Anesthesiology: Past, Present, and Future
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The medical specialty of anesthesiology is founded on patient experience and patient safety. Having major surgery would be a very different experience without anesthesia. Before the advent of safe anesthesia techniques, the world of surgery was basically limited to amputations and other attempts at life-saving maneuvers. Dr. Bigelow’s publication describing the safe administration of ether changed everything, and the New England Journal of Medicine called this the most important article in its history. With this article, the science and clinical practice of anesthesiology, as well as the modern era of surgery, were born. Understanding and appreciating the rich history of anesthesiology will help guide the future direction of this specialty. Physician anesthesiologists have the skills necessary to take the quality of perioperative medicine to the next level, combat the opioid epidemic, and redesign the surgical experience,
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Anesthesiology: Past, Present, and Future
- 1. @@EMARIANOMD Anesthesiology: Past, Present, and Future Edward R. Mariano, M.D., M.A.S. Professor of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine Chief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care System
- 2. @EMARIANOMD Financial Disclosures • Halyard Health, B Braun – Unrestricted educational program funding paid to my institution The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.
- 3. @EMARIANOMD Short Trip Down Memory Lane 1998
- 4. @EMARIANOMD
- 5. @EMARIANOMD Why Anesthesiology? “Once a hot specialty, anesthesiology cools as insurers scale back” Anders G. Wall Street Journal. March 17, 1995. http://www.apnewsarchive.com/1995/Numb-and-Number-Once-a-Hot-Specialty- Anesthesiology-Cools-As-Insurers-Scale-Back/id-0ff8af6e9ab84b8a994aa4f123c6dc74
- 6. @EMARIANOMD An Unpopular Specialty 0 200 400 600 800 1000 1200 1400 1600 1800 2000 1995 1996 1997 1998 1999 2000 2001 2002 2003 Anesthesiology Residency Graduates Nationwide USA International
- 7. @EMARIANOMD People Forgot • Why does anesthesiology exist? –Patient experience –Patient safety • It’s just “going to sleep,” right??
- 11. @EMARIANOMD To Err is Human Anesthesiology’s contributions to patient safety
- 12. @EMARIANOMD To Err is Human
- 15. @EMARIANOMD The “Triple Aim” Berwick et al., Health Aff (Millwood) 2008;27:759 Vetter et al., Anesth Analg 2014;118(5):1131
- 17. @EMARIANOMD Emphasis on Patient Experience • Patients are surveyed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)1 • 32 questions • Publicly reported 4 times a year2 • HCAHPS is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge 1. http://www.hcahpsonline.org 2. http://www.hospitalcompare.hhs.gov
- 18. @EMARIANOMD If Anesthesiologists Are Anonymous Anesthesia is Just a Commodity
- 19. @EMARIANOMD Evolution of Anesthesia Practice • Traditional private practice models are changing – Horizontal integration: merging of small and large groups to form mega-groups; some are funded by private equity or venture capital – Vertical integration: acquisition of smaller practices into larger groups (ie, ACOs) • California law prohibits the corporate practice of medicine (physician employees) except VA
- 23. @EMARIANOMD
- 24. @EMARIANOMD • There are 135 VA facilities with anesthesia services. • Veterans are complex patients with many illnesses. • There is no shortage of anesthesiologists in VA. • The national VA anesthesia handbook is pro-team.
- 26. @EMARIANOMD
- 27. @EMARIANOMD Medicare Access & CHIP Reauthorization Act (MACRA)
- 29. @EMARIANOMD MIPS Payments in 2019 EVERYONE who isn’t part of an APM will be subject to MIPS Quality Resource use Clinical Practice Improvement Activities EHR meaningful use
- 30. @EMARIANOMD The Future of Anesthesiology Where Is This Specialty Going?
- 31. @EMARIANOMD Anesthesia Services Anesthesia Services: Care Team or MD only In OR Surgery Centers Clinic- Based Hospital Out-of- OR
- 32. @EMARIANOMD Anesthesia Services Anesthesia Services: Care Team or MD only In OR Surgery Centers Clinic- Based Hospital Out-of- OR Who will be on this team? Physician Anesthesiologists? Nurse Anesthetists? Anesthesiologist Assistants?
- 33. @EMARIANOMD Anesthesiologist Assistants AB 890 (2015-16)
- 35. @EMARIANOMD Perioperative Surgical Home “a patient-centered, physician anesthesiologist- led, multidisciplinary team-based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence. Mariano, et al. A&A 2015;120:1163 Kain, et al. A&A 2014;118:1126
- 36. @EMARIANOMD Perioperative Surgical Home Anesthesiology 2015;123:A23
- 37. @EMARIANOMD Out of the Operating Room 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000 FY11 FY12 FY13 FY14 FY15 NUMBEROFENCOUNTERS ANESTHESIA OUT-OF-OR ENCOUNTERS FY11-15 Total 419 PRE/POST 420 PAIN 427 REGIONAL 434 NON-OR/APS 441 PHONE
- 38. @EMARIANOMD Mariano, Walters, Kim, Kain. A&A 2015;120:1163 Walters, Mariano, Clark. Pain Med 2015;16;1666 Walters, et al. Semin CV Anes 2016;20:133
- 39. @EMARIANOMD Does PSH Fit into MACRA? • Participants in Advanced Alternative Payment Models are exempt from MIPS: • The following ARE expected to qualify: – Comprehensive ESRD Care – Comprehensive Primary Care – Medicare Shared Savings Program ACOs – Oncology Care Model • NOT Comprehensive Care for Joint Replacement (yet)
- 40. @EMARIANOMD We Must Continuously Improve Federal Register May 3, 2007
- 41. @EMARIANOMD Who Are Our Partners?
- 44. @EMARIANOMD Rethink Residency Training? Growing demand for these new hospital positions: • Chief Safety Officer • Chief Patient Experience Officer • Chief Improvement Officer
- 45. @EMARIANOMD Design, Improvement, and Medicine
- 46. @EMARIANOMD
Editor's Notes
- Goals is to achieve Triple Aim
- Initial stages of PSH implementation Today’s discussion is in line with available publications. More of a case report of our experience at VA Palo Alto rather than research article. Not a “one-size fits all” – no single ideal PSH model