Value-based care and quality improvement are related concepts used to measure and improve clinical care. Value-based care represents the relationship between the incremental gain in outcome for patients and cost efficiency. It is achieved by identifying outcomes that are important to patients, codesigning solutions using multidisciplinary teams, measuring both outcomes and costs to drive further improvements, and developing partnerships across the health system. Quality improvement is focused on process improvement and compliance with best practice, and often uses “Plan-Do-Study-Act” cycles to identify, test, and implement change. Validated, standardized core outcome sets for perioperative neuroscience are currently lacking, but neuroanesthesiologists can consider using traditional clinical indicators, patient-reported outcomes measures, and perioperative core outcome measures. Several examples of bundled care solutions have been successfully implemented in perioperative neuroscience to increase value; for example, enhanced recovery for spine surgery, delirium reduction pathways, and same-day discharge craniotomy. This review proposes potential individual- and system-based solutions to address barriers to value-based care and quality improvement in perioperative neuroscience.
Value-based care and quality improvement (QI) are key components of a successful health care system and represent a shift from traditional service-volume outcomes to a focus on patient-centered outcomes, satisfaction, and experience. Recently, Scott Wallace1 advocated for an urgent shift toward value-based care in anesthesiology to avoid commoditization of the specialty.1 Others have similarly cautioned that the anticipated shift from fee-for-service to risk-based alternative payment models means that it is essential that the contribution of anesthesiology to overall quality and cost efficiency measures must be recognized, otherwise the value of physician-led perioperative care to an organization will diminish.2 System transformation within perioperative neuroscience requires several steps: identification and measurement of disease-specific, standardized, and patient-centered outcomes; implementation of bundled care initiatives; and a focus on continuous QI for patients at risk of, or diagnosed with, neurological conditions. This review will provide an overview of strategies and frameworks for value-based care and QI, define relevant patient-centered outcomes, and present examples relevant to perioperative neuroscience.
VALUE-BASED HEALTH CARE AND QI: CONCEPTS AND FRAMEWORKS
Value-based care and QI are interrelated but distinct concepts (Fig. 1). Value in health care is defined as the health care outcomes achieved per dollar spent, and value creation rests upon the improvement in measured outcomes.6 Though value is increased with efficiency, value is not simply cost reduction, depending instead on results rather than inputs.6 According to Porter,6 outcomes and costs should be measured for every patient; these outcomes should be relevant to patients, encompass short- and long-term health, and incorporate risk adjustment for baseline conditions. Value-based care should be organized around condition or patient segment through integrated units, rather than providers. Wallace and Teisberg7 have characterized these outcomes from the patient perspective in terms of capability (function), comfort (relief from suffering), and calm (ability to live normally during care). A strategic framework has been proposed to guide organizations in their transformation (Fig. 1)3; the framework starts with understanding the shared health needs of the patient group (eg, brain tumor and stroke), followed by multidisciplinary cocreation of solutions to meet those needs. Health care outcome and cost measurement is then necessary to learn and drive further improvements and expand partnerships with other centers and levels of the health system.3 Neuroanesthesiologists are ideally situated to engage in health system transformation because of their role in a specialized care team centered around patients with neurological conditions, and the current pressures on surgical services. As part of this process, neuroanesthesiologists must further engage with others outside of their immediate professional groupings and integrate into cross-disciplinary teams.
In contrast, QI typically focuses on process improvement and adherence to evidence-based guidelines, rather than outcomes.3 The Agency for Health Care Research and Quality has defined 6 domains of quality: care that is safe, effective, patient centered, timely, efficient, and equitable (Fig. 1).4 QI and patient safety initiatives often use Plan-Do-Study-Act cycles to identify, test, evaluate, and implement change to improve care systematically.5 Process measurement and compliance is important to increase the quality of care and therefore value, as even when evidence-based best practices are identified they may not be implemented. For example, previous studies have shown that few institutions “always” follow the Brain Trauma Foundation guidelines8 when managing patients with traumatic brain injury, nearly half of anesthesiologists were unaware of delirium prevention guidelines,9 and higher compliance with Enhanced Recovery After Surgery (ERAS) protocols was associated with improved outcomes.10 Ultimately, QI needs to be linked to relevant outcomes and cost efficiency to effectively drive value.6
OUTCOMES MEASURES IN PERIOPERATIVE NEUROSCIENCE
Outcome metrics allow measurement of the effect of health care processes, resource utilization, and benchmarking, and support continuous QI (Table 1). The ideal outcome metric is patient centered and reliable, and measures an outcome that is relevant to both health care service users and providers.6 Such outcomes should be generated by consensus, with clear definitions to facilitate meaningful comparison between trials, as well as for the analysis of QI initiatives.11
|Clinical indicators||A measure of health care structure, process, or outcome||Length of stay Mortality after surgery Functional outcome Unplanned readmission to hospital Unplanned ICU admission Complications after surgery Hospital-acquired infections||Variability in reporting and definitions Data comparison Validity in perioperative neuroscience Less important to patients Need for risk stratification Resources for data collection and analysis|
|Core outcomes measures or sets||Minimum outcomes that should be measured and reported in clinical effectiveness trials||In development: Chronic subdural hematoma Cranioplasty Neuro-oncology Consensus: Perioperative medicine||Validity in perioperative neuroscience Resources for data collection and analysis Risk stratification for meaningful comparison|
|Patient-centered outcomes||Outcomes measures of importance to patients||Days alive out of hospital disability-free survival PROM||Validity in perioperative neuroscience Resources for data collection and analysis|
|Patient-reported outcome measures||Standardized outcome measure reported directly by patients||Generic (nonspecific) Quality of life Health status Health care experiences Disease specific: Stroke Degenerative spine disease Epilepsy Quality of Life in Neurological Disorders NIH toolbox for Assessment of neurological and behavioral function Neurosurgery specific Chicago Chiari Outcomes Score||Validity in perioperative neuroscience Responsiveness & reliability Patient co-morbidities e.g. cognitive dysfunction and need for a tool that is validated for proxy completion Resources for data collection and analysis Need for education and training|
|Process measures||Adherence to evidence-based perioperative care||Surgical safety checklists Use of care bundles eg, central venous catheter insertion, DrEaMing, prevention of PONV||Evidence for bundled care in perioperative neuroscience Resources for data collection and analysis Education and training including improvement science|
Core outcome sets define the minimum outcomes that should be measured and reported in clinical effectiveness trials for a particular area of health care.12 Several initiatives have proposed core outcome sets, including the Core Outcome Measures in Effectiveness Trials initiative12 and Core Outcome Measures in Perioperative and Anaesthetic Care group.13 The Core Outcome Measures in Perioperative and Anaesthetic Care group has developed standardized endpoints (STePs) for perioperative medicine. Although some STePs are relevant to perioperative neuroscience, there are currently no specific core outcome sets published for postoperative neurological outcomes. The core outcome sets in development or implemented for neurosurgery include cranioplasty, chronic subdural hematoma, neuro-oncology, brain injury, and stroke.12
Clinical indicators, such as length of stay or postoperative complications, are the frequently used endpoints for trials in perioperative medicine14 and can be similarly applied in patients with neurological disease. These metrics are commonly collected for the US Merit-based Incentive Payment System, and include outcomes such as documentation of current medications, use of safety checklists, and use of combination therapy for prevention of postoperative nausea and vomiting.2 Other clinical metrics can make meaningful comparisons challenging because of variability in definitions and reporting. As examples, the incidence of postoperative delirium can vary substantially depending upon the method of assessment,15 and national quality benchmarking programs in the United States and United Kingdom have both failed to identify a significant number of complications after elective craniotomy.16 Recently, there has been a shift away from traditional outcome metrics toward outcomes that are more important to patients, including days alive out of hospital, disability-free survival, disease-specific outcomes, and patient-reported outcome measures (PROMs).
Patient Reported Outcome Measures
A PROM, which may be generic or disease specific, can be defined as “any measure of the outcome of a treatment that is reported directly by patients”17; for example, quality of life or change in symptoms. Perioperative neuroscience presents a particular challenge due to the cognitive and functional changes neuroscience patients often experience, along with their unique pathology. A recent systematic review of the neurosurgical literature identified numerous PROMs (9 generic and 17 disease specific), although few were specific to neurological surgery.17 Moonesinghe et al18 recently recommended the EuroQol-5 Dimension (EQ-5D) quality of life measure in the STePs for patient-centered outcomes in perioperative medicine.18 Although EQ-5D is validated for some neurosurgical cohorts, this measure did not improve in other cohorts, such as epilepsy surgery, indicating that more work is required to determine the best metrics to support QI/improving value of health care in perioperative neuroscience. Neuro-specific PROMs such as the Quality of Life in Neurological Disorders19 may be useful, although not specifically designed for surgical patients. As the neurosurgical patient cohort frequently experience changes in function, objective measures of functional outcome in combination with PROMs are required.20
CURRENT EVIDENCE: ENHANCED RECOVERY AND BUNDLED CARE
Within the non-neurosurgical setting, focused care bundles improve perioperative outcomes and may add value to health care. For example, the “DrEaMing” intervention advocates for the delivery of drinking, eating, and mobilizing within 24 hours after surgery. A large observational study of patients undergoing non-neurological, noncardiac surgery included in the UK Perioperative Quality Improvement Program database found that consistent compliance with the DrEaMing bundle was associated with substantial reductions in length of stay and complications.21 Whether these results are applicable to patients with neurological compromise requires further study, given the unique considerations of this population.
Other examples of successful bundled care pathways for patients at risk for neurological complications include recommendations for postoperative delirium reduction. For example, the Hospital Elder Life Program has been shown to dramatically reduce the incidence of postoperative delirium in older adults by incorporating both nonpharmacological and pharmacological interventions.22 However, bundled delirium reduction strategies have not been well defined for patients undergoing neurosurgical procedures, despite the elevated risk of postoperative delirium in this patient population.
The ERAS concept was first developed to improve the care of patients undergoing colorectal surgery, and its use has since spread to other surgical subspecialties. ERAS programs incorporate multidisciplinary, evidence-based, standardized care pathways and are relatively recent within neurosurgery; such programs reduce the incidence of complications, length of stay and costs, and improve the quality of care and patient outcomes.23 Process mapping and dashboards are examples of tools that have been successfully applied to value-based neurosurgical care to design solutions and continuously evaluate outcomes, respectively.24,25 Though current evidence supports improved outcomes with ERAS programs in spine surgery, including a reduction in complications, length of stay, and improved postoperative pain management,26 the Society for Neuroscience in Anesthesiology and Critical Care guidelines for major complex spine surgery27 noted variability in the current literature in the components relevant to anesthesia. Recent systematic reviews have also highlighted limited evidence on best practice.28 Though evidence for ERAS protocols in elective cranial neurosurgery is more limited, individual evidence-based interventions can improve recovery and outcomes.23 In the absence of robust evidence for ERAS in this patient cohort, clinicians can instead focus on improving individual aspects of care, which may be easier to implement.
The development of same-day discharge craniotomy programs is another example of multidisciplinary collaboration and process innovation to improve health care outcomes and value. In this initiative, patients reported high rates of satisfaction, decreased anxiety, and better psychological support at home, along with a decrease in complications such as infection.29 Combined with a reduction in health care costs and resource utilization, same-day discharge after craniotomy in selected patients is not only feasible but represents an opportunity to improve value.
FUTURE RESEARCH AND CHALLENGES TO VALUE-BASED CARE IN PERIOPERATIVE NEUROSCIENCE
Improving value and quality of care for patients at risk for neurological complications or for those undergoing neurological procedures is a worthy goal, yet most health care institutions struggle to do this effectively. Barriers and potential solutions to the implementation of value-based care and QI in surgical patients with neurological disease are summarized in Table 2 and discussed below.
|Lack of validated, robust, consensus-driven indicators of success||Individual||Start with pragmatic, easy-to-measure process outcomes for QI initiatives (eg, length of hospital or PACU stay, compliance with protocols, complications, patient satisfaction). Gather information from neurological patients about what they care about most in their health journey. Consider using nonsurgical validated neurological patient-reported outcomes (eg, NIH Toolbox for Assessment of Neurological and Behavioural Function, Quality of Life in Neurological Disorders).|
|System||Support national or specialty-wide development of consensus-driven core outcome sets for periperative use across organizations and countries (eg, COMET, PROMIS), with focus on neurological diseases and outcomes.|
|Lack of skills and expertise to implement quality improvement and value-based care||Individual||Take advantage of cross-disciplinary skill sets and collaboration in complementary specialties, eg, surgery, neurology, internal medicine. Provide training and embed skilled champions into local teams caring for neurologically impaired or at-risk surgical patients.|
|System||Integrate formal skill development in QI and value-based care into residency and neuroanesthesia fellowship programs. Define learning objectives and formal curricula.|
|Inadequate resources for outcome measurement||Individual||Focus on a limited number of feasible, core outcomes to start. Smaller/less resourced organizations can learn and extrapolate from more highly resourced systems Enhance collaboration with multidisciplinary teams focused on neurological patients (eg, neurosurgery, neurology, neurointerventional radiology) to share outcome databases and innovate process. Start with regular multidisciplinary rounds and reports.|
|System||Advocate for health care organizations to commit infrastructure and resources for measurement of disease-specific patient-reported outcomes for patients with neurological conditions, eg, stroke and brain tumor.|
First, anesthesiology commonly lacks validated, robust, consensus-driven indicators of success to demonstrate the role of anesthesiologists in creating value.1 Given the unique features of patients with neurological disease, further work is required to identify optimal perioperative outcomes for this cohort.30 Although surrogate metrics are often collected (eg, preoperative antibiotic administration), they typically focus on process compliance, are rarely patient-centered, and do not directly measure outcomes. Some neuroanesthesiologists may view their role as having limited impact on patients’ functional outcomes, even though anesthetic management is integrated across the care pathway for many neurological diseases and can have significant impact on the prevention of secondary brain injury, complications, time to discharge, quality of recovery, and experience. As a result, neuroanesthesiologists and organizations alike may not appreciate the contribution that anesthetic management makes to value-based care pathways. One solution is for anesthesiology groups caring for patients with neurological conditions to strengthen multidisciplinary perioperative teams to share data and cocreate solutions. For example, as neuroanesthesiologists are increasingly an essential part of the clinical pathway for endovascular thrombectomy for acute ischemic stroke, aspects of anesthesia care should be integrated into key indicators of success (eg, time to reperfusion, functional outcomes, and mortality). Similarly, neuroanesthesiologists are closely integrated in enhanced recovery after spine surgery programs and should collaborate with spine surgery teams to share metrics, define outcomes, and innovate processes.
Another barrier to health care transformation is lack of training and skills to implement value-based health care and QI. Most clinician education programs do not provide trainees with core competencies in QI and value-based care implementation,31 although there are examples of successful innovation and integration into anesthesiology residency32 and surgical fellowship33 curricula. Notably, the International Council for Perioperative Neuroscience Training accreditation body for neuroanesthesia fellowship training explicitly incorporates quality assurance conferences and simulation in curricular guidelines,34 though whether individual sites are well-equipped to undertake this component of training is uncertain. Recently, hospitals and health care organizations are offering mentorship, training, and support for QI initiatives to develop skilled “champions” of QI and value-based care who can then support neuroanesthesia-focused groups.
A further frequent barrier to health care transformation is a lack of robust infrastructure and resources to measure and report patient-centered outcomes and inform system improvement, particularly given the overworked and exhausted health care workforce.
Appropriate risk adjustment is essential when assessing performance metrics to account for differences in populations served and to avoid penalizing organizations that serve vulnerable populations.3 A recent analysis of the US Merit-based Incentive Payment System program found that anesthesiologists who serve low socioeconomic status populations were less likely to receive incentive payments, suggesting insufficient risk adjustment.2 Furthermore, in patients with neurological injury, predictors may differ depending on the type of outcome used. For example, predictors of 3-month EQ-5D differed considerably from the predictors of other clinical outcomes, such as mortality and modified Rankin Scale, after ischemic stroke.35 Overall, optimal risk adjustment for patients with neurological conditions requires further investigation to determine optimal disease-specific outcome measures and appropriate risk adjustment for meaningful comparison.
Health care systems are facing increased pressures, providing incentive to evolve toward a model of value-based care with strong QI programs. Neuroanesthesiologists should apply these frameworks to the care of patients with neurological disease by identifying and measuring disease-specific, patient-centered outcomes, by developing multidisciplinary teams, by applying continuous QI, and by increasing efficiency. Applying these concepts will support surgical patients with neurological disease to retain capabilities, receive health care without chaos, and minimize pain and suffering.