There is strong agreement among respondents to a nationwide survey that anesthesiologists’ coordination of health care following the perioperative surgical home (PSH) model will help reduce health care costs by improving efficiencies and outcomes.
A recent study found that American physicians are enthusiastic about strategies that focus on quality of health care and continuity of care, rather than strategies that focus on financial reforms (JAMA 2013;310:380-389). To that end, principal investigator Darren R. Raphael, MD, MBA, and his colleagues at the University of California, Irvine, queried anesthesiologists about the concept of the PSH, the health care model that calls for an anesthesiologist-led coordination of care extending from the decision to operate until 30 days after discharge.
After development by a task force of anesthesiologists, a cross-sectional survey was emailed to 6,000 randomly chosen members of the American Society of Anesthesiologists. Respondents were asked about responsibility for cost reduction, enthusiasm for cost reduction strategies, their understanding of the PSH model and comfort with new practice roles. Data were collected between March and May 2014.
As Dr. Raphael reported at the 2015 annual meeting of the International Anesthesia Research Society (abstract S-150), 883 anesthesiologists (14.7%) completed the survey (Table). The majority (75%) expressed fair or good understanding of the PSH model. More than half agreed that anesthesiologists should coordinate patient care from scheduling to hospital discharge (60%), and that coordination of preoperative (81%) and postoperative (64%) care should become standard.
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Less Comfort With Post-op Period
Most respondents also expressed comfort managing preoperative (95%), intraoperative (100%) and postoperative (79%) care. “In the preoperative phase, we see a very strong response of people feeling comfortable,” said Dr. Raphael, assistant professor of anesthesiology and perioperative care at the University of California, Irvine. “Although the majority of people also express feeling comfortable managing the postoperative phase, the response is less. It’s likely that people have been out of the postoperative management game for so long that they feel uncomfortable.”
Despite any trepidation they may have had about their involvement in the full spectrum of patient care, most respondents agreed that coordination of postoperative care would improve outcomes (89%) while reducing costs (82%), hospital length of stay (81%) and readmission rate (73%). In contrast, most anesthesiologists were either somewhat or not enthusiastic about Medicare payment cuts (99%), implementing bundled payments (95%) and eliminating fee for service (92%). Slightly more than half attributed the primary responsibility for cost reduction to hospitals (57%) and insurance companies (54%). About one-fifth or fewer indicated that they felt professional societies (21%), trial lawyers (18%) and employers (17%) bear no responsibility for cost reduction.
As Dr. Raphael noted, while the PSH concept is clearly gaining traction in the minds of anesthesiologists across the country, the key to successful implementation is education. “We get calls from people saying they think PSH is a great idea, but they have no idea how to implement it,” he said. “I think that’s the key to future success: not only educating people about it, but also how to go about it.”
That responsibility, he explained, falls on the shoulders of professional societies such as the ASA. “I think our societies really have to be the force that motivates us for change. We see a great example of this in the … Perioperative Surgical Home Summit, which is jointly provided by the ASA and the University of California, Irvine, Department of Anesthesiology and Perioperative Care. It would be a tragedy to leave our colleagues to their own devices; it’s a difficult thing to do on your own.”
Nevertheless, the researchers saw the PSH as an opportunity for anesthesiologists to cement their role in the spectrum of perioperative care. “I think you have to believe, first of all, that we’re on a burning platform and there’s an urgent need to move into that space,” Dr. Raphael said. “Once we realize that, we’ll really see this as an opportunity, since we are the best-placed specialty to do this work.”
Alex Macario, MD, MBA said that since the country is still in the early stages of adapting the PSH, each hospital and anesthesia group will need to determine the structure and function that work best for them. “At Stanford, there are examples that illustrate how this might work,” said Dr. Macario, who is professor of anesthesia and health research and policy at Stanford University School of Medicine, in Stanford, Calif. “For instance, a preoperative evaluation clinic has existed since the early 1990s, and clinical pathways for joint replacements were first developed more than a decade ago. The department also staffs a high-risk obstetric anesthesia clinic that consults with high-risk parturients early in pregnancy so there is a plan in place for when the patient arrives on the labor and delivery floor.”
The challenge going forward, Dr. Macario added, is to properly train anesthesiologists for the entire PSH spectrum, including evidence-based medicine. “This begins with the decision for surgery and carries through to discharge,” he said. “It includes medical consultation prior to surgery—including prehabilitation to manage risk factors—as well as postoperative care on the patient wards, which historically not many anesthesiologists have undertaken.
“There are also financial challenges,” he added, “as we need to ensure that these perioperative activities are recognized by health systems as valuable and therefore compensated appropriately.”