Judging by the experience of two large hospitals, the perioperative surgical home (PSH) model of care can create substantial cost savings, an important benefit as the idea seeks to be widely adopted.
The PSH model is a patient-focused multidisciplinary approach whose goal is to optimize health care value, with anesthesiologists at the head of a multidisciplinary, comprehensive care team. At the American Society of Anesthesiologists’ annual meeting in New Orleans, physicians from Kaiser Permanente in California and Ochsner Health System in Louisiana, reported that PSHs have reduced hospital lengths of stay (LOS), kept patients out of skilled nursing facilities (SNFs) and reduced the costs associated with care.
The transition from a system of volume-based reimbursement to one that is value-based has created both uncertainty as well as new opportunities for the specialty of anesthesiology, according to Chunyuan Qiu, MD, of Kaiser Permanente’s Baldwin Park Medical Center. “As a result, reengineering the perioperative processes is not only an imperative for the present, but also a necessity for the future of anesthesiology,” he said.
The PSH provides “broader, deeper care” to patients and conveys “tremendous financial and professional rewards,” Dr. Qiu said. He calculated his hospital saved more than $1 million by caring for 516 patients in the PSH model compared with a traditional model.
“In our view, anesthesia practice needs to go beyond the operating room. The PSH allows us to practice the 2.0 version of anesthesia,” he said in his presentation, which earned a Best Clinical Abstract distinction.
Dr. Qiu’s co-investigator, Narendra S. Trivedi, MD, who described the Kaiser Permanente model at another session, said that although the PSH involves slightly more work for anesthesiologists and less for surgeons, the gain to anesthesiology is clear. “We are getting out of our small silo of the OR [operating room] to become entire perioperative physicians. The hospital is happy—it is getting results, saving money. Patients are happy. We have enlarged our scope of practice and this makes us happy. Surgeons work less, so they are happy. There’s no losing here.”
The aims of the PSH include medical optimization of the patient before surgery, intraoperative anesthetic management and postoperative facilitation of functional recovery after discharge—all coordinated by anesthesiologists.
“Traditional patient care is sequential, decentralized and has a lot of gaps. PSH is patient-centered, multidisciplinary and anesthesia-linked, with functional recovery as a part of it,” Dr. Qiu explained. “It means we are not just looking at nausea and vomiting, or morbidity. We are providing a blueprint for our patients to be healthier as a result of better overall functioning.”
Kaiser Permanente Model: Total Knee Arthroplasty
At Baldwin Park Medical Center, medical optimization begins at the first appointment with the anesthesiologist, three to 14 days before the scheduled total knee arthroplasty. High-risk patients have a joint consultation with an anesthesiologist and internist in a single appointment. The specialists then formulate a coordinated plan for perioperative care.
Dr. Qiu and his colleagues compared outcomes between 518 patients treated over eight months using the PSH care model and 546 patients cared for under the hospital’s traditional fast-track model during the previous year. They found the PSH group had shorter LOS, fewer SNF admissions and lower costs of care, with no compromise in patient satisfaction or quality of care (Table).
Table. Outcomes for PSH vs. Fast-Track
Outcome PSH (N=518) Fast-Track (N=546) P Value
Spinal anesthesia, % 74.3 43.7 <0.05
Nerve block rate, % 99.9 50.1 <0.05
Mean hospital LOS, d 1.9 3.2 <0.05
All pain scores <4, % 64 68 NS
POD 0 physical therapy, % 78. 7 0 <0.05
POD 1 home discharge, % 43. 1 0 <0.05
30-d readmission, % 1.2 0.9 NS
SNF bypass rate, % 94 80 <0.05
LOS, length of stay; NS, not significant; POD, postoperative day; PSH, perioperative surgical home; SNF, skilled nursing facility
The improvements above and beyond “what were already very good outcomes,” according to Dr. Qiu, resulted in substantial cost savings. There were 72 fewer SNF admissions (279 fewer than the national average). Hospital LOS was reduced by 673 days (by 1,088 days vs. the national average). The hospital’s potential cost savings (by 2014 fee schedules) for these 518 patients was $1,1912,538.
“Any company looking at this number would support the concept of having anesthesiologists manage perioperative care,” Dr. Trivedi said. Based on these results, Kaiser Permanente will consider implementing the PSH in other hospitals, he said.
Ochsner Health System Model: Total Hip Replacement
For its pilot PSH program, Ochsner Hospital chose patients having primary total hip arthroplasty (THA), an area with room for improvement, said David Broussard, MD, vice chair of anesthesiology.
In 2013, a patient’s average LOS for a THA was 3.5 days, but with the PSH, instituted in March 2014, this dropped to 2.1 days. “This is more than a full day less, which creates more capacity in the hospital, decreases the patient’s risks related to hospitalization and reduces cost of care,” Dr. Broussard said in an interview.
With an anesthesiologist coordinating care, the patient is assessed preoperatively for frailty and risk for complications using a comprehensive triage process. An anesthesiologist coordinates the preoperative workup and ensures the patient is medically optimized, focusing on identifying and remediating risk, educating patients and decreasing unnecessary testing. “Prehabilitation,” nutritional counseling, correction of anemia and other interventions are employed as needed, according to Matthew E. Patterson, MD, who presented the study at the late-breaking abstract session.
The intraoperative and postoperative processes were standardized, and included the following:
• For surgery, combined spinal epidural is the anesthetic of choice unless contraindicated. IV fluid is standardized to minimize risk for postoperative acute renal injury.
• Postoperatively, the anesthesiologist makes rounds daily to medically manage and coordinate postoperative care; the goal is “rapid de-escalation of care.”
• Epidural analgesia is discontinued the morning of postoperative day 1.
• Physical therapy is initiated on the day of surgery in the recovery room, then twice daily.
• Low-frailty patients who perform well in physical therapy are eligible for discharge on postoperative day 1.
The pilot met its milestones. Before the PSH was implemented, 27% of patients transitioned to a SNF and only 5% were capable of home self-care. Today, only 17% go to SNF and 14% manage home self-care. The average Harris Hip Score, a measure of outcome, was 94%. The decrease in hospital LOS resulted in increased hospital bed capacity, which accrued an additional $201,931 income per year, Dr. Patterson reported.
Furthermore, Ochsner is the first hospital to have the Anesthesia Quality Institute’s survey on Patient Satisfaction and Experience with Anesthesia incorporated into its electronic medical records. In that survey, 95% of PSH patients gave their experience the highest satisfaction rating.
“Our PSH model achieved the triple aim of providing high-quality patient care and high patient satisfaction while reducing overall cost of care,” Dr. Patterson reported.
Need for More Evaluation
Michael J. Avram, PhD, who moderated the Best Clinical Abstracts session, commented on the studies for Anesthesiology News. Dr. Avram, of Northwestern University Feinberg School of Medicine, in Chicago, is executive editor of Anesthesiology.
“There is a need and a movement to redefine the specialty of anesthesiology in terms of the PSH. In creating this movement, I think there is also a need for top-drawer research evaluating this model and comparing it with our present models of care,” he said. “We need this so that we can say whether or not PSH really has a positive impact on patient care as well as economics, and therefore is an advantage, not just to anesthesiology—in terms of a new practice paradigm—but also in terms of outcomes for the patient.”