May 14, 2012

“Coordinated care” is one of the key concepts in health system reform.  It is central to the cost savings and quality improvements expected from Accountable Care Organizations, value-based purchasing and the medical home.  It is also the basis of the American Society of Anesthesiologists’ model, the perioperative surgical home.

A just-published study demonstrates the potential of coordinated management of patients, inter alia, to reduce complications in knee replacement surgery.  A research team from the High Value Healthcare Collaborative used administrative data to examine differences in their delivery of primary total knee replacement (TKR) care.  They reported their findings in A Collaborative Of Leading Health Systems Finds Wide Variations In Total Knee Replacement Delivery And Takes Steps To Improve Value (Ivan M. Tomek, Allison L. Sabel, Mark I. Froimson, George Muschler, David S. Jevsevar, Karl M. Koenig, David G. Lewallen, James M. Naessens, Lucy A. Savitz, James L. Westrich, William B. Weeks, and James N. Weinstein, published 10 May 2012, 10.1377/hlthaff.2011.0935.  The article will appear in the June 2012 print edition of Health Affairs.)

The study team identified nine conditions and procedures to examine based on prevalence and the national level cost of treatment.  TKR was first on the list, for several reasons:

1. In 2008, TKR inpatient costs exceeded $9 billion, the highest aggregate cost among the ten surgical procedures for which demand is growing the fastest.  (Growth in demand is not surprising, perhaps, when one considers that knee implant manufacturers have begun advertising their devices directly to consumers.  (See, e.g., TIME Magazine, May 7, 2012, p. 2. Stryker’s advertisement for its “GetAroundKnee.”)
2. TKR is much more effective in treating severe knee disease than medical management.
3. Population-level data on TKR procedures and outcomes do not yet exist in the United States.
4. There is wide variation in knee arthroplasty rates among Medicare enrollees based on geographic location as well as race and gender, according to the Dartmouth Atlas Project.

The researchers identified variations in care, processes, resource consumption, discharge dispositions and outcomes.   Across health care systems, hospital length of stay and operating time varied significantly (minimum mean operating time: 80 minutes; maximum: 105 minutes).  Longer operating time was associated with longer lengths of stay, and mean operating time decreased with surgeon caseloads.  TKRs done later in the week had longer lengths of stay and higher inpatient complication rates.  Increased medical co-morbidity has been associated with increased complication rates. Greater surgeon caseloads were also inversely related to complications. Earlier studies have shown similar results. 

The High Value Healthcare Collaborative partners’ analysis of variations in TKR delivery led them to decide to focus their subsequent efforts on three key findings:

1. Coordinated management of patients.  “First, we found that the health system with the lowest in-hospital complication rate had successfully developed and implemented an outpatient preoperative approach that emphasized multispecialty evaluation of potential arthroplasty candidates, followed by an inpatient comanagement approach involving anesthesia, internal medicine, and orthopedic surgery.”
2. Dedicated operating room team.  “The benefit of a dedicated operating room team seems logical, given that total knee replacement is a procedure that requires staff to be familiar with multiple pans of instruments, machinery, and other technologies that are used to implant the knee prostheses. The total knee replacement surgeons agreed that working with an experienced arthroplasty team led to a smoother and faster workday.”  The article does not mention anesthesiologists or nurse anesthetists as part of the dedicated OR team, but it seems reasonable that familiarity across both sides of the ether screen would be beneficial.
3. Management of patients’ expectations.  “[A]fter having examined its data, one member health care system implemented a patient expectations management process, whereby patients were activated and engaged in the process of discharge planning before admission. The result was an initial reduction in length-of-stay, without a change in complication rates.”

The Collaborative researchers were thus able to examine basic administrative data (including information about the hospital stay, length of hospitalization, and type of admission; patient demographics; source of admission; payer; diagnosis codes; procedure codes; charges; discharge disposition; and the operating surgeon) in a new way, identifying several potential innovations that warranted further investigation or implementation.  The first of those potential innovations, as shown above, emphasizes multispecialty evaluation of potential arthroplasty candidates, “followed by an inpatient comanagement approach involving anesthesia, internal medicine, and orthopedic surgery.”

This begins to sound a lot like the perioperative surgical home that ASA is hoping to make the subject of demonstration projects in the near future.  There is no detail in the Health Affairs article on the “multispecialty evaluation” or the “inpatient comanagement approach.” Coordination strategies described in Report [310-3.2], “Surgical Home Draft Proposal,” submitted to the ASA House of Delegates on Aug. 21, 2011, by then ASA President Mark Warner, M.D. provides suggestions for areas to be explored in terms of their ability to improve outcomes and/or reduce unnecessary costs.  The summary below comes from the California Society of Anesthesiologists’ Winter 2012 Bulletin.

To achieve success for the surgical home, the following may be required:

• Surgeons, internists and family practitioners, in either an inpatient or an outpatient setting, would involve the anesthesiologist in patient assessment, and do so earlier in the presurgical period than occurs under the current common practice of non-anesthesiologist physicians and nurses evaluating patients shortly before surgery and determining which tests and studies are needed. This schema for change in practice would potentially avoid unnecessary (and duplicative) tests and studies, and the results of those deemed necessary would be available in a timely manner for the anesthesiologist. Surgical delays and last minute postponements would be minimized.
• Earlier contacts with patients, soon after decision to operate, would allow for the various anesthetic and postoperative management options to be discussed and explained, making for better-informed patients who now would be more empowered to partner with their physicians. Patient satisfaction would be enhanced.
• Primary care physicians, anesthesiologists and other medical and surgical physicians would work to improve communication and coordination of care and be better positioned to address complications or patient concerns as well as to provide for efficient and effective transfers of care between all health care settings.
• Anesthesiologists would become more involved in the development of hospital protocols and systems that positively impact perioperative management. Examples include anticoagulation, transfusion and diabetic management guidelines; strategies to ensure timely administration and re-administration of antibiotics; and educating physicians and nurses on issues, such as pain management, that frequently contribute to prolonged hospitalization.
• Other areas that can be systematically retooled would include the availability of essential airway management equipment and skills throughout the hospital; development and oversight of rapid response teams; efficient and cost-effective preoperative testing (such as echocardiograms, pulmonary function tests); fluid resuscitation, shock treatment and cardiopulmonary resuscitation protocols.
• Coordination and oversight of a variety of functions that improve outcomes and curb postoperative pain, morbidity and mortality.

Most of the strategies listed above are objectively measurable.  To the extent that data cannot be pulled—or cannot be pulled easily—from the patient’s hospital record or the anesthesia record, one can design and implement systems on various platforms that will capture the data one wishes to analyze.  ABC continues to develop and enhance our integrated software platform, OneSourceAnesthesia, which interfaces with hospital and EHR technology.  This platform, and our partnerships with other health information systems vendors, should facilitate the recording and reporting of virtually any information relevant to the perioperative surgical home.  We would be delighted to help with the specific data needs of any client who is designing an appropriate demonstration project.

With best wishes,

Tony Mira
President and CEO