Regional Anesthesia PSH Triple Aim

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
Does regional anaesthesia
have a place in modern
perioperative care?

2. Conflicts of Interest
 Consultant: Teleflex Medical

5. cmccartney@toh.ca

6. Summary
 Regional anaesthesia (RA) has significant
short, medium and long-term benefits
 Pressures in modern medicine are
adversely influencing use of RA
 RA and the Triple Aim
 Key questions remain to be answered

7. Why I care about outcomes?
 Anaesthetist since 1993
 Regional Anaesthesia and Pain Medicine
since 1994
 Research since 1999
 Head of Anaesthesia, The Ottawa Hospital
since 2014
 Member of TOH Senior Management Team
since 2014
 Exposure to practice in UK, Canada and
US

10. Why should we care about
outcomes?
 Our patients
 Our system: cost:benefit
 Our specialty: expertise in perioperative
and pain medicine
 We need to invest in research and
education

11. After Lunch Quotes
 If we are not at the table we might be on
the menu
 If you don’t like change you are going to
like irrelevance even less
 We have to act like doctors, not
technicians and be involved in evaluation
of outcomes

12. Summary
 Regional anaesthesia (RA) has significant
short, medium and long-term benefits
 Pressures in modern medicine are
adversely influencing use of RA
 RA and the Triple Aim
 Key questions remain to be answered

13. What are the key unquestioned
benefits of regional
anaesthesia?
 Pain control
 Reduction in adverse effects of opioid
analgesia

14. Regional Anesthesia
Reduces Pain
Anesthesia & Analgesia 2012

15. Value of RA on short term
outcomes

17. What are the generally
supported benefits of RA?
 Improved resp fnctn (Ballantyne et al)
 Faster return of GI function (Liu SS et al)
 Improved early ambulation (Ilfeld et al)
 Better sleep? (Riazi S et al)

18. Regional and Respiratory

19. Regional and GI function

20. What are the questionable
benefits?
 Reduction in surgical site infection
 Reduced critical care utilization
 Faster discharge
 Reduced readmission
 Reduced chronic pain
 Reduction in cancer recurrence
 Reduction in mortality

21. BMJ 2000

23.  400 hospitals between 2006-10
 Data from primary hip/knee arthroplasty
 Subgrouped by anesthetic technique
 30 day morbidity and mortality data
Anesthesiology 2013

24.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

28. Summary
 Regional anaesthesia (RA) has significant
short, medium and long-term benefits
 Pressures in modern medicine are
adversely influencing use of RA
 RA and the Triple Aim
 Key questions remain to be answered

29. Regional and and Current
Perioperative Care
 “Take your time” (as long as it’s not mine)
 Problems of budgetary silos and funding
 Regional anaesthesia and education
 Regional anaesthesia and complications

30. “Take your Time”: Barriers to RA
 Poorly taught
 Difficult to learn
 Patients do not like
needles
 Delays surgery?
 Significant risk of
failure?
 Risk of complications

31. Budgetary Silos

32. Barriers to RA
 Patient education
 Surgeon education
 Anesthesiology
education

33. Risks of complications

34. Summary
 Regional anaesthesia (RA) has significant
short, medium and long-term benefits
 Pressures in modern medicine are
adversely influencing use of RA
 RA and the Triple Aim
 Key questions remain to be answered

35. Institute for Healthcare Improvement
Triple Aim in Healthcare

36. Value in HealthCare
Value=Experience x Functional Outcome
Cost (intensity x length of care)

37. Outcomes in Regional
Anesthesia
 Based on IHI Triple Aim
 Experience of care: Pain, Function, AEs
 Population Health: Morbidity/Mortality
benefits
 Cost of care: Efficiency, Early discharge,
Reduction in readmission

38. 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)

40. 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

41. 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.

43. 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

44.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

46. 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

47. Outcomes in Regional
Anesthesia
 Based on IHI Triple Aim
 Experience of care: Pain, Function, AEs
 Population Health: Morbidity/Mortality
benefits
 Cost of care: Efficiency, Early discharge,
Reduction in readmission

48. What is patient experience?

49.  “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

50. Outcomes in Regional
Anesthesia
 Based on IHI Triple Aim
 Experience of care: Pain, Function, AEs
 Population Health: Morbidity/Mortality
benefits
 Cost of care: Efficiency, Early discharge,
Reduced overtime and case cancellation,
Reduction in readmission

52. Outcomes in Regional
Anesthesia
 Based on IHI Triple Aim
 Experience of care: Pain, Function, AEs
 Population Health: Morbidity/Mortality
benefits
 Cost of care: Efficiency, Early discharge,
Reduced overtime and case cancellation,
Reduction in readmission

53. 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

54. 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

55. 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

56. Data from Brian’s study
 RCDB 50 patients undergoing TKA
 cFNB or placebo
 Multimodal analgesia
 Time to achieve three distinct discharge
criteria

58. Ilfeld et al 2008

59. RA and Cost of Care
 Reduced LOS and reduction in readmission
with PNB
 No difference in falls (McIsaac D unpublished)
 Reduction in SSI: Cost of SSI from $400 to
$30,000 (Urban J 2006)

60. Outcomes in Regional
Anesthesia
 Based on IHI Triple Aim
 Experience of care: Pain, Function, AEs
 Population Health: Morbidity/Mortality
benefits
 Cost of care: Efficiency, Early discharge,
Reduced overtime and case cancellation,
Reduction in readmission

61. Summary
 Regional anaesthesia (RA) has significant
short, medium and long-term benefits
 Pressures in modern medicine are
adversely influencing use of RA
 RA and the Triple Aim
 Key questions remain to be answered

62. What questions remain?
 Pain after discharge from hospital
 Identification and validation of novel
measures of recovery after surgery
 Knowledge translation and RA
 Value of RAPM
 Impact of RA on opioid utilization after
surgery

63. Summary
 Regional anaesthesia (RA) has significant
short, medium and long-term benefits and
has a major place in modern healthcare
 Pressures in modern medicine are
adversely influencing use of RA
 RA and the Triple Aim
 Key questions remain to be answered

64. Conclusions
 Governments talking about resource
allocation based on Triple Aim
 Currently much talk about ”cost” and less
about “value”
 RA costs money but improves value
through all parts of the Triple Aim: Patient
experience, Population Health and Per
Capita Cost
 Some courage required to make
fundamental changes

65. “To improve is to change, to be perfect is to
change often”
WS Churchill