Why regional anesthesia can positively influence all aspects of the triple aim in patient care

1. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Chair of Anesthesiology and Pain Medicine
University of Ottawa
Head of Anesthesiology and Pain Medicine
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Outcomes after Surgery:
Can Regional Anesthesia
make a difference?

2. Conflicts of Interest
 None

3. 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

4. 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

7. Why should we care about
outcomes?
 Our patients
 Our system: Value of Care
 Our specialty: expertise in perioperative
and pain medicine

8. After Breakfast Quotes
 We have to be leading the evaluation of
outcomes in our specialty
 If we are not at the table we might be on
the menu
 If we don’t like change we are going to
like irrelevance even less

9. 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

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

11. Regional Anesthesia
Reduces Pain
Anesthesia & Analgesia 2012

12. Value of RA on short term
outcomes

14. From the patients perspective?
 Two TKA procedures
five years apart
 First TKA-GA + PCA
 Nausea, pain
 Difficulty in
mobilising
 Mental effects of
continuous pain
 Next knee-no
chance!

15. From the patients perspective?
 2nd TKA
 Spinal + multimodal
 Better pain control
 Much faster
ambulation
 “Mental wellness”
 GA patients were
easy to identify

16. RAPM 2011

17. What are other benefits of RA?
 Reduced respiratory dysfunction
 Faster return GI function
 Reduction in surgical site infection
 Reduced critical care utilization
 Faster discharge
 Reduced readmission
 Reduced chronic pain
 Reduction in cancer recurrence
 Reduction in mortality

18. Regional and Respiratory

19. Regional and GI function

20. BMJ 2000

22.  400 hospitals between 2006-10
 Data from primary hip/knee arthroplasty
 Subgrouped by anesthetic technique
 30 day morbidity and mortality data
Anesthesiology 2013

23.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

27. Evidence: How Much is Enough?
 Small RCTs
 Large RCTs
 Qualitative studies
 Surveys
 Systematic review
 Large database
studies

28. Shaughnessy and Slawson BMJ 2004

29. 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

30. 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

31. “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

32. Budgetary Silos

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

34. Risks of complications

35. 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

36. Berwick DM et al 2008

37. Institute for Healthcare Improvement
Triple Aim in Healthcare

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

39. 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

40. 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)

42. 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

43. 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.

44. 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

45.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

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

49. What is patient experience?

50.  “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

51. 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. 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

54. RA and Cost of Care

55. 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
From: HOAC

56. 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
Thanks: HOAC and Dr. Susan Belo

57. 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
Thanks: Dr. Jeffrey Gollish

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

60. Ilfeld et al 2008

61. RA and Cost of Care
 Reduced LOS and reduction in readmission
with PNB for TKA
 No difference in falls

62. 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

63. 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

64. 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

65. Summary
 Regional anaesthesia (RA) has significant
short, medium and long-term outcome
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

66. 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
 We need to be at the table: clinically,
administratively and academically
 Courage and persistence required to make
fundamental changes

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

68. cmccartney@toh.ca