The document discusses important outcomes in healthcare and how acute pain medicine can influence value-based care. It outlines key outcomes defined by patients, providers, governments in the US, Canada, and UK. The Triple Aim framework of improving patient experience, population health, and reducing costs is examined. The document argues acute pain medicine can impact these areas by reducing pain and adverse effects, improving efficiency through faster recovery and discharge, and potentially improving health outcomes. Regional anesthesia techniques are discussed as ways to positively influence value-based goals through improved recovery and resource utilization.

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 the Outcomes That
Matter for Perioperative Pain
Medicine

2. Conflicts of Interest
 None

3. Overview
 Important outcomes/who defines?
 USA, Canada, UK
 How can acute pain medicine influence
value based on the IHI triple aim?

4. Overview
 Important outcomes/who defines?
 USA, Canada, UK
 How can acute pain medicine influence
value based on the IHI triple aim?

5. 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)

6. Institute for Healthcare Improvement
Triple Aim in Healthcare

7. 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 will be 2% by 2017

8. Elements of Value-Based Purchasing

9. 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
HCAHPS: Hospital Consumer Assessment of
Healthcare Providers and Systems

10. 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

11. 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.

13. 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

16.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

17.  Reduced postoperative pain, opioid
consumption, adverse effects
 No difference in blood loss or TE events
 No difference in mortality

19. 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

20. Commissioning 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

21. CQUINS for 2014/15

22. 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

23. What is patient experience?

24.  “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

25. Patient Experience vs Satisfaction
 Patient experience goes beyond patient
satisfaction and making patients happy
 You may have a negative outcome but a positive
experience
 You may have a positive outcome but a negative
experience
 Patient experience is linked to staff engagement
 Patients judge healthcare providers not only on
outcome but on compassionate and excellent
patient care

27. Overview
 Important outcomes/who defines?
 USA, Canada, UK
 How can acute pain medicine influence
value based on the IHI triple aim?

28. How can acute pain medicine
influence value
 Triple aim: Quality, Health of populations
and Cost
 Reduce pain: both acute and chronic
 Reduces AEs related to opioid sparing
 Reduction in cost: reduced overtime, case
cancellations, earlier discharge
 Facilitate early rehabilitation

29. Health Services Research 2009

31. HSR 2009

32. What about regional
anesthesia?

33. Regional Anesthesia
Reduces Pain
Anesthesia & Analgesia 2012

34. Regional Anesthesia and Impact
on Perioperative Medicine

35. Memtsoudis SG RAPM 2013

36. 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

37. 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

38.  Overall lack of evidence with majority of
studies in colorectal surgery
 Value-based outcomes (IHI related) were
rarely reported
 Improved pain control, reduced adverse
events, faster mobility and enhanced
return of bowel function with RA
McIsaac D, Cole E, McCartney CJ BJA In Press

40. Defining Value in Acute Pain Medicine
Improved pain control
Less adverse effects
Mortality and Morbidity Benefits
Greater Efficiency, Faster discharge,
Reduced readmission

41. Overview
 Important outcomes/who defines?
 USA, Canada, UK
 How can acute pain medicine influence
value based on the IHI triple aim?

42. The Future
 Greater involvement of patients and government
in determining healthcare funding allocation
 Funding based on quality, effectiveness and
value
 Individual provider and hospital metrics to look
at our own measures of quality (e.g. NSQIP)
 Standardization of care to allow easier
measurement of outcomes (e.g. QBPs)
 Movement of care back to the community

43. The Future
 Better research across large numbers of patients
examining value-based outcomes
 Get engaged in building the research base
 Apply current evidence in practice
 Use regional anesthesia but manage adverse
effects such as motor block
 In this era of “Value-Based Medicine” make sure
we don’t decline to “Cost-Based Medicine”
 Don’t confuse patient experience with patient
satisfaction

44. 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/