How do we as anesthesiologists address the need for acute pain medicine physicians and have a positive impact on the patient experience? We can take the lead in developing multimodal perioperative pain management protocols. Anesthesiologists can also add value through cost savings for the hospital. More effective pain management can prevent inadvertent admissions or readmissions due to pain. In addition, an effective multimodal analgesic protocol can directly or indirectly prevent hospital-acquired conditions (HACs). HACs are considered by CMS to be “never events” and supposedly preventable (4); hospitals reporting HACs as secondary diagnoses are not entitled to Medicare or Medicaid payments for related care.

1. @EMARIANOMD
Regional Anesthesia:
Identifying Gaps in Quality
and Demonstrating Value
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
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.

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Overview
 Value-based purchasing
 Measuring the patient experience
 Demonstrating value
 Reaching for the stars

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Overview
 Value-based purchasing
 Measuring the patient experience
 Demonstrating value
 Reaching for the stars

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The Problem
http://www.cms.gov
Time for Value, Not
Just Volume

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VALUE = Quality
Cost

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The Triple Aim
Berwick et al., Health Aff (Millwood) 2008;27:759
Vetter et al., Anesth Analg 2014;118(5):1131

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Measuring Quality is Not Easy
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-
based-purchasing/Downloads/NPCSlides071112.pdf

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 Authorized by the Affordable Care Act but
has been around longer
 “Pays for care that rewards better value,
patient outcomes, and innovations,
instead of just volume of services”
 Funded by withholding a percent of
prospective payments from participating
hospitals
Value-Based Purchasing (VBP)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-
value-based-purchasing/downloads/HospVBP_ODF_072711.pdf

10. @EMARIANOMD
Overview
 Value-based purchasing
 Measuring the patient experience
 Demonstrating value
 Reaching for the stars

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Assessing 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

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HCAHPS Questions
 Directly relate to pain:
– During this hospital stay, how often was your
pain well controlled?
– During the hospital stay, how often did the
hospital staff do everything they could to help
you with your pain?

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HCAHPS Questions
 Indirectly relate to pain:
– Before giving you any new medications, how
often did the hospital staff tell you what the
medicine was for?
– …did the hospital staff describe possible side
effects in a way that you could understand?
– Using a number from 0-10, what number
would you rate this hospital during your stay?
– Would you recommend this hospital to your
friends and family?

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 “Unlike current questions, which ask about
the efficacy of pain treatment, the new set
will focus on the communication between
doctor and patient about pain.”
http://www.nytimes.com/2016/08/05/health/pain-treatment-
hospitals-emergency-rooms-surveys.html?_r=0

15. @EMARIANOMD
Overview
 Value-based purchasing
 Measuring the patient experience
 Demonstrating value
 Reaching for the stars

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Develop Patient Care Pathways
Hebl JR, et al. JBJS 2005;87 Suppl 2:63

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Perioperative Surgical Home (PSH)
“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

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PSH = Perioperative Medicine
https://www.rcoa.ac.uk/perioperativemedicine

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Mariano, Walters, Kim, Kain. A&A 2015;120:1163
Walters, Mariano, Clark. Pain Med 2015;16:1666.

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Think as a Team
 In April 2012, clinical pathway changed
from CFNB to continuous adductor canal
blocks due to concern over quad weakness
 Hypothesis for retrospective cohort study:
patients with continuous adductor canal
blocks ambulate further than those with
continuous femoral nerve blocks on
postoperative day (POD) 1 without
reduction in analgesia
Mudumbai & Mariano, et al. CORR 2014;472:1377

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 Patients in the
adductor canal group
walked 37 (0-90)
meters vs. 6 (0-51)
meters in the femoral
catheter group
(p=0.003).
 Pain scores, opioid
consumption, and
hospital length of
stay were similar.
Be Patient-Centered
Mudumbai & Mariano, et al. CORR 2014;472:1377

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Change Clinical Practice
 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

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Change Clinical Practice
 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
Mudumbai & Mariano, et al. Healthcare 2017;4:334

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TKA Protocol (VA Palo Alto)
Preop 1. Adductor canal catheter
2. Oral gabapentin if opioid-dependent
OR Spinal anesthesia, LIA, IV acetaminophen
Postop 1. Continuous perineural infusion (0.2%
ropivacaine 6 ml/h basal)
2. Oral NSAID and acetaminophen ATC
3. Oral opioid ATC and PRN
4. IV opioid PRN but no IV PCA
Mariano, et al. Adv Anesthesia 2013;31:119

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Avoid “Never” Events
Federal Register May 3, 2007

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Anesth Clinics 2014;32:853

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Deliver a Consistent Product

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Overview
 Value-based purchasing
 Measuring the patient experience
 Demonstrating value
 Reaching for the stars

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Wall Street Journal

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The Newest Subspecialty

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Prevent Persistent Pain?
Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients

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Design, Improvement, and Medicine

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Summary
 We discussed:
– Value-based purchasing
– Measuring the patient experience
– Demonstrating value
– Reaching for the stars

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Questions?
“The sooner patients can be removed from
the depressing influence of general hospital
life the more rapid their convalescence.”
- Dr. Charles Mayo, Lancet 1916