1.
@EMARIANOMD
How Regional Anesthesia
Can Improve Outcomes
that Matter
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System

2.
@EMARIANOMD
Disclosures
 None financial.
 Other disclosures:
– FDA public workshop on regional anesthesia
– CMS quality and cost measures
– The Joint Commission hospital-based pain
management standards
– ACGME accreditation of regional
anesthesiology and acute pain medicine
– National Academy of Medicine action
collaborative countering the opioid epidemic

3.
@EMARIANOMD
Society
Healthcare
System
Patient

4.
@EMARIANOMD
Society
Healthcare
System
Patient

5.
@EMARIANOMD
Start with the Patient

6.
@EMARIANOMD
“Personalize” Pain Medicine

7.
@EMARIANOMD
What Do Patients Know?

8.
@EMARIANOMD
What Do Patients Want?

9.
@EMARIANOMD
Which Functional Outcomes?
 Range of motion
(degrees)
 Timed ambulation
distance (meters)
– 6-MWT
– 2-MWT
 Muscle strength
(force)
 Timed performance
(min)
– TUG
 Western Ontario and
McMaster Univ
Osteoarthritis Index
(WOMAC)
 Knee Society Score
 Lower Extremity
Functional Scale
 Health-Related
Quality of Life
Choi S, et al. RAPM 2013;38:340
Bernucci & Carli. Curr Op Anaes 2012;25:621
Performance-Based Self-Reported
&

10.
@EMARIANOMD
For regional anesthesia
to improve outcomes,
it has to be accessible
to ALL.

11.
@EMARIANOMD
2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016

12.
@EMARIANOMD
2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016
100% at VA Palo Alto

13.
@EMARIANOMD
So Many Options
Kandarian, Elkassabany, Tamboli, Mariano. Best Pract, in press

14.
@EMARIANOMD
So Many Options
Kandarian, Elkassabany, Tamboli, Mariano. Best Pract, in press

15.
@EMARIANOMD
Society
Healthcare
System
Patient

16.
@EMARIANOMD
Regional Anesthesia is One Part
Anesthesiology 2012;116:248

17.
@EMARIANOMD
We Love Regional Anesthesia

18.
@EMARIANOMD

19.
@EMARIANOMD
Have We Made Regional
Anesthesia Too Difficult?

20.
@EMARIANOMD
Evaluate New Blocks/Protocols
Mudumbai & Mariano, et al. Pain Manag 2018;8:475

21.
@EMARIANOMD
Evaluate New Blocks/Protocols
Mudumbai & Mariano, et al. Pain Manag 2018;8:475
Point system
= 100 total
25
50
15
10
Practice-
dependent

22.
@EMARIANOMD
Protocol = Checklist, Not a Recipe
Hebl JR, et al. JBJS 2005;87 Suppl 2:63

23.
@EMARIANOMD
VALUE = Quality
Cost

24.
@EMARIANOMD
CMS Fee-for-Service to MIPS 2017
https://qpp.cms.gov/
Promoting
Interoperability
Updated in 2019

25.
@EMARIANOMD
CMS Fee-for-Service (MIPS)
60%25%
15%
2017
Quality
Advancing Care Information
Improvement Activities
45%
25%
15%
15%
2019
Quality
Promoting Interoperability
Improvement Activities
Cost
https://qpp.cms.gov/

26.
@EMARIANOMD
Pain Quality Measures
https://www.asra.com/news/185/four-new-quality-pain-measures-approved
Under Consideration for MIPS

27.
@EMARIANOMD
CMS Fee-for-Service (MIPS)
60%25%
15%
2017
Quality
Advancing Care Information
Improvement Activities
45%
25%
15%
15%
2019
Quality
Promoting Interoperability
Improvement Activities
Cost
https://qpp.cms.gov/

28.
@EMARIANOMD
Episode-Based Cost Measures
30 days
before to
90 days
after

29.
@EMARIANOMD
Role of Acute Pain Service
Hernandez-Boussard, et al. Ann Surg 2017;266:516
Postoperative pain trajectories identify populations at risk for
30-day readmissions and ED visits

30.
@EMARIANOMD
Resource Utilization
 >1 million patients
 PNB associated with:
– Lower rates of complications
– Decrease length of stay
– Lower rates of transfusion
– Lower rate of ICU admission (THA only)
Memtsoudis SG, et al. Anesth 2013;118:1046

31.
@EMARIANOMD
Society
Healthcare
System
Patient

32.
@EMARIANOMD
Death?
 30-day mortality was lower for neuraxial
and neuraxial/GA vs. GA alone for TKA
 Most in-hospital complications were lower
for neuraxial and neuraxial/GA vs. GA alone
 Transfusion requirements lowest for
neuraxial
Memtsoudis SG, et al. Anesth 2013;118:1046

33.
@EMARIANOMD
Chronic Pain?

34.
@EMARIANOMD
Cost of Chronic Pain
https://www.sciencedaily.com/releases/2012/09/120911091100.htm

35.
@EMARIANOMD
Cancer Recurrence?
 14 studies met criteria EA±GA vs. GA
(including Cummings study, n=42,151)
 Improved overall survival with EA
 No difference in cancer recurrence
Chen & Miao. PLOS ONE 2013;8:e56540
Cummings KC, et al. Anesth 2012;116:797
Does the intervention match
the trajectory of recovery?

36.
@EMARIANOMD
Opioid Abuse?

37.
@EMARIANOMD
Mudumbai & Mariano, et al. Pain Med 2016;17:1732
The Opioid Crisis is Complex

38.
@EMARIANOMD

39.
@EMARIANOMD
How Long Does Pain Last?
Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients at
3 months
42% Pain Free
47% Persistent Pain
11% Neuropathic Pain

40.
@EMARIANOMD
Opportunities for Pain Medicine
Mariano, Walters, Kim, Kain. A&A 2015;120:1163
Walters, Mariano, Clark. Pain Med 2015;16:1666.

41.
@EMARIANOMD
Transitional Pain
Katz, et al. J Pain Res 2015;8:695
Huang, et al. Pain Manag 2016;6:435

42.
@EMARIANOMD
Summary
 We discussed how regional anesthesia can
improve outcomes that matter to:
– Our patients
– Healthcare systems
– Society