Asra defining value may 2015
- 1. Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPC Professor and Chair of Anaesthesia University of Ottawa Head of Anaesthesia The Ottawa Hospital Scientist, Ottawa Hospital Research Institute Defining Value in Regional Anesthesia: What are the Important Outcomes and Who Gets to Define Them
- 2. Conflicts of Interest None
- 3. Important outcomes: who gets to define? Patient: Board of governors, Patient advocates, Research: patient oriented Provider/Physician: Private model driven by quality, patient experience and efficiency Government: More and more involved through incentive driven outcomes e.g. CQUINS (UK), QBPs (Ontario) and CMS (US)
- 4. Institute for Healthcare Improvement Triple Aim in Healthcare
- 5. USA Centre for Medicaid and Medicare Services (CMS) Best Care at Lower Cost 2012 Performance transparency between providers and consumers Set % of withhold of payments based on performance related payments Currently 1.25% and increasing each year
- 6. Elements of Value-Based Purchasing
- 7. Patient Experience of Care HCAHPS 32 questions Publicly reported 4 times per year 7 questions that directly or indirectly relate to pain Acute pain medicine needed for many reasons! www.edmariano.com
- 8. Quality-Based Procedures and Cost-Per Weighted Case (Ontario) Ontario: 13.5 million people OHIP covers all medical care (tax-based system) Quality-based procedures being standardized based on best evidence Hospitals measured on case cost (per weighting) and funded/penalized based on costs
- 9. Quality Based Procedures (QBP) ‘Price x Volume’ approach Funding allocated to procedures targeting areas demonstrating opportunity to: – introduce evidence into clinical pathways – reduce practice variation – attain cost efficiencies – catalyze alignment of quality and funding.
- 11. How are guidelines developed? Expert consensus Health Quality Ontario Hip fracture/Hip and knee arthroplasty Try as much as possible to use evidence from the literature Often evidence poor or not present Underlines importance of research in our specialty
- 14. 382,000 patients 25% neuraxial Neuraxial associated with less mortality, length of stay, in-patient morbidity Anesthesiology 2013
- 15. Reduced postoperative pain, opioid consumption, adverse effects No difference in blood loss or TE events No difference in mortality
- 17. Strengths/Limitations of QBPs Strengths: first attempt to standardize practice across Ontario, Drives KT process, Drives further research Weaknesses: based on limited evidence, opinion-based, limited input from patient experience of care, most funding remains based on geography/population base
- 18. Commisioning for Quality and Innovation Payments (CQUINS) UK Targets/Drivers for which hospitals can obtain extra revenue Goal-directed therapy for major abdominal surgery Time to surgery for hip fracture Dr. Foster-independent organization measures and publishes outcome data across centres in England
- 20. Important outcomes: what are they? Patient: pain, function, awareness, nausea Physician: Quality and safety. Efficiency Hospital: Patient experience, Q+S, Efficiency Society: Quality and safety, Patient experience, Efficiency
- 21. What is patient experience?
- 22. “a national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years” http://www.theatlantic.com
- 23. How can regional anesthesia influence value Triple aim: Quality, Health of populations and Cost Reduces pain: both acute and chronic Reduces AEs related to opioid sparing Reduction in cost: reduced overtime, case cancellations
- 24. Value of RA on short term outcomes
- 25. RA and short term outcomes Reduced pain Reduced nausea Faster discharge Faster return of GI function Improved rehabilitation Reduced respiratory complications Reduced MI and CVS complications etc etc
- 26. 23 RCTs in total Pooled 3 studies for epidural after thoracotomy and 2 for PVB after breast surgery
- 27. Andreae MH et al BJA 2013
- 28. Value of RA in major outcomes?
- 29. 382,000 patients 25% neuraxial Neuraxial associated with less mortality, length of stay, in-patient morbidity Anesthesiology 2013
- 33. How can regional anesthesia influence value Increased efficiency: block room model, enhanced recovery, discharge, ambulatory care Reduced readmission: better pain control Population Health: reduced mortality and possible effects on other outcomes
- 34. A Day in the OR: pre-block room OR time map AT PPD surgery out TO 20 15 75 15 20 52 % efficiency OT = 95 min
- 35. A Day in the OR OR time map with RA + block area: AT is outside the OR in the block area AT PPD surgery out TO 75 min15 6 20 65% efficiency OT = 0 min
- 36. OR Time KneesHips Type 125 100 75 50 25 0 MeanSurgicalTime Error bars: +/- 1 SD 2007 2004 Year 17% decrease in time for patient-in to patient-out from 2004 to 2007 in total knee arthroplasties 18.6% decrease in time required from patient-in to patient-out for total hip arthroplasties
- 37. OR Overtime (* cancellations) 0 5 10 15 20 25 30 35 June July September October Overtime(hours) 2004 2007 *27 *14 *21 *11 4 5 3 8
- 38. Defining Value in Regional Anesthesia Improved pain control Less adverse effects Mortality and Morbidity Benefits Greater Efficiency, Faster discharge
- 39. Further reading: ACS Physician quality reporting system: https://www.facs.org/advocacy/regulatory/pqrs Pay for Performance in periop pain: http://www.edmariano.com/archives/684 Triple aim: http://www.ihi.org/Engage/Initiatives/TripleAim/ pages/default.aspx Dr. Foster: http://www.drfoster.com/about-us/