What’s in a name? Everything to proponents of the American Society of Anesthesiologists’ (ASA) concept of the Perioperative Surgical Home (PSH), which sees the anesthesiologists’ role in the surgical suite morphing into that of a “perioperativist.”
Alan E. Curle, MD, associate professor of clinical anesthesiology and director, Center for Perioperative Medicine, University of Rochester Medical Center, Rochester, N.Y., and Jonathan S. Gal, MD, assistant professor of anesthesiology, Icahn School of Medicine at Mount Sinai, New York City, presented their perspectives on the PSH model during the 68th New York State Society of Anesthesiologists’ Post Graduate Assembly (PGA).
“No one can escape the drumbeat of concern over the escalation of costs associated with the delivery of health care in the United States,” Dr. Curle said. “For us, as anesthesiologists, 60% of the health care dollars spent in the United States currently are being spent on procedural care. In addition, our outcomes overall—or the value for the dollars spent—are much worse than those of other countries with similar resources, based on indicators such as infant mortality and life expectancy.”
Concerns over the costs—and outcomes—associated with surgery will become even more acute, experts believe, with the continued aging of the American population, particularly as older individuals are at greater risk for complications during surgery, due to increased comorbidities. To address this, the PSH approach was launched by the ASA and modeled after a similar care philosophy—the Patient-Centered Medical Home—developed by and for primary care physicians. The PSH model is a patient-focused multidisciplinary approach designed to optimize health care value, with anesthesiologists at the head of a multidisciplinary, comprehensive care team.
The ‘Triple Aim’
“The goal of the PSH is to enhance value and to help achieve what has been termed the triple aim—a better patient experience, better health care, at a lower cost,” Dr. Curle said. “One can also consider the PSH as one side of a two-sided coin, with an accountable care organization, that takes on the coordination of patient care in a global sense.”
Under the PSH model, the anesthesiologist effectively guides the surgical process for individual patients in coordination with their center’s director of anesthesiology and the surgical team. Once it has been determined that a patient needs surgery, Dr. Curle explained, the anesthesiologist—or perioperativist—will assess the patient within the context of available data with respect to preexisting comorbidities that may lead to complications during a procedure. In addition to crafting the appropriate administration of anesthesia, the perioperativist would guide patients—and/or their families—in the determination of “best practices” and “next steps.” The perioperativist will then coordinate the surgical plan—allocating the necessary resources within the surgical center—and map out the postoperative recovery period.
“As important as the gathering of … outcomes data is on the front end, the system must allow for the easy recall of any outcomes data that can be used to decrease risk for this and future patients and reduce the costs associated with the delivery of that care,” Dr. Curle said. He added that there is potential to reduce avoidable readmissions and unsubstantiated variations in care, costs, satisfaction and hospital length of stay.
According to Dr. Gal, the anesthesiologist in the PSH model acts as an “integrator,” coordinating the “path of care from the time the procedure is booked to 30 days postoperatively.” The biggest challenge to the approach, he added, entails the “macro-system integration, which means [the anesthesiologist] getting involved in the pre-op clinic, as well as working with pharmacy, labs, physical therapy, social work and/or visiting nurse aids during the post-op period.” As evidence of the model’s effectiveness, he cited a study published by Raphael et al (Perioper Med [Lond]2014;3:6) documenting its implementation in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) at the UC-Irvine Medical Center, in California.
The PSH at UC-Irvine integrates four perioperative phases: preoperative, intraoperative, postoperative and post-discharge. The preoperative process incorporates expectation management, early discharge planning, protocol-driven health risk assessment and medical optimization. Intraoperative management includes standardized anesthetic, nursing and surgical care protocols, as well as goal-directed fluid therapy. Postoperative management provides for multimodal analgesia, a targeted recovery plan, early ambulation, nutrition management and prompt rescue from complications. Post-discharge care begins in the hospital with a coordinated transition to an appropriate rehabilitation setting.
Raphael et al found that, under the PSH model, total per-diem costs for TKA and THA were $10,042 and $9,952, respectively, significantly less than literature-reported benchmarks of $17,588 for TKA and $16,267 for THA. Costs were reduced by an overall reduction in hospital lengths of stay (from four days to three). With PSH, implant cost was $7,482 for TKA and $9,869 for THA. In-room to incision time cost was $1,263 for TKA and $1,341 for THA and surgery time cost was $1,558 for TKA and $1,930 for THA. Postanesthesia care unit time cost was $507 for TKA and $557 for THA. All of these figures are well below national benchmarks.
“A main driver for their cost savings relative to the benchmark they compare themselves to is the lack of post-discharge readmissions and hospital expenses,” explained Dr. Gal.
“There is still a lot of things we don’t know, such as how much it truly costs to implement PSH,” added Dr. Curle, who also acknowledged that anesthesiologists may be met with resistance by some other specialists who are reluctant to relinquish control.
Although he understands the desire among anesthesiologists to take a leadership role in the management of patient care in the surgical setting, Frederick L. Greene, MD, FACS, former chairman of surgery and residency program director at Carolinas Medical Center in Charlotte, N.C. said that the “concept of a medical home implies full care,” and that this may not be realistic at “all surgical sites, where the roles of anesthesiologists may be vastly different depending on the complexity of the institution and its patients.
“Anesthesiologists are supposed to know how to give anesthesia and how to give it safely,” said Dr. Greene. “While anesthesiologists should play an important role in the preparation of the surgical patient for an operation, they should not subsume the surgeon’s role in the perioperative setting. I do agree that the management of the surgical patient has to be team-based involving surgeons, anesthesiologists and nurses.”
Leave a Reply
You must be logged in to post a comment.