Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of AnaesthesiaUniversity of OttawaHead of AnaesthesiaThe Ottawa HospitalScientist, Ottawa Hospital Research Institute

Defining Value in Regional Anesthesia:

What are the Important Outcomes and Who Gets to Define Them

Conflicts of Interest

None

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)

Institute for Healthcare Improvement

Triple Aim in Healthcare

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

Elements of Value-Based Purchasing

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

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

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.

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

382,000 patients 25% neuraxial Neuraxial associated with less

mortality, length of stay, in-patient morbidity

Anesthesiology 2013

Reduced postoperative pain, opioid consumption, adverse effects

No difference in blood loss or TE events

No difference in mortality

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

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

CQUINS for 2014/15

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

What is patient experience?

“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

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

Value of RA on short term outcomes

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

23 RCTs in total Pooled 3 studies for epidural after

thoracotomy and 2 for PVB after breast surgery

Andreae MH et al BJA 2013

Value of RA in major outcomes?

382,000 patients 25% neuraxial Neuraxial associated with less

mortality, length of stay, in-patient morbidity

Anesthesiology 2013

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

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

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

OR Time

KneesHips

Type

125

100

75

50

25

0

Mea

n S

urg

ical

Tim

e

Error bars: +/- 1 SD

2007

2004

Year

17% decrease in time for patient-in to patient-out from 2004 to 2007 in total knee arthroplasties18.6% decrease in time required from patient-in to patient-out for total hip arthroplasties

OR Overtime(* cancellations)

June July September October0

5

10

15

20

25

30

35

2004

2007

Ove

rtim

e (h

ou

rs)

*27

*14

*21*11

4

53

8

Defining Value in Regional Anesthesia

Improved pain controlLess adverse effects

Mortality and Morbidity Benefits

Greater Efficiency, Faster discharge

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/