. In: Buttigieg SC, Rathert C, Von Eiff W, eds. Advances in Health Care Management, Volume 17. Emerald Group Publishing Limited, 2015:161–94 14. Masursky D, Dexter F, Isaacson SA, Nussmeier NA. Surgeons’ and anesthesiologists’ perceptions of turnover times. Anesth Analg 2011;112:440–4 15. Wright JG, Roche A, Khoury AE. Improving on-time surgical starts in an operating room. Can J Surg 2010;53:167–70
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20. Eden J, Berwick D, Wilensky G. Graduate Medical Education That Meets the Nation’s Health Needs. Report of the Institute of Medicine. Washington, DC: The National Academies Press, 2014 21. Butterworth JF 4th, Green JA. The anesthesiologist-directed perioperative surgical home: a great idea that will succeed only if it is embraced by hospital administrators and surgeons. Anesth Analg 2014;118:896–7 22. Grocott MP, Pearse RM. Perioperative medicine: the future of anaesthesia? Br J Anaesth 2012;108:723–6 23. Huang J, Schweitzer M. The perioperative surgical home: what anesthesiologists need to do. J Med Pract Manage 2014;29:235–7
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