E THE OPEN MIND
The Perioperative Surgical Home: How Anesthesiology Can Collaboratively Achieve and Leverage the Triple Aim in Health Care Thomas R. Vetter, MD, MPH, Arthur M. Boudreaux, MD, Keith A. Jones, MD, James M. Hunter Jr, MD, and Jean-Francois Pittet, MD ORIGINS AND PARTICIPANTS OF THE PERIOPERATIVE SURGICAL HOME Guiding Principles of the Triple Aim and the Patient-Centered Medical Home
By 2019, an estimated 19.3% of the United States gross domestic product will be devoted to health care.1 Health care delivery and payment systems in the United States must fundamentally change to contain this spending while improving quality of care. Berwick et al.,2 and the Institute for Healthcare Improvement (IHI) have promulgated the “Triple Aim” as a basic framework for this much needed overall health care reform.3 The IHI Triple Aim comprises 3 interdependent goals: (1) improving the individual experience of care, (2) improving the health of populations, and (3) reducing per capita costs of care.2,3 Achieving this Triple Aim requires an “integrator” to optimise services on all 3 of its dimensions.2 This integrator is an entity that accepts responsibility for achieving all 3 components of the Triple Aim for a specified population.2,3 Such an integrator for primary care is the Patient-Centered Medical Home (PCMH).4 Recent data suggest that the PCMH improves outcomes and produces cost savings.5 Surgical care currently accounts for an estimated 52% of hospital admission expenses in the United States.6 Factors contributing to excessive surgical expenditures include fragmentation and inefficiencies in delivery, defensive medicine, discordant incentives between stakeholders who deliver versus pay for care, and a lack of emphasis on value.7,8 To address these and other factors, the Perioperative Surgical Home (PSH) model has been developed using the guiding principles of the PCMH.9 The PSH is a patient-centered approach to the surgical patient, with a strong emphasis on standardization, coordination and transitions, and value of care, throughout the perioperative continuum, including the From the Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama. Accepted for publication January 27, 2014. Funding: UAB Department of Anesthesiology internal funds. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Thomas R. Vetter, MD, MPH, Department of Anesthesiology, University of Alabama at Birmingham, JT862, 619 19th St. South, Birmingham, AL 35249. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000228
May 2014 • Volume 118 • Number 5
postdischarge phase.9,10 We posit in this The Open Mind article that the PSH can serve as the needed integrator for achieving and leveraging the IHI Triple Aim for surgical patients.
The Broad Set of Participants in the Perioperative Surgical Home
The PSH requires a physician team leader, the “perioperativist,” who provides seamless continuity of current best practices of care, while actively involving the patient, family, and the other health care stakeholders and providers, including the primary care physician.9 Several clinical specialists could serve as this perioperativist in the PSH. The surgeon has traditionally served as the perioperative team leader. However, the individual surgeon’s ability to provide solo perioperative care is diminishing because of increasing expected intraoperative productivity, in addition to continuing surgical advances and expanding health insurance coverage, that are fueling demand for services, all without a proportionate increase in newly trained surgeons.11,12 Internal medicine hospitalists have historically comanaged surgical patients, and in some settings, hospitalists will likely continue to serve in this expanded perioperativist role. Anesthesiologists are uniquely positioned to serve as perioperativists because of their understanding and ability to assess, evaluate, and prepare patients with a multitude of complex comorbidities for their procedure and their ability to manage these complex comorbidities intraoperatively and postoperatively. This global understanding will allow anesthesiologists to drive the standardization of care needed to reduce risk and to optimise perioperative outcomes.
ACHIEVING THE TRIPLE AIM WITH THE SURGICAL PATIENT
The PSH strives to enhance the patient experience and to improve the health of the surgical population at the same or lower cost. Analogous to the PCMH, the PSH serves as the integrator to accomplish the interdependent elements of the Triple Aim within surgical care (Fig. 1).2,3 The PSH is thus well positioned to achieve the IHI Triple Aim, and achieving the Triple Aim can serve as a leverage point for anesthesiologists and other advocates to obtain the needed local political and fiscal support for developing and implementing a PSH model. www.anesthesia-analgesia.org 1131
E The Open Mind
Figure 1. The Perioperative Surgical Home serving as the Integrator to accomplish the Institute for Healthcare Improvement’s Triple Aim within surgical care
Figure 2. A Personalized Care Matrix created by the amalgamation of all the standardized elements of a surgical procedure-specific integrated care pathway and any applicable condition-specific standardized clinical assessment and management plans. ICP = integrated care pathway; SCAMP = standardized clinical assessment and management plan. In this example of a Personalized Care Matrix, the integrated care pathway (e.g., for total hip arthroplasty) contains 16 specific, standardized elements, and the patient’s comorbidities warrant 3 standardized clinical assessment and management plans (e.g., preoperative anemia, obstructive sleep apnea, and myocardial injury after noncardiac surgery).
Standardized Clinical Assessment and Management Plans
Although intended to reduce variation and improve care, conventional clinical practice guidelines have drawbacks that can limit clinician buy-in.13 In contrast, standardized clinical assessment and management plans (SCAMPs) offer a clinician-designed and driven approach that accommodates localised individual and population patient differences, respects local providers’ clinical acumen, and keeps pace with the rapid growth of medical knowledge.14 Examples of perioperative SCAMPs include protocols focused on anemia and goal-directed blood transfusion, anticoagulants, nausea and vomiting, multimodal analgesia, delirium and cognitive dysfunction, myocardial injury after noncardiac surgery, obstructive sleep apnea, and mode of mechanical ventilation. SCAMPs can play a major and innovative role in the PSH, especially with the multiple effective variants of the PSH concept that are predicated on institutional infrastructure and internal/external forces. In contrast to SCAMPs, integrated care pathways are task-orientated care plans that detail the essential elements
1132 www.anesthesia-analgesia.org
in the care of all patients undergoing a specific surgical procedure (e.g. total hip or knee arthroplasty) and then highlight and address any lack of process standardization and resulting inefficiencies and waste.15,16 SCAMPs naturally complement and strengthen such surgical p rocedure-specific integrated care pathways. A Personalized Care Matrix can be created by the amalgamation of all the standardized elements of a surgical procedure-specific integrated care pathway and applicable condition-specific SCAMPs (Fig. 2). Triple Aim 1: Improving the Individual Experience of Care Rising consumerism in health care is exemplified by an emphasis on patient-centered care and shared decision-making.17,18 However, patient-centered care and shared decision-making are not simply capitulating to patients’ requests, giving them what they want, when they want it, regardless of cost or value, nor is it throwing information at them and leaving them to sort it out on their own.19 Instead, at their core, both require teamwork by like-minded clinicians and are predicated on strong communication and trust among clinicians, patients, and patients’
anesthesia & analgesia
Perioperative Surgical Home and the Triple Aim in Health Care
families.19 The PSH seeks to improve the individual experience of care, specifically, perioperative patient engagement and satisfaction. An estimated 32% of U.S. elderly (aged 65 years or older) undergo surgery in the year before their death. The rate and intensity of this end-of-life surgery varies substantially by age and region, implying discretion in health care providers’ decisions to intervene surgically at the end of life.20 Nearly 5% of preoperative outpatients at a tertiary care hospital died within 1 year after their procedure.21 Among all preoperative outpatients at the same institution, half of those expected clinically to require a postoperative intensive care unit admission were not aware of this fact, and a significant number of patients reported feeling conflicted about having surgery.22 These data collectively underscore the need for the more robust patient centeredness and shared decision-making afforded by the PSH. In the PSH, p atient-centered care plans are generated based on a patient’s coexisting medical conditions and active participation of the patient and family in surgical and anesthetic decision-making. This allows for a personalized care plan designed to achieve optimal outpatient and inpatient outcomes. Personalized medicine (precision medicine) is often viewed as synonymous with pharmacogenomic medicine.23,24 However, a broader, more apropos concept is personalized health care (PHC): defined as a coordinated, strategic approach to patient care that combines systems biology with personalized, predictive, preventive, and participatory care (“P4 medicine”).25,26 PHC incorporates an individual patient’s biopsychosocial characteristics and maximises patient/provider involvement, engagement, and satisfaction.25,27 The use of a Personalized Care Matrix (Fig. 2), which is tailored to a given surgical patient’s needs, enhances the ability of the PSH to deliver such PHC. The PSH is also consonant with this broader PHC concept, if surgical patients, with the assistance of their perioperative transitions coach, can move from being passive consumers of clinical care to more active members of their health care team.10,28 Triple Aim 2: Improving the Health of Populations The number of Americans aged 65 years or older is projected to reach 55 million by 2020 and 72 million by 2030.29 By 2020, 157 million Americans are predicted to have 1 chronic disease, and 81 million to have multiple diseases.30 Older age and chronic disease are independently associated with greater surgical morbidity and mortality.31,32 Despite this greater associated risk, the rate of surgical procedures in older Americans has continued to increase.33,34 The PSH seeks to improve the health of the defined population, specifically, the targeted aging and increasingly chronically ill population undergoing surgery. Better health is achieved via preoperative risk assessment and mitigation, including prehabilitation to increase functional capacity (physiological reserve) in preparation for surgery.35,36 Unlike the current conventional preoperative evaluation of older adults, a salient PSH component is the use of standardized preoperative markers for frailty (Mini-Cog Test score), disability (Katz score), and comorbidity (Charlson Index score), which have been shown
May 2014 • Volume 118 • Number 5
to predict 6-month postoperative mortality and postdischarge institutionalization.37 A SCAMP evaluating preoperative frailty, using a consistent definition and assessment tool, strengthens risk assessment and thus helps patients and physicians make better informed, shared decisions.38 Another prototypic SCAMP focuses on perioperative patient blood management in a systematic manner with multidisciplinary teams.39 A preoperative anemia management program40 can be incorporated into the comprehensive Preoperative Assessment, Consultation, and Treatment Clinic within the PSH. Triple Aim 3: Reducing Per Capita Costs of Health Care Current large and unwarranted geographical variation in the provision of surgical and anesthetic care must be recognised and addressed.41,42 Research has demonstrated marked variation in perioperative care by location, with only speculated root causes.43–45 These variations occur even within single institutions. Each specialty organization formulates guidelines for management of specific conditions, many of which differ depending on which specialty produces the guideline. Ultimately, such widely variable surgical and anesthesia practice in the United States leads to higher costs without achieving better patient outcomes.42,46,47 The PSH seeks to reduce, or at least control, the per capita cost of care, by implementing strategies to optimise clinical outcomes via risk stratification and standardization of care but in a more inclusive manner by widely applying perioperative SCAMPs.48 The PSH relies on greater integration of surgical care to reduce variation. This integration requires a professional component, emphasizing formal collaboration among health care professionals within an institution and a clinical component focusing on activities intended to coordinate patient care services across people, functions, activities, and operating units over time.49 In the PSH, interprofessional teams of physicians, nurses, pharmacists, rehabilitation specialists, social workers, and care coordinators seek to develop evidence-based SCAMPs tailored to the local environment, implement those plans, and ideally hold each other accountable for implementation. In the absence of adequate robust published data, SCAMPs are evidence-informed, in other words, based on local expert opinion and quality assurance and improvement data. In the PSH, “flexible regimentation” is also applied to develop and iteratively improve a common or standard process for performing a specific service, based on the best available evidence.50
LEVERAGING THE TRIPLE AIM WITH THE SURGICAL PATIENT
To successfully leverage the Triple Aim, advocates and early adopters of any PSH model must demonstrate its various espoused patient-centered and systems-level benefits. This will require the rigorous, reiterative application of the effectiveness, efficiency, and equity criteria, set forth by the Berwick et al.2 and others, in evaluating the health services performance of this alternate perioperative care model.51 The PSH model is essentially a health program, with a multitude of stakeholders (e.g., patients, providers, payers, and policymakers) and pertinent clinical, operational, and fiscal outcomes. The well-established principles of
www.anesthesia-analgesia.org 1133
E The Open Mind health program development and evaluation (e.g., a preintervention versus postintervention cost-effectiveness analysis)52 can thus likely be applied to the PSH. This will result in a beneficial amalgamation of biomedical and community/public health promotion methodology and literature. Dissemination and implementation (D&I) of a PSH model will require that its broad set of stakeholders want it (“pull”) and that systematic, organizational efforts help adopters apply (“push”) this innovation.53–55 D&I science examines processes for transferring interventions into local settings, which may be similar to or different from those in which the intervention was initially developed and tested via an efficacy or effectiveness trial.53,56 Once again there will undoubtedly be multiple future variations of the PSH concept that may work effectively, depending on local infrastructure and politics, as well as known and yet to be identified forces.10 The tenets of D&I science will also be essential in validating, and hence, leveraging these various PSH models that will be created, trialed, and applied as surgical paradigms evolve in response to evidence, economics, and policy.
PAYING FOR THE PERIOPERATIVE SURGICAL HOME
A central question to achieving and leveraging the Triple Aim, which is yet to be adequately answered, is how does one get compensated for creating, piloting, and sustaining a PSH? Returning to the guiding principles of the PCMH, some insight can be gained from this new model, although for complex chronic care management.4 The 4 cornerstones of the PCMH model are primary care, patient-centered care, new-model practice, and payment reform.57 The PCMH is predicated on a payment structure that combines fee-for-service, pay-for-performance, and an explicit separate payment for care coordination and integration, including management of transitions of care.4,57 This model also requires financial compensation for case-mix differences, implementation of health information technology for safety and quality improvement, savings from reduced hospitalizations, and achievement of quality metrics.57 A survey of actual PCMH demonstration project participants revealed that most demonstrations were single payer, and most used a 3-component payment model that comprised traditional fee for service, monthly per person fixed payments, and performance-based bonus payments.58 After ample internal dialogue and external discussions with anesthesiology colleagues at other institutions, our Perioperative Surgical Home Group at University of Alabama at Birmingham has concluded that a health care organization must be willing to “purchase” the “value” created by a PSH model (i.e., value-based purchasing must be applied at the local microeconomic level).59,60 Essentially, creating a PSH must be a local institutional and not simply an anesthesia or other specialty practice initiative. The role of a given anesthesia (or other specialty) practice should then be to lead its own institution in recognizing the value that this new surgical practice model creates by improving patient centeredness and access, and providing higher
1134 www.anesthesia-analgesia.org
quality and better outcomes, all at the same or lower cost (i.e., achieving the Triple Aim).61 To accomplish this, it would appear that 3 conditions must be met: (1) there is an institutional need or desire to improve 1, 2, or all 3 domains of the Triple Aim; (2) the institution has the ability to capture via its informatics infrastructure the impact of this new model on the benchmarks for each Aim; and (3) the anesthesia practice is financially “aligned” with the institution.60,62 Although there may be others, based on local politics and economics, this financial alignment can be met in at least 3 ways: (1) the anesthesia practice becomes fully employed by the institution; (2) the anesthesia practice and the institution remain distinct corporate entities but develop an integrated funds flow model that aligns their collective goals and objectives; or (3) the anesthesia practice and institution remain distinct corporate entities but develop comanagement contracts, which also incorporate the surgical-related services yet clearly align financial incentives with the collective goals and objectives of both entities (e.g., “back-stop” contracts, or “at-risk” hospital support). We have recently adopted a new funds flow model within the University of Alabama at Birmingham Health System. This new funds flow model incorporates the entire scope of anesthesia clinical services, including the additional perioperative, critical care, and pain medicine services provided in our PSH model. In this funds flow model, patient care revenue no longer flows directly to the clinical departments. Payments to departments are based on (a) Medical Group Management Association specialty-specific benchmarks and (b) departmental clinical productivity as measured by applicable work Relative Value Units (wRVUs) or American Society of Anesthesiologists Relative Value Guide units. Nevertheless, perhaps the greatest argument against the anesthesiologist functioning as the perioperativist in the PSH is the differential in apparent cost between perioperative services provided by an anesthesiologist versus an internal medicine hospitalist. Even if payers and administrators agree that anesthesiologists might be better suited for this expanded perioperativist role, given ever increasing reimbursement constraints, these key stakeholders will be apt to view internal medicine hospitalists as significantly more “cost-effective” providers. The differential in salary compensation between these 2 specialties may be attributed partly to differences in (a) total work hours per year and/ or (b) amount of clinical productivity, per full time equivalent.63,64 However, there is currently no assuredly valid way to convert American Society of Anesthesiologists Relative Value Guide units into wRVUs. Ultimately, the added value across various pay-for-performance metrics and the resulting at least cost-neutrality if not cost-benefit of an anesthesiologist versus internal medicine hospitalist must be demonstrated in any PSH proof-of-concept pilot.
CONCLUSIONS
The PSH has the promise to achieve the Triple Aim in the surgical setting, which in turn can be used collaboratively by anesthesiologists and their various colleagues as a leverage point to obtain needed local political and fiscal support. Success of the PSH requires the continued close
anesthesia & analgesia
Perioperative Surgical Home and the Triple Aim in Health Care
clinical collaboration of anesthesiologists, hospitalists, primary care physicians, and surgeons, working in concert with nurses, pharmacists, rehabilitation specialists, and social workers. There must also be a strategic, operational, and financial alignment of payers, hospitals, and physicians and other providers across the perioperative care continuum. E DISCLOSURES
Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write the manuscript. Attestation: Thomas R. Vetter approved the final manuscript. Name: Arthur M. Boudreaux, MD. Contribution: This author helped write the manuscript. Attestation: Arthur M. Boudreaux approved the final manuscript. Name: Keith A. Jones, MD. Contribution: This author helped write the manuscript. Attestation: Keith A. Jones approved the final manuscript. Name: James M. Hunter Jr, MD. Contribution: This author helped write the manuscript. Attestation: James M. Hunter Jr, approved the final manuscript. Name: Jean-Francois Pittet, MD. Contribution: This author helped write the manuscript. Attestation: Jean-Francois Pittet approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD. REFERENCES 1. Sisko AM, Truffer CJ, Keehan SP, Poisal JA, Clemens MK, Madison AJ. National health spending projections: the estimated impact of reform through 2019. Health Aff (Millwood) 2010;29:1933–41 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759–69 3. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement, 2012 4. Bindman AB, Blum JD, Kronick R. Medicare payment for chronic care delivered in a patient-centered medical home. JAMA 2013;310:1125–6 5. Arend J, Tsang-Quinn J, Levine C, Thomas D. The patient-centered medical home: history, components, and review of the evidence. Mt Sinai J Med 2012;79:433–50 6. Health Care Cost Institute. Health Care Cost and Utlization Report: 2011. Washington, DC: Health Care Cost Institute, 2012 7. Cormier JN, Cromwell KD, Pollock RE. Value-based health care: a surgical oncologist’s perspective. Surg Oncol Clin N Am 2012;21:497–506, x 8. Fry DE, Pine M, Jones BL, Meimban RJ. The impact of ineffective and inefficient care on the excess costs of elective surgical procedures. J Am Coll Surg 2011;212:779–86 9. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol 2013;13:6 10. Vetter TR, Ivankova NV, Goeddel LA, McGwin G Jr, Pittet JF; UAB Perioperative Surgical Home Group. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology 2013;119:1261–74 11. Association of American Medical Colleges. The Impact of Health Care Reform on the Future Supply and Demand for Physicians Updated Projections Through 2025. Washington, DC: Association of American Medical Colleges; 2010 12. Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: role of surgeons and other providers. Adv Surg 2008;42:63–85
May 2014 • Volume 118 • Number 5
13. Harrison MB, Légaré F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context and assessing barriers to their use. CMAJ 2010;182:E78–84 14. Farias M, Jenkins K, Lock J, Rathod R, Newburger J, Bates DW, Safran DG, Friedman K, Greenberg J. Standardized Clinical Assessment And Management Plans (SCAMPs) provide a better alternative to clinical practice guidelines. Health Aff (Millwood) 2013;32:911–20 15. Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated care pathways. BMJ 1998;316:133–7 16. Napolitano LM. Standardization of perioperative management: clinical pathways. Surg Clin North Am 2005;85:1321–7, xiii 17. Berwick DM. What ‘patient-centered’ should mean: confes sions of an extremist. Health Aff (Millwood) 2009;28:w555–65 18. Kon AA. The shared decision-making continuum. JAMA 2010;304:903–4 19. Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Aff (Millwood) 2010;29:1489–95 20. Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, Jha AK. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet 2011;378:1408–13 21. Barnet CS, Arriaga AF, Hepner DL, Correll DJ, Gawande AA, Bader AM. Surgery at the end of life: a pilot study comparing decedents and survivors at a tertiary care center. Anesthesiology 2013;119:796–801 22. Ankuda C, Block S, Cooper Z, Correll D, Hepner D, Lasic M, Gawande A, Bader A. Measuring quality of decision-making for advance care planning and surgery. J Surg Res 2012; 172:189 23. Mirnezami R, Nicholson J, Darzi A. Preparing for precision medicine. N Engl J Med 2012;366:489–91 24. Chen R, Snyder M. Systems biology: personalised medicine for the future? Curr Opin Pharmacol 2012;12:623–8 25. Simmons LA, Dinan MA, Robinson TJ, Snyderman R. Personalised medicine is more than genomic medicine: confusion over terminology impedes progress towards personalised healthcare. Pers Med 2011;9:85–91 26. Weston AD, Hood L. Systems biology, proteomics, and the future of health care: toward predictive, preventative, and personalised medicine. J Proteome Res 2004;3:179–96 27. Teng K, Eng C, Hess CA, Holt MA, Moran RT, Sharp RR, Traboulsi EI. Building an innovative model for personalised healthcare. Cleve Clin J Med 2012;79 Suppl 1:S1–9 28. Payne PR, Marsh CB. Towards a “4I” approach to personalised healthcare. Clin Transl Med 2012;1:14 29. Administration on Aging. A Profile of Older Americans: 2011. Washington, DC: U.S. Department of Health and Human Services, 2011:1–16 30. Decker SL, Schappert SM, Sisk JE. Use of medical care for chronic conditions. Health Aff (Millwood) 2009;28:26–35 31. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006;203:865–77 32. Al-Refaie WB, Parsons HM, Habermann EB, Kwaan M, Spencer MP, Henderson WG, Rothenberger DA. Operative outcomes beyond 30-day mortality: colorectal cancer surgery in oldest old. Ann Surg 2011;253:947–52 33. Al-Refaie WB, Parsons HM, Henderson WG, Jensen EH, Tuttle TM, Vickers SM, Rothenberger DA, Virnig BA. Major cancer surgery in the elderly: results from the American College of Surgeons National Surgical Quality Improvement Program. Ann Surg 2010;251:311–8 34. Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing 2012;41:142–7 35. Cheema FN, Abraham NS, Berger DH, Albo D, Taffet GE, Naik AD. Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults. Ann Surg 2011;253:867–74 36. Mayo NE, Feldman L, Scott S, Zavorsky G, Kim do J, Charlebois P, Stein B, Carli F. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery 2011;150:505–14
www.anesthesia-analgesia.org 1135
E The Open Mind 37. Robinson TN, Eiseman B, Wallace JI, Church SD, McFann KK, Pfister SM, Sharp TJ, Moss M. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg 2009;250:449–55 38. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010;210:901–8 39. Goodnough LT, Shander A. Patient blood management. Anesthesiology 2012;116:1367–76 40. Goodnough LT, Maniatis A, Earnshaw P, Benoni G, Beris P, Bisbe E, Fergusson DA, Gombotz H, Habler O, Monk TG, Ozier Y, Slappendel R, Szpalski M. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 2011;106:13–22 41. McCulloch P, Nagendran M, Campbell WB, Price A, Jani A, Birkmeyer JD, Gray M. Strategies to reduce variation in the use of surgery. The Lancet 2013;382:1130–9 42. Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. Variation in the practice of preoperative medical consultation for major elective noncardiac surgery: a population-based study. Anesthesiology 2012;116:25–34 43. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs–lessons from regional variation. N Engl J Med 2009;360:849–52 44. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet 2013;382:1121–9 45. Seim AR, Sandberg WS. Shaping the operating room and perioperative systems of the future: innovating for improved competitiveness. Curr Opin Anaesthesiol 2010;23:765–71 46. Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood) 2011;30:2107–15 47. Rivera RA, Nguyen MT, Martinez-Osorio JI, McNeill MF, Ali SK, Mansi IA. Preoperative medical consultation: maximizing its benefits. Am J Surg 2012;204:787–97 48. Ravikumar TS, Sharma C, Marini C, Steele GD Jr, Ritter G, Barrera R, Kim M, Safyer SM, Vandervoort K, De Geronimo M, Baker L, Levi P, Pierdon S, Horgan M, Maynor K, Maloney G, Wojtowicz M, Nelson K. A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts. Ann Surg 2010;252:486–96 49. Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev 2011;68:112–27
1136 www.anesthesia-analgesia.org
50. Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc 2013;88:74–82 51. Begley CE, Lairson David, Morgan Robert O. Evaluating the Healthcare System: Effectiveness, Efficiency, and Equity. 4th ed. Chicago, IL: Health Administration Press, 2013 52. Issel LM. Health Program Planning and Evaluation: A Practical, Systematic Approach for Community Health. 3rd ed. Burlington, MA: Jones & Bartlett Learning, 2013 53. Colditz GA. The promise and challenges of dissemination and implemenation research. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and Implementation Research in Health: Translating Science to Practice. New York, NY: Oxford University Press, 2012:3–22 54. Emmons KM, Weiner B, Fernandez ME, Tu SP. Systems antecedents for dissemination and implementation: a review and analysis of measures. Health Educ Behav 2012;39:87–105 55. Aaarons GA, Horowitz J, Dlugosz L, Ehrhart M. The role of organizational process in dissemination and implementation research. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and implementation research in health: translating science to practice. New York, NY: Oxford University Press, 2012:128–53 56. National Institutes of Health. PAR-13–055: Dissemination and Implementation Research in Health (R01). Bethesda, MD: National Institutes of Health Office of Extramural Research, 2013 57. Rittenhouse DR, Shortell SM. The patient-centered medi cal home: will it stand the test of health reform? JAMA 2009;301:2038–40 58. Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med 2010;25:584–92 59. VanLare JM, Conway PH. Value-based purchasing–national programs to move from volume to value. N Engl J Med 2012;367:292–5 60. American Hospital Association. Metrics for the Second Curve of Health Care. Chicago, IL: Health Research & Educational Trust, 2013 61. Martin J, Cheng D. Role of the anesthesiologist in the wider governance of healthcare and health economics. Can J Anaesth 2013;60:918–28 62. American Hospital Association. Hospitals and Care Systems of the Future. Chicago, IL: Health Research & Educational Trust, 2011 63. Abouleish AE, Prough DS, Whitten CW, Zornow MH, Lockhart A, Conlay LA, Abate JJ. Comparing clinical productivity of anesthesiology groups. Anesthesiology 2002;97:608–15 64. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med 2012;7:402–10
anesthesia & analgesia
The Perioperative Surgical Home: How Anesthesiology Can Collaboratively Achieve and Leverage the Triple Aim in Health Care Thomas R. Vetter, MD, MPH, Arthur M. Boudreaux, MD, Keith A. Jones, MD, James M. Hunter Jr, MD, and Jean-Francois Pittet, MD ORIGINS AND PARTICIPANTS OF THE PERIOPERATIVE SURGICAL HOME Guiding Principles of the Triple Aim and the Patient-Centered Medical Home
By 2019, an estimated 19.3% of the United States gross domestic product will be devoted to health care.1 Health care delivery and payment systems in the United States must fundamentally change to contain this spending while improving quality of care. Berwick et al.,2 and the Institute for Healthcare Improvement (IHI) have promulgated the “Triple Aim” as a basic framework for this much needed overall health care reform.3 The IHI Triple Aim comprises 3 interdependent goals: (1) improving the individual experience of care, (2) improving the health of populations, and (3) reducing per capita costs of care.2,3 Achieving this Triple Aim requires an “integrator” to optimise services on all 3 of its dimensions.2 This integrator is an entity that accepts responsibility for achieving all 3 components of the Triple Aim for a specified population.2,3 Such an integrator for primary care is the Patient-Centered Medical Home (PCMH).4 Recent data suggest that the PCMH improves outcomes and produces cost savings.5 Surgical care currently accounts for an estimated 52% of hospital admission expenses in the United States.6 Factors contributing to excessive surgical expenditures include fragmentation and inefficiencies in delivery, defensive medicine, discordant incentives between stakeholders who deliver versus pay for care, and a lack of emphasis on value.7,8 To address these and other factors, the Perioperative Surgical Home (PSH) model has been developed using the guiding principles of the PCMH.9 The PSH is a patient-centered approach to the surgical patient, with a strong emphasis on standardization, coordination and transitions, and value of care, throughout the perioperative continuum, including the From the Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama. Accepted for publication January 27, 2014. Funding: UAB Department of Anesthesiology internal funds. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Thomas R. Vetter, MD, MPH, Department of Anesthesiology, University of Alabama at Birmingham, JT862, 619 19th St. South, Birmingham, AL 35249. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000228
May 2014 • Volume 118 • Number 5
postdischarge phase.9,10 We posit in this The Open Mind article that the PSH can serve as the needed integrator for achieving and leveraging the IHI Triple Aim for surgical patients.
The Broad Set of Participants in the Perioperative Surgical Home
The PSH requires a physician team leader, the “perioperativist,” who provides seamless continuity of current best practices of care, while actively involving the patient, family, and the other health care stakeholders and providers, including the primary care physician.9 Several clinical specialists could serve as this perioperativist in the PSH. The surgeon has traditionally served as the perioperative team leader. However, the individual surgeon’s ability to provide solo perioperative care is diminishing because of increasing expected intraoperative productivity, in addition to continuing surgical advances and expanding health insurance coverage, that are fueling demand for services, all without a proportionate increase in newly trained surgeons.11,12 Internal medicine hospitalists have historically comanaged surgical patients, and in some settings, hospitalists will likely continue to serve in this expanded perioperativist role. Anesthesiologists are uniquely positioned to serve as perioperativists because of their understanding and ability to assess, evaluate, and prepare patients with a multitude of complex comorbidities for their procedure and their ability to manage these complex comorbidities intraoperatively and postoperatively. This global understanding will allow anesthesiologists to drive the standardization of care needed to reduce risk and to optimise perioperative outcomes.
ACHIEVING THE TRIPLE AIM WITH THE SURGICAL PATIENT
The PSH strives to enhance the patient experience and to improve the health of the surgical population at the same or lower cost. Analogous to the PCMH, the PSH serves as the integrator to accomplish the interdependent elements of the Triple Aim within surgical care (Fig. 1).2,3 The PSH is thus well positioned to achieve the IHI Triple Aim, and achieving the Triple Aim can serve as a leverage point for anesthesiologists and other advocates to obtain the needed local political and fiscal support for developing and implementing a PSH model. www.anesthesia-analgesia.org 1131
E The Open Mind
Figure 1. The Perioperative Surgical Home serving as the Integrator to accomplish the Institute for Healthcare Improvement’s Triple Aim within surgical care
Figure 2. A Personalized Care Matrix created by the amalgamation of all the standardized elements of a surgical procedure-specific integrated care pathway and any applicable condition-specific standardized clinical assessment and management plans. ICP = integrated care pathway; SCAMP = standardized clinical assessment and management plan. In this example of a Personalized Care Matrix, the integrated care pathway (e.g., for total hip arthroplasty) contains 16 specific, standardized elements, and the patient’s comorbidities warrant 3 standardized clinical assessment and management plans (e.g., preoperative anemia, obstructive sleep apnea, and myocardial injury after noncardiac surgery).
Standardized Clinical Assessment and Management Plans
Although intended to reduce variation and improve care, conventional clinical practice guidelines have drawbacks that can limit clinician buy-in.13 In contrast, standardized clinical assessment and management plans (SCAMPs) offer a clinician-designed and driven approach that accommodates localised individual and population patient differences, respects local providers’ clinical acumen, and keeps pace with the rapid growth of medical knowledge.14 Examples of perioperative SCAMPs include protocols focused on anemia and goal-directed blood transfusion, anticoagulants, nausea and vomiting, multimodal analgesia, delirium and cognitive dysfunction, myocardial injury after noncardiac surgery, obstructive sleep apnea, and mode of mechanical ventilation. SCAMPs can play a major and innovative role in the PSH, especially with the multiple effective variants of the PSH concept that are predicated on institutional infrastructure and internal/external forces. In contrast to SCAMPs, integrated care pathways are task-orientated care plans that detail the essential elements
1132 www.anesthesia-analgesia.org
in the care of all patients undergoing a specific surgical procedure (e.g. total hip or knee arthroplasty) and then highlight and address any lack of process standardization and resulting inefficiencies and waste.15,16 SCAMPs naturally complement and strengthen such surgical p rocedure-specific integrated care pathways. A Personalized Care Matrix can be created by the amalgamation of all the standardized elements of a surgical procedure-specific integrated care pathway and applicable condition-specific SCAMPs (Fig. 2). Triple Aim 1: Improving the Individual Experience of Care Rising consumerism in health care is exemplified by an emphasis on patient-centered care and shared decision-making.17,18 However, patient-centered care and shared decision-making are not simply capitulating to patients’ requests, giving them what they want, when they want it, regardless of cost or value, nor is it throwing information at them and leaving them to sort it out on their own.19 Instead, at their core, both require teamwork by like-minded clinicians and are predicated on strong communication and trust among clinicians, patients, and patients’
anesthesia & analgesia
Perioperative Surgical Home and the Triple Aim in Health Care
families.19 The PSH seeks to improve the individual experience of care, specifically, perioperative patient engagement and satisfaction. An estimated 32% of U.S. elderly (aged 65 years or older) undergo surgery in the year before their death. The rate and intensity of this end-of-life surgery varies substantially by age and region, implying discretion in health care providers’ decisions to intervene surgically at the end of life.20 Nearly 5% of preoperative outpatients at a tertiary care hospital died within 1 year after their procedure.21 Among all preoperative outpatients at the same institution, half of those expected clinically to require a postoperative intensive care unit admission were not aware of this fact, and a significant number of patients reported feeling conflicted about having surgery.22 These data collectively underscore the need for the more robust patient centeredness and shared decision-making afforded by the PSH. In the PSH, p atient-centered care plans are generated based on a patient’s coexisting medical conditions and active participation of the patient and family in surgical and anesthetic decision-making. This allows for a personalized care plan designed to achieve optimal outpatient and inpatient outcomes. Personalized medicine (precision medicine) is often viewed as synonymous with pharmacogenomic medicine.23,24 However, a broader, more apropos concept is personalized health care (PHC): defined as a coordinated, strategic approach to patient care that combines systems biology with personalized, predictive, preventive, and participatory care (“P4 medicine”).25,26 PHC incorporates an individual patient’s biopsychosocial characteristics and maximises patient/provider involvement, engagement, and satisfaction.25,27 The use of a Personalized Care Matrix (Fig. 2), which is tailored to a given surgical patient’s needs, enhances the ability of the PSH to deliver such PHC. The PSH is also consonant with this broader PHC concept, if surgical patients, with the assistance of their perioperative transitions coach, can move from being passive consumers of clinical care to more active members of their health care team.10,28 Triple Aim 2: Improving the Health of Populations The number of Americans aged 65 years or older is projected to reach 55 million by 2020 and 72 million by 2030.29 By 2020, 157 million Americans are predicted to have 1 chronic disease, and 81 million to have multiple diseases.30 Older age and chronic disease are independently associated with greater surgical morbidity and mortality.31,32 Despite this greater associated risk, the rate of surgical procedures in older Americans has continued to increase.33,34 The PSH seeks to improve the health of the defined population, specifically, the targeted aging and increasingly chronically ill population undergoing surgery. Better health is achieved via preoperative risk assessment and mitigation, including prehabilitation to increase functional capacity (physiological reserve) in preparation for surgery.35,36 Unlike the current conventional preoperative evaluation of older adults, a salient PSH component is the use of standardized preoperative markers for frailty (Mini-Cog Test score), disability (Katz score), and comorbidity (Charlson Index score), which have been shown
May 2014 • Volume 118 • Number 5
to predict 6-month postoperative mortality and postdischarge institutionalization.37 A SCAMP evaluating preoperative frailty, using a consistent definition and assessment tool, strengthens risk assessment and thus helps patients and physicians make better informed, shared decisions.38 Another prototypic SCAMP focuses on perioperative patient blood management in a systematic manner with multidisciplinary teams.39 A preoperative anemia management program40 can be incorporated into the comprehensive Preoperative Assessment, Consultation, and Treatment Clinic within the PSH. Triple Aim 3: Reducing Per Capita Costs of Health Care Current large and unwarranted geographical variation in the provision of surgical and anesthetic care must be recognised and addressed.41,42 Research has demonstrated marked variation in perioperative care by location, with only speculated root causes.43–45 These variations occur even within single institutions. Each specialty organization formulates guidelines for management of specific conditions, many of which differ depending on which specialty produces the guideline. Ultimately, such widely variable surgical and anesthesia practice in the United States leads to higher costs without achieving better patient outcomes.42,46,47 The PSH seeks to reduce, or at least control, the per capita cost of care, by implementing strategies to optimise clinical outcomes via risk stratification and standardization of care but in a more inclusive manner by widely applying perioperative SCAMPs.48 The PSH relies on greater integration of surgical care to reduce variation. This integration requires a professional component, emphasizing formal collaboration among health care professionals within an institution and a clinical component focusing on activities intended to coordinate patient care services across people, functions, activities, and operating units over time.49 In the PSH, interprofessional teams of physicians, nurses, pharmacists, rehabilitation specialists, social workers, and care coordinators seek to develop evidence-based SCAMPs tailored to the local environment, implement those plans, and ideally hold each other accountable for implementation. In the absence of adequate robust published data, SCAMPs are evidence-informed, in other words, based on local expert opinion and quality assurance and improvement data. In the PSH, “flexible regimentation” is also applied to develop and iteratively improve a common or standard process for performing a specific service, based on the best available evidence.50
LEVERAGING THE TRIPLE AIM WITH THE SURGICAL PATIENT
To successfully leverage the Triple Aim, advocates and early adopters of any PSH model must demonstrate its various espoused patient-centered and systems-level benefits. This will require the rigorous, reiterative application of the effectiveness, efficiency, and equity criteria, set forth by the Berwick et al.2 and others, in evaluating the health services performance of this alternate perioperative care model.51 The PSH model is essentially a health program, with a multitude of stakeholders (e.g., patients, providers, payers, and policymakers) and pertinent clinical, operational, and fiscal outcomes. The well-established principles of
www.anesthesia-analgesia.org 1133
E The Open Mind health program development and evaluation (e.g., a preintervention versus postintervention cost-effectiveness analysis)52 can thus likely be applied to the PSH. This will result in a beneficial amalgamation of biomedical and community/public health promotion methodology and literature. Dissemination and implementation (D&I) of a PSH model will require that its broad set of stakeholders want it (“pull”) and that systematic, organizational efforts help adopters apply (“push”) this innovation.53–55 D&I science examines processes for transferring interventions into local settings, which may be similar to or different from those in which the intervention was initially developed and tested via an efficacy or effectiveness trial.53,56 Once again there will undoubtedly be multiple future variations of the PSH concept that may work effectively, depending on local infrastructure and politics, as well as known and yet to be identified forces.10 The tenets of D&I science will also be essential in validating, and hence, leveraging these various PSH models that will be created, trialed, and applied as surgical paradigms evolve in response to evidence, economics, and policy.
PAYING FOR THE PERIOPERATIVE SURGICAL HOME
A central question to achieving and leveraging the Triple Aim, which is yet to be adequately answered, is how does one get compensated for creating, piloting, and sustaining a PSH? Returning to the guiding principles of the PCMH, some insight can be gained from this new model, although for complex chronic care management.4 The 4 cornerstones of the PCMH model are primary care, patient-centered care, new-model practice, and payment reform.57 The PCMH is predicated on a payment structure that combines fee-for-service, pay-for-performance, and an explicit separate payment for care coordination and integration, including management of transitions of care.4,57 This model also requires financial compensation for case-mix differences, implementation of health information technology for safety and quality improvement, savings from reduced hospitalizations, and achievement of quality metrics.57 A survey of actual PCMH demonstration project participants revealed that most demonstrations were single payer, and most used a 3-component payment model that comprised traditional fee for service, monthly per person fixed payments, and performance-based bonus payments.58 After ample internal dialogue and external discussions with anesthesiology colleagues at other institutions, our Perioperative Surgical Home Group at University of Alabama at Birmingham has concluded that a health care organization must be willing to “purchase” the “value” created by a PSH model (i.e., value-based purchasing must be applied at the local microeconomic level).59,60 Essentially, creating a PSH must be a local institutional and not simply an anesthesia or other specialty practice initiative. The role of a given anesthesia (or other specialty) practice should then be to lead its own institution in recognizing the value that this new surgical practice model creates by improving patient centeredness and access, and providing higher
1134 www.anesthesia-analgesia.org
quality and better outcomes, all at the same or lower cost (i.e., achieving the Triple Aim).61 To accomplish this, it would appear that 3 conditions must be met: (1) there is an institutional need or desire to improve 1, 2, or all 3 domains of the Triple Aim; (2) the institution has the ability to capture via its informatics infrastructure the impact of this new model on the benchmarks for each Aim; and (3) the anesthesia practice is financially “aligned” with the institution.60,62 Although there may be others, based on local politics and economics, this financial alignment can be met in at least 3 ways: (1) the anesthesia practice becomes fully employed by the institution; (2) the anesthesia practice and the institution remain distinct corporate entities but develop an integrated funds flow model that aligns their collective goals and objectives; or (3) the anesthesia practice and institution remain distinct corporate entities but develop comanagement contracts, which also incorporate the surgical-related services yet clearly align financial incentives with the collective goals and objectives of both entities (e.g., “back-stop” contracts, or “at-risk” hospital support). We have recently adopted a new funds flow model within the University of Alabama at Birmingham Health System. This new funds flow model incorporates the entire scope of anesthesia clinical services, including the additional perioperative, critical care, and pain medicine services provided in our PSH model. In this funds flow model, patient care revenue no longer flows directly to the clinical departments. Payments to departments are based on (a) Medical Group Management Association specialty-specific benchmarks and (b) departmental clinical productivity as measured by applicable work Relative Value Units (wRVUs) or American Society of Anesthesiologists Relative Value Guide units. Nevertheless, perhaps the greatest argument against the anesthesiologist functioning as the perioperativist in the PSH is the differential in apparent cost between perioperative services provided by an anesthesiologist versus an internal medicine hospitalist. Even if payers and administrators agree that anesthesiologists might be better suited for this expanded perioperativist role, given ever increasing reimbursement constraints, these key stakeholders will be apt to view internal medicine hospitalists as significantly more “cost-effective” providers. The differential in salary compensation between these 2 specialties may be attributed partly to differences in (a) total work hours per year and/ or (b) amount of clinical productivity, per full time equivalent.63,64 However, there is currently no assuredly valid way to convert American Society of Anesthesiologists Relative Value Guide units into wRVUs. Ultimately, the added value across various pay-for-performance metrics and the resulting at least cost-neutrality if not cost-benefit of an anesthesiologist versus internal medicine hospitalist must be demonstrated in any PSH proof-of-concept pilot.
CONCLUSIONS
The PSH has the promise to achieve the Triple Aim in the surgical setting, which in turn can be used collaboratively by anesthesiologists and their various colleagues as a leverage point to obtain needed local political and fiscal support. Success of the PSH requires the continued close
anesthesia & analgesia
Perioperative Surgical Home and the Triple Aim in Health Care
clinical collaboration of anesthesiologists, hospitalists, primary care physicians, and surgeons, working in concert with nurses, pharmacists, rehabilitation specialists, and social workers. There must also be a strategic, operational, and financial alignment of payers, hospitals, and physicians and other providers across the perioperative care continuum. E DISCLOSURES
Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write the manuscript. Attestation: Thomas R. Vetter approved the final manuscript. Name: Arthur M. Boudreaux, MD. Contribution: This author helped write the manuscript. Attestation: Arthur M. Boudreaux approved the final manuscript. Name: Keith A. Jones, MD. Contribution: This author helped write the manuscript. Attestation: Keith A. Jones approved the final manuscript. Name: James M. Hunter Jr, MD. Contribution: This author helped write the manuscript. Attestation: James M. Hunter Jr, approved the final manuscript. Name: Jean-Francois Pittet, MD. Contribution: This author helped write the manuscript. Attestation: Jean-Francois Pittet approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD. REFERENCES 1. Sisko AM, Truffer CJ, Keehan SP, Poisal JA, Clemens MK, Madison AJ. National health spending projections: the estimated impact of reform through 2019. Health Aff (Millwood) 2010;29:1933–41 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759–69 3. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement, 2012 4. Bindman AB, Blum JD, Kronick R. Medicare payment for chronic care delivered in a patient-centered medical home. JAMA 2013;310:1125–6 5. Arend J, Tsang-Quinn J, Levine C, Thomas D. The patient-centered medical home: history, components, and review of the evidence. Mt Sinai J Med 2012;79:433–50 6. Health Care Cost Institute. Health Care Cost and Utlization Report: 2011. Washington, DC: Health Care Cost Institute, 2012 7. Cormier JN, Cromwell KD, Pollock RE. Value-based health care: a surgical oncologist’s perspective. Surg Oncol Clin N Am 2012;21:497–506, x 8. Fry DE, Pine M, Jones BL, Meimban RJ. The impact of ineffective and inefficient care on the excess costs of elective surgical procedures. J Am Coll Surg 2011;212:779–86 9. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol 2013;13:6 10. Vetter TR, Ivankova NV, Goeddel LA, McGwin G Jr, Pittet JF; UAB Perioperative Surgical Home Group. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology 2013;119:1261–74 11. Association of American Medical Colleges. The Impact of Health Care Reform on the Future Supply and Demand for Physicians Updated Projections Through 2025. Washington, DC: Association of American Medical Colleges; 2010 12. Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: role of surgeons and other providers. Adv Surg 2008;42:63–85
May 2014 • Volume 118 • Number 5
13. Harrison MB, Légaré F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context and assessing barriers to their use. CMAJ 2010;182:E78–84 14. Farias M, Jenkins K, Lock J, Rathod R, Newburger J, Bates DW, Safran DG, Friedman K, Greenberg J. Standardized Clinical Assessment And Management Plans (SCAMPs) provide a better alternative to clinical practice guidelines. Health Aff (Millwood) 2013;32:911–20 15. Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated care pathways. BMJ 1998;316:133–7 16. Napolitano LM. Standardization of perioperative management: clinical pathways. Surg Clin North Am 2005;85:1321–7, xiii 17. Berwick DM. What ‘patient-centered’ should mean: confes sions of an extremist. Health Aff (Millwood) 2009;28:w555–65 18. Kon AA. The shared decision-making continuum. JAMA 2010;304:903–4 19. Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Aff (Millwood) 2010;29:1489–95 20. Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, Jha AK. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet 2011;378:1408–13 21. Barnet CS, Arriaga AF, Hepner DL, Correll DJ, Gawande AA, Bader AM. Surgery at the end of life: a pilot study comparing decedents and survivors at a tertiary care center. Anesthesiology 2013;119:796–801 22. Ankuda C, Block S, Cooper Z, Correll D, Hepner D, Lasic M, Gawande A, Bader A. Measuring quality of decision-making for advance care planning and surgery. J Surg Res 2012; 172:189 23. Mirnezami R, Nicholson J, Darzi A. Preparing for precision medicine. N Engl J Med 2012;366:489–91 24. Chen R, Snyder M. Systems biology: personalised medicine for the future? Curr Opin Pharmacol 2012;12:623–8 25. Simmons LA, Dinan MA, Robinson TJ, Snyderman R. Personalised medicine is more than genomic medicine: confusion over terminology impedes progress towards personalised healthcare. Pers Med 2011;9:85–91 26. Weston AD, Hood L. Systems biology, proteomics, and the future of health care: toward predictive, preventative, and personalised medicine. J Proteome Res 2004;3:179–96 27. Teng K, Eng C, Hess CA, Holt MA, Moran RT, Sharp RR, Traboulsi EI. Building an innovative model for personalised healthcare. Cleve Clin J Med 2012;79 Suppl 1:S1–9 28. Payne PR, Marsh CB. Towards a “4I” approach to personalised healthcare. Clin Transl Med 2012;1:14 29. Administration on Aging. A Profile of Older Americans: 2011. Washington, DC: U.S. Department of Health and Human Services, 2011:1–16 30. Decker SL, Schappert SM, Sisk JE. Use of medical care for chronic conditions. Health Aff (Millwood) 2009;28:26–35 31. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006;203:865–77 32. Al-Refaie WB, Parsons HM, Habermann EB, Kwaan M, Spencer MP, Henderson WG, Rothenberger DA. Operative outcomes beyond 30-day mortality: colorectal cancer surgery in oldest old. Ann Surg 2011;253:947–52 33. Al-Refaie WB, Parsons HM, Henderson WG, Jensen EH, Tuttle TM, Vickers SM, Rothenberger DA, Virnig BA. Major cancer surgery in the elderly: results from the American College of Surgeons National Surgical Quality Improvement Program. Ann Surg 2010;251:311–8 34. Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing 2012;41:142–7 35. Cheema FN, Abraham NS, Berger DH, Albo D, Taffet GE, Naik AD. Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults. Ann Surg 2011;253:867–74 36. Mayo NE, Feldman L, Scott S, Zavorsky G, Kim do J, Charlebois P, Stein B, Carli F. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery 2011;150:505–14
www.anesthesia-analgesia.org 1135
E The Open Mind 37. Robinson TN, Eiseman B, Wallace JI, Church SD, McFann KK, Pfister SM, Sharp TJ, Moss M. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg 2009;250:449–55 38. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010;210:901–8 39. Goodnough LT, Shander A. Patient blood management. Anesthesiology 2012;116:1367–76 40. Goodnough LT, Maniatis A, Earnshaw P, Benoni G, Beris P, Bisbe E, Fergusson DA, Gombotz H, Habler O, Monk TG, Ozier Y, Slappendel R, Szpalski M. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 2011;106:13–22 41. McCulloch P, Nagendran M, Campbell WB, Price A, Jani A, Birkmeyer JD, Gray M. Strategies to reduce variation in the use of surgery. The Lancet 2013;382:1130–9 42. Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. Variation in the practice of preoperative medical consultation for major elective noncardiac surgery: a population-based study. Anesthesiology 2012;116:25–34 43. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs–lessons from regional variation. N Engl J Med 2009;360:849–52 44. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet 2013;382:1121–9 45. Seim AR, Sandberg WS. Shaping the operating room and perioperative systems of the future: innovating for improved competitiveness. Curr Opin Anaesthesiol 2010;23:765–71 46. Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood) 2011;30:2107–15 47. Rivera RA, Nguyen MT, Martinez-Osorio JI, McNeill MF, Ali SK, Mansi IA. Preoperative medical consultation: maximizing its benefits. Am J Surg 2012;204:787–97 48. Ravikumar TS, Sharma C, Marini C, Steele GD Jr, Ritter G, Barrera R, Kim M, Safyer SM, Vandervoort K, De Geronimo M, Baker L, Levi P, Pierdon S, Horgan M, Maynor K, Maloney G, Wojtowicz M, Nelson K. A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts. Ann Surg 2010;252:486–96 49. Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev 2011;68:112–27
1136 www.anesthesia-analgesia.org
50. Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc 2013;88:74–82 51. Begley CE, Lairson David, Morgan Robert O. Evaluating the Healthcare System: Effectiveness, Efficiency, and Equity. 4th ed. Chicago, IL: Health Administration Press, 2013 52. Issel LM. Health Program Planning and Evaluation: A Practical, Systematic Approach for Community Health. 3rd ed. Burlington, MA: Jones & Bartlett Learning, 2013 53. Colditz GA. The promise and challenges of dissemination and implemenation research. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and Implementation Research in Health: Translating Science to Practice. New York, NY: Oxford University Press, 2012:3–22 54. Emmons KM, Weiner B, Fernandez ME, Tu SP. Systems antecedents for dissemination and implementation: a review and analysis of measures. Health Educ Behav 2012;39:87–105 55. Aaarons GA, Horowitz J, Dlugosz L, Ehrhart M. The role of organizational process in dissemination and implementation research. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and implementation research in health: translating science to practice. New York, NY: Oxford University Press, 2012:128–53 56. National Institutes of Health. PAR-13–055: Dissemination and Implementation Research in Health (R01). Bethesda, MD: National Institutes of Health Office of Extramural Research, 2013 57. Rittenhouse DR, Shortell SM. The patient-centered medi cal home: will it stand the test of health reform? JAMA 2009;301:2038–40 58. Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med 2010;25:584–92 59. VanLare JM, Conway PH. Value-based purchasing–national programs to move from volume to value. N Engl J Med 2012;367:292–5 60. American Hospital Association. Metrics for the Second Curve of Health Care. Chicago, IL: Health Research & Educational Trust, 2013 61. Martin J, Cheng D. Role of the anesthesiologist in the wider governance of healthcare and health economics. Can J Anaesth 2013;60:918–28 62. American Hospital Association. Hospitals and Care Systems of the Future. Chicago, IL: Health Research & Educational Trust, 2011 63. Abouleish AE, Prough DS, Whitten CW, Zornow MH, Lockhart A, Conlay LA, Abate JJ. Comparing clinical productivity of anesthesiology groups. Anesthesiology 2002;97:608–15 64. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med 2012;7:402–10
anesthesia & analgesia
