Using Anesthesiologists As Peri-op Hospitalists Improves Outcomes

Author: Michael Vlessides

Anesthesiology News

A pilot project has concluded that using anesthesiologists as perioperative hospitalists may offer both financial and patient care benefits for institutions. The study found that using anesthesiologists in this role decreased patients’ length of stay (LOS) after urologic surgery while reducing complication rates and total direct patient costs.

“Within the context of a surgical episode of care, who assumes the role of perioperative physician?” asked Gary R. Stier, MD, an associate professor of anesthesiology, internal medicine and critical care medicine at Loma Linda University Medical Center, in California. “We believe that anesthesiologists are well suited as perioperative hospitalists, since we’re experts in nearly all phases of the surgical episode.

“Expending the role of the anesthesiologist within the perioperative paradigm can help streamline the processes of care through each phase of the surgical episode, from preoperative preparation through hospital discharge,” Dr. Stier continued. “Such involvement utilizes the unique training of anesthesiologist to provide enhanced value, both for patients and the health care organizations in which they work.”

“We hypothesized that implementation of this model would result in an improvement in patient recovery,” Dr. Stier said.

The researchers assessed the impact of the program by comparing data from before and after its implementation. The study’s primary outcome was LOS; secondary outcome measures included complication rates, return of bowel function, number of consultations, total direct patient costs and number of bed-days.

Success Prompts Question: Do Anesthesiologists Want This?

As Dr. Stier reported at the 2018 annual meeting of the American Society of Anesthesiologists (abstract A1013), pre- and post-implementation data were compared with and without propensity matching. Propensity matching found statistically significant reductions in LOS for all three surgical procedures (P<0.05).

Indeed, this analysis revealed that LOS fell from a mean of 2.0 days to 1.0 day after prostatectomy (P=0.009), from 4.0 to 3.0 days after nephrectomy (P<0.001), and from 9.0 to 7.0 days after cystectomy (P=0.009).

“If you look at the total length of stay in aggregate, 246 bed-days were saved over the two-year period of implementation of the hospitalist service,” Dr. Stier explained. “So if you assume that the average length of stay for an intermediate-risk surgery is three or four days, those extra bed-days could have accommodated an additional 60 procedures.”

Similarly, both analyses revealed significant reductions in complication rates and ileus when anesthesiologists ran the perioperative hospitalist service. Perhaps not surprisingly, reductions in total direct patient costs and the frequency of consultations also were observed.

In the propensity-matched analysis, for example, direct costs dropped 5.59±2.54% in prostatectomies, 15.88±3.18% in nephrectomies and 22.15±6.21% in cystectomies. The number of consultations in this analysis dropped from four to two among prostatectomy patients, from 19 to 11 among nephrectomy patients, and from eight to three among cystectomy patients.

The success of the anesthesiologist-led perioperative service has not gone unnoticed at Loma Linda. Since August 2017, the hospital has asked the service to transition to other surgical specialties. “Interestingly, we’ve looked at the urology data since we left and have found that the length of stay numbers are once again starting to climb a bit,” Dr. Stier said.

Given the strength of these findings, the investigators were confident that anesthesiologists can successfully use their skills to serve as hospitalists. “Within the changing landscape of perioperative care, emphasis has been placed on anesthesiologists to diversify their practice paradigms to maintain a specialty significance within the field of medicine,” Dr. Stier concluded. “This study suggests that perioperative care coordination and postoperative management are definitely within our skill set, and actually demonstrates the ability of anesthesiologists to function in the role of perioperative hospitalist.”

Girish P. Joshi, MBBS, MD, a professor of anesthesiology and pain management at the University of Texas Southwestern Medical Center, in Dallas, agreed that involving anesthesiologists in the postoperative care of surgical patients improves surgical outcomes. “In 2007, we published an article emphasizing that anesthesiologists embrace their role as perioperative physicians and expand their scope into postoperative care [Proc (Bayl Univ Med Cent) 2007;20(2):140-142],” Dr. Joshi said.

“We already play a major role in preoperative evaluation and the optimization of surgical patients, and moving into the postoperative period naturally allows for the continuation of care,” Dr. Joshi continued. “In fact, recent studies suggest that postoperative outcomes would improve if we continued the excellent intraoperative care we provide our patients into the postoperative period.

“However, as we state in the 2007 article, the question remains if anesthesiologists will seek or accept broader perioperative responsibilities,” he added. “It is possible that younger anesthesiologists may get involved in postoperative/perioperative care if the American Board of Anesthesiologists creates a board certification in perioperative medicine, similar to its board certification in sleep medicine.”