REVIEW URRENT C OPINION
Trends in healthcare and the role of the anesthesiologist in the perioperative surgical home – the US perspective Natalie F. Holt
Purpose of review Although advances in science are important, changes in population structure and developments in health policy have equally critical roles in shaping the future of anesthesia practice. Therefore, it is important for anesthesiologists to be aware of these trends and their implications. Recent findings As in other industrialized nations, population aging implies that patients presenting for elective surgery in future decades will be older and sicker. Nevertheless, in part for economic reasons, the fraction of surgeries performed in the ambulatory environment will continue to increase. Furthermore, the gradual elimination of fee-for-service care in favor of bundled payments will place additional risk on providers to prevent costly complications. In the USA, the American Society of Anesthesiologists has offered the ‘surgical home’ as a new model for perioperative care delivery in which the anesthesiologist serves as the coordinator of care from the preoperative through the postoperative phase. The purpose is not only to increase patient-centeredness but also to find opportunities for cost savings and increased efficiencies. Summary Global demographic and health policy trends are calling for new models of healthcare delivery. Anesthesiologists have much experience in the fields of risk assessment and quality improvement. They are well positioned to become leaders in the perioperative care environment of the future. Keywords bundled payments, perioperative surgical home, population aging
INTRODUCTION Significant changes in population demographics, healthcare delivery, and health policy are converging that will impact the practice of anesthesia in the coming decades. As the US population continues to age and mortality from chronic diseases declines, those presenting for surgery are more likely to be American Society of Anesthesiologists (ASA) Physical Status 3 and 4 patients. Although this patient group is naturally more vulnerable to perioperative complications, new provider payment systems – so-called ‘bundled payments’ – will have limited tolerance; in other words, it will not be willing to pay for these events. At the same time, a growing percentage of surgical services are being provided as ambulatory surgery, wherein preanesthetic evaluations are often cursory and the role of the anesthesiologist in postoperative follow-up is generally absent. Although these trends are not entirely unique to the USA, the fragmented
healthcare financing and delivery system in this country adds additional layers of complexity to the problem and any proposed solutions that are not present in countries with centralized insurance and healthcare systems. In response to these emerging developments, the ASA has outlined a paradigm for the delivery of perioperative services called the surgical home. This article describes this model and the healthcare trends it was intended to address.
Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Natalie F. Holt, MD, MPH, Staff Anesthesiologist, Medical Director, Ambulatory Procedures Unit, Veterans Affairs Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, Connecticut 06520, USA. Tel: +1 203 654 1677; fax: +1 203 865 2586; e-mail: [email protected] Curr Opin Anesthesiol 2014, 27:371–376 DOI:10.1097/ACO.0000000000000064
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Anesthesia and medical disease
US population by age, 2000 and 2050 (projected)
KEY POINTS Changes in population demographics and health policy are converging that will have a significant impact on the practice of anesthesia in future decades. By 2050, the proportion of the US population older than 65 years is expected to be 20%, meaning that the population of patients presenting for elective surgery will be sicker and at greater risk for perioperative complications.
Population (millions)
250 000 % change, 32.9% 200 000 150 000 % change, 135.4%
100 000 50 000
% change, 349.8% 0
At the same time, partially for economic reasons, there will be continued demand to perform surgeries in the ambulatory setting, wherein preoperative evaluation and follow-up are often cursory. In the USA, the CMS has introduced ‘bundled payments’ for episodes of care in order to align incentives among hospitals and providers toward maximizing patient outcomes and eliminating unnecessary expenditures. In response to these developments, the ASA has introduced the concept of the perioperative surgical home in which the anesthesiologist serves as leader of the patient’s care team from the preoperative through the postoperative phase to maximize patient outcomes, while maintaining safety and efficiency.
CHANGING POPULATION DEMOGRAPHICS Improved medical management of chronic conditions such as cardiovascular disease, combined with the aging of Americans portend that in the coming decades, the population of patients presenting for elective surgeries will be sicker and at greater risk for perioperative complications. In the four decades from 2010 to 2050, the US population older than 65 years is projected to more than double – from 40 million to 88.5 million, or approximately 20% of the total population (Table 1, Fig. 1) [1,2]. These changes are occurring in most industrialized countries. In fact, compared with the USA, most
Table 1. US population by age, 2000 and 2050, projecteda Age (years) 16–64
2000
2050
% change
177 974
236 602
32.9
65þ
34 835
81 999
135.4
85þ
4312
19 352
349.8
Reproduced with permission from [2]. a Population in millions
372
www.co-anesthesiology.com
16–64
65+
85+
Age
FIGURE 1. US population by age, 2000 and 2050, projected. In the coming decades, the working age population of the United States is expected to increase by only about 33%. At the same time, the number of people older than 65 years is expected to more than double and the number of people more than 85 years of age is expected to increase at an even higher rate. This will mean that sicker patients will be presenting for elective surgery. Additionally, it portends additional burden on public programs such as Medicare that are already in financial distress. Data from [2].
Western European countries already have a relatively higher proportion of their population older than 65 years (Table 2) [3]. As expected, older people more commonly present with chronic medical conditions. According to data from the 2009 Behavioral Risk Factor Surveillance System conducted in the USA, 35.7% of adults aged 60–69 years reported at least one chronic medical condition; 33.8% reported two or more such conditions. Furthermore, the majority of older individuals with chronic illness also testify to a concomitant functional limitation [4]. As a result, in all industrialized nations, about 35–45% of all healthcare dollars are spent on elderly care (Table 3) [3]. It is becoming clear that older patients presenting for surgery are not only at higher risk for perioperative complications, but also that common postoperative complications often have unique manifestations in this age group. Delirium is relatively common after moderate to high-risk surgery, occurring in nearly 50% of patients presenting for open heart surgery and 20–40% of patients presenting for orthopedic, vascular, and colorectal surgery [5]. Furthermore, the development of postoperative delirium is itself a risk factor for subsequent complications [6], prolonged hospital stay [6,7], poorer functional recovery [8,9], and increased short-term mortality [7,8]. Age is also associated Volume 27 Number 3 June 2014
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Trends in US healthcare and the perioperative surgical home Holt Table 2. Percentage of total population age 65 and older and age 80 and older in eight countries, 1980–2000 Percentage age 65 and older percentage increase 1980–2000
2000–2020
Australia
26
39
Canada
36
43
France
14
26
5
32
Japan
89
54
New Zealand
17
34
6
24
12
33
Germany
UK USA
Other common postoperative complications may present themselves differently in older patients, increasing the risk of missed or late diagnosis. For example, confusion may be the first manifestation of infection, rather than leukocytosis. In addition, myocardial ischemia is estimated to be silent in 80% of elderly patients [5]. Furthermore, management of complications is more complex. Although thromboembolic events disproportionately affect the elderly [10], so too do bleeding complications related to anticoagulant use [11,12]. Subtle preoperative renal dysfunction may become florid in the face of polypharmacy or dehydration postoperatively. Therefore, the margin for error in this population is narrow.
Percentage age 80 and older Percentage increase 1980–2000 Australia
2000–2020
66
30
Canada
74
42
France
23
45
Germany
30
76
170
107
New Zealand
65
24
UK
52
22
USA
39
14
Japan
Adapted with permission from [3].
with an increased risk for venous thromboembolism, likely as a result of the presence of a greater number of risk factors in this population, including immobilization and atherosclerotic disease. It is estimated that over 90% of all pulmonary emboli occur in patients over age 50 years [5].
Table 3. Health spending for the elderly in eight countries, 1993–1995 Percentage of total health spending on the elderly
Estimated percentage of GDP spent on health for the elderly
Australia (1994)
35
3.0
Canada (1994)
40
3.6
France (1993)
35
3.4
Germany (1994)
34
3.5
Japan (1994)
47
3.4
New Zealand (1994)
34
2.5
UK (1993)
43
2.8
USA (1995)
38
5.0
Country
GDP, gross domestic product. Adapted with permission from [3].
TRANSITION TO AMBULATORY SURGERY In contradistinction to the growing complexity of the patient population presenting for surgery is the trend to push the boundaries between hospitalbased and ambulatory medicine, in favor of outpatient care. Currently, about 67% of elective surgical procedures are performed on an outpatient basis, and this number is estimated to increase over the next decade [13]. Ambulatory surgery centers (ASCs) have the benefit of offering patient and provider convenience, as well as enhanced efficiency. For this reason, they are often profit centers for hospitals and physicians. Medicare and private insurance companies often save money when procedures are performed in an ASC relative to a hospital setting. For this reason, over the past several years, the Centers for Medicare & Medicaid Services (CMS) has adopted criteria that allow more procedures to be covered in an ASC. This presents a challenge for anesthesiologists, who will be faced with a sicker patient population now coming for more complex surgical procedures, yet still tasked with maintaining outcomes and safety comparable with the inpatient setting. It is not entirely clear how best to achieve these standards. The value of preanesthetic evaluations has been contested in general; they are especially controversial for patients presenting for outpatient surgeries. In a National Surgical Quality Improvement Program review of preoperative testing, abnormal test results were found in 61% of patients, yet serious postoperative complications occurred in only 0.3% of patients and were not predicted by preoperative test abnormalities [14]. Nevertheless, although most anesthesiologists agree that too many preoperative tests are currently ordered, few agree that their complete elimination is the answer [15]. Research involving cataract surgery patients, who represent an older cohort with more comorbid
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conditions, has also shown that although preanesthesia evaluations identify new medical issues in approximately one in five patients, these issues rarely lead to delays or change surgical outcomes [16]. However, although day of surgery outcomes might not have been changed, the impact of the new findings on the patients’ overall health was not well addressed by this research and might have been significant. As with inpatient care, the incentive to maintain high standards in the outpatient setting is now being translated into financial terms. In 2012, CMS began requiring that ASCs report on specific quality measures, including prophylactic antibiotic administration, wrong site surgery, and unexpected hospital admission or transfer. Those not reporting face a 2% reduction in reimbursement effective in 2014. Anesthesiologists have experience from inpatient practice to make a positive impact on quality management and patient safety in the ambulatory surgery setting; although they have not traditionally been the leaders in these practice environments, developing new collaborations with surgical colleagues may be a future trend.
MOVE TO BUNDLED PAYMENTS Bundled payments are payments for episodes of medical care. This payment structure is replacing the long-established practice of paying providers for individual services rendered during the course of a single illness (a.k.a. fee-for-service care). The purpose of this unified payment system is to align incentives among hospitals, physicians, and other practitioners toward maximizing patient outcomes, creating a motivation to eliminate unnecessary perioperative expenditures and prevent costly – and ostensibly preventable – complications. In January 2013, CMS began testing the bundled payment system for a defined set of Diagnostic Related Group codes across a specific set of healthcare facilities [17 ]. These include surgical procedures such as joint replacement and coronary artery bypass surgery. There are several models of bundled payment currently being tested – some that include only acute care services, others that include only postacute care services, and others that combine both acute and postacute care services. Interestingly, early experience with the bundled payment system suggests that, in many cases, Medicare payments in the 90 days following an acute care hospitalization are just as high as for the initial hospitalization [18]. &
PERIOPERATIVE SURGICAL HOME MODEL In 2011, the ASA developed the Committee on Future Models of Anesthesia Practice (CFMAP) 374
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designed to address the role of anesthesiologists in emerging models of healthcare intended to confront the reality of bundled payments [19 ]. Ultimately, the CFMAP conceived of the perioperative surgical home. Purported benefits of the perioperative surgical home model (data from Reference [19 ]) are as follows: &
&
(1) Reduced preoperative testing and consultative services (2) Reduced day of surgery cancellations (3) Improved clinical outcomes (4) Improved compliance with healthcare metrics (e.g., Surgical Care Improvement Project) (5) Development of clinical initiatives for pre and postprocedure care (e.g., postoperative nausea and vomiting prophylaxis, anticoagulation management) (6) Reduced postoperative complications (7) Cost reduction (through reduced testing, reduced postoperative complications, decreased postanesthesia care unit, ICU, and hospital stays) (8) Improved care coordination and discharge planning. In the perioperative surgical home model, a coordinated, multidisciplinary team led by an anesthesiologist is responsible for the care of patients from the preoperative period through the postdischarge phase. When possible, evidencebased protocols drive decision-making. Preoperative evaluations are conducted in an anesthesia-run clinic. Decisions regarding preoperative lab testing, the need for specialty consultation, and changes in medication management prior to surgery are made by the consulting anesthesiologist, not a surgeon or primary care physician. Patient education, including the anesthesia plan and expectations about postoperative pain management, is also discussed during the preanesthetic interview. And perhaps most importantly, rather than be managed only by a surgical team, an anesthesia-intensivist remains involved in the postoperative care of the patient, overseeing decisions regarding, for example, glycemic control, venous thromboembolism prophylaxis, as well as pain management (Table 4). The concept of the surgical home was an extension of the medical home, a term first introduced by the American Academy of Pediatrics in 1967 and conceived of by Dr Calvin Sia, based primarily on his experience working with at-risk families and children with special needs [20]. Unlike the surgical home, the medical home is a fairly well established concept. In 2009, the Accreditation Association for Ambulatory Healthcare issued specific accrediting Volume 27 Number 3 June 2014
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Trends in US healthcare and the perioperative surgical home Holt Table 4. Traditional care vs. perioperative surgical home
Preoperative
Traditional care
Perioperative surgical home
Surgeon orders preoperative lab work and chest x-ray when the surgery is booked
Anesthesiologist orders preoperative lab work, chest x-ray, and other tests as needed after preanesthesia interview
Surgeon orders blood products to be available for day of surgery
Anesthesiologist considers strategies for medical optimization (e.g., statins, anticoagulation, diabetes control, treatment of anemia) Anesthesiologist conducts routine screening of high-risk patient groups and considers plan to prevent complications (e.g., dementia/delirium, substance abuse) Anesthesiologist outlines intraoperative and expected pain management plan
Intraoperative
Anesthesiologist makes management decisions based on personal judgment of the patient’s medical readiness for surgery
Anesthesiologist establishes patient readiness according to criteria outlined during preanesthesia visit Anesthesiologist conducts anesthesia and pain management plan according to course established in preanesthesia visit (to the extent appropriate)
Postoperative
Surgeon is dominant physician in the OR
Anesthesiologist becomes the OR team leader, facilitating decisions such as disposition of postoperative patient
Surgical team manages patient’s medical/surgical care during hospitalization
Anesthesiologist-intensivist manages patient’s medical care during hospitalization Anesthesiologist applies evidence-based protocols and checklists are used where appropriate (e.g., DVT prophylaxis, ventilator weaning, antibiotic discontinuation)
DVT, deep vein thrombosis; OR, operating room.
guidelines for organizations wishing to be designated medical homes. Several state governments and large self-insured companies, including IBM, have begun to use the medical home concept, particularly in the management of patients with chronic diseases [20]. Furthermore, early evidence suggests that implementation of the medical home can improve quality of care while simultaneously reducing costs and acute care visits [21,22]. In several European countries, such as Denmark and the UK, although the term medical home is not used, the gate-keeping role of the general practitioner in the care of patients serves an analogous function [23]. To date, the surgical home is an untested concept. However, at some institutions, its practical application is being tested. At the Keck Medical Center at the University of Southern California, a surgical home concept has been utilized in the anesthesia ICU for over 30 years. In a retrospective trial, investigators compared outcomes of patients who had the same anesthesiologist for intra and postoperative care vs. those whose care was managed by different anesthesiologists. They found that both ICU days (2.72 vs. 4.85 days, P < 0.001) and hospital days (6.87 vs. 10.1 days, P ¼ 0.004) were significantly reduced in patients who had been managed according to the surgical home model.
In addition, ICU readmission rates were significantly less among patients in the surgical home group (1.65 vs. 15%, P < 0.001). Furthermore, mortality among patients managed in the surgical home was also significantly reduced (3.79 vs. 8.33%, P ¼ 0.005) [24]. The role of the anesthesiologist in the surgical home is somewhat analogous to the hospitalist. Once resisted by primary care physicians as encroaching upon their ‘territory’, hospitalists are now increasingly embraced by those same physicians, who now see it as a way for them to enhance efficiency allowing them to focus on outpatient care [25]. Medical co-management of high-risk surgical patients by hospitalists is indeed not a new concept. Although some studies suggest such practice can lead to lower mortality and shorter hospital length of stay [26–28], others have shown no significant outcomes effects [29,30]. However, anesthesiologists have the advantage over hospitalists of already being familiar with the surgical issues of the patient. Therefore, they are arguably better equipped to oversee perioperative medical issues than the hospitalist. There are some elements of the surgical home that are easier to operationalize than others. In the inpatient setting and for patients in the ICU especially, anesthesia-led patient care management is a fairly easy transition. The role of the
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anesthesiologist in posthospital follow-up care is a far less well developed concept. Furthermore, adaptation of the surgical home to the outpatient setting has yet to be described, but clearly warrants attention, as more than two-thirds of surgeries now take place in that environment.
CONCLUSION Hospital–physician collaborations will increasingly be needed in light of the obligatory risk-sharing implied by a bundled payment system. The development of the surgical home requires buy-in not only from surgeons but also from hospital administration. Improvement in patient outcomes and net reduction in hospital costs will be the best forms of evidence that the model is a success. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Vincent GK, Velkoff VA. The next four decades. The older population in the United States: 2010 to 2050. Current Population Reports. Washington, D.C., USA: Census Bureau; 2010; pp 25–1138. 2. Wiener JM, Tilly J. Population ageing in the United States of America: implications for public programmes. Int J Epidemiol 2002; 31:776–781. 3. Anderson GF, Hussey PS. Population aging: a comparison among industrialized countries. Health affairs 2000; 19:191–203. 4. Pearson WS, Bhat-Schelbert K, Probst JC. Multiple chronic conditions and the aging of america: challenge for primary care physicians. J Prim Care community Health 2012; 3:51–56. 5. Lagoo-Deenadayalalan SA, Newell MA, Pofahl WE. Common perioperative complications in older patients. In: Rosenthal RA, Zenilman ME, Katlic MR, editors. Principles and practice of geriatric surgery. Volume 2. New York: Springer Science Business Media, LLC; 2011. pp. 361–376. 6. Olin K, Eriksdotter-Jonhagen M, Jansson A, et al. Postoperative delirium in elderly patients after major abdominal surgery. Brit J Surg 2005; 92:1559– 1564. 7. Robinson TN, Raeburn CD, Tran ZV, et al. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg 2009; 249:173–178.
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8. Edelstein DM, Aharonoff GB, Karp A, et al. Effect of postoperative delirium on outcome after hip fracture. Clin Orthop Relat Res 2004; 422:195– 200. 9. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc 2000; 48:618–624. 10. Kim V, Spandorfer J. Epidemiology of venous thromboembolic disease. Emerg Med Clin North Am 2001; 19:839–859. 11. Di Minno G, Tufano A. Challenges in the prevention of venous thromboembolism in the elderly. J Thromb Haemost 2004; 2:1292–1298. 12. Jaffer AK, Brotman DJ. Prevention of venous thromboembolism in the geriatric patient. Clin Geriatr Med 2006; 22:93–111; ix. 13. U.S. Outpatient Surgeries on the Rise. CDC National Center for Health Statistics Press Release. Available at http://www.cdc.gov/media/pressrel/ 2009/r090128.htm, January 28, 2009. 14. Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg 2012; 256:518–528. 15. van Gelder FE, de Graaff JC, van Wolfswinkel L, van Klei WA. Preoperative testing in noncardiac surgery patients: a survey amongst European anaesthesiologists. Eur J Anaesthesiol 2012; 29:465–470. 16. Phillips MB, Bendel RE, Crook JE, Diehl NN. Global health implications of preanesthesia medical examination for ophthalmic surgery. Anesthesiology 2013; 118:1038–1045. 17. Bundled Payments for Care Improvement Initiative. Centers for Medicare & & Medicaid Services Fact Sheet. Available at http://innovation.cms.gov/initiatives/bundled-payments/, September 30, 2013. This fact sheet describes the concept of the bundled payment and how CMS plans to roll-out the new payment structure. 18. Mechanic R, Tompkins C. Lessons learned preparing for Medicare bundled payments. N Engl J Med 2012; 367:1873–1875. 19. Schweitzer M, Fahy B, Leib M, Rosenquist R, et al. The perioperative surgical & home model. ASA Newsletter 2013; 77:58–59. This article outlines the ASA’s concept of the perioperative surgical home. 20. Backer LA. The medical home: an idea whose time has come...again. Fam Pract Manag 2007; 14:38–41; Available at http://www.aafp.org/fpm/2007/ 0900/. 21. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs 2010; 29:835–843. 22. Steiner BD, Denham AC, Ashkin E, et al. Community care of North Carolina: improving care through community health networks. Ann Fam Med 2008; 6:361–367. 23. Solberg LI, Van Royen P. The medical home: is it a blind men and elephant tale? Fam Pract 2009; 26:425–427. 24. Atoian A, Haney M, Gabel E, et al. The evidence for a surgical home (abstract). ASA Practice Management 2013. January 25-27, 2013. Las Vegas, NV. Available at education.asahq.org/sites/education.asahq.org/files/users/pm20. pdf 25. Fuchs VR. Major trends in the U.S health economy since 1950. N Engl J Med 2012; 366:973–977. 26. Auerbach AD, Wachter RM, Cheng HQ, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Inter Med 2010; 170:2004–2010. 27. Phy MP, Vanness DJ, Melton LJ 3rd. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med 2005; 165:796–801. 28. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics 2009; 32:495. 29. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med 2004; 141:28–38. 30. Siegal EM. Just because you can, doesn’t mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med 2008; 3:398– 402.
Volume 27 Number 3 June 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Trends in healthcare and the role of the anesthesiologist in the perioperative surgical home – the US perspective Natalie F. Holt
Purpose of review Although advances in science are important, changes in population structure and developments in health policy have equally critical roles in shaping the future of anesthesia practice. Therefore, it is important for anesthesiologists to be aware of these trends and their implications. Recent findings As in other industrialized nations, population aging implies that patients presenting for elective surgery in future decades will be older and sicker. Nevertheless, in part for economic reasons, the fraction of surgeries performed in the ambulatory environment will continue to increase. Furthermore, the gradual elimination of fee-for-service care in favor of bundled payments will place additional risk on providers to prevent costly complications. In the USA, the American Society of Anesthesiologists has offered the ‘surgical home’ as a new model for perioperative care delivery in which the anesthesiologist serves as the coordinator of care from the preoperative through the postoperative phase. The purpose is not only to increase patient-centeredness but also to find opportunities for cost savings and increased efficiencies. Summary Global demographic and health policy trends are calling for new models of healthcare delivery. Anesthesiologists have much experience in the fields of risk assessment and quality improvement. They are well positioned to become leaders in the perioperative care environment of the future. Keywords bundled payments, perioperative surgical home, population aging
INTRODUCTION Significant changes in population demographics, healthcare delivery, and health policy are converging that will impact the practice of anesthesia in the coming decades. As the US population continues to age and mortality from chronic diseases declines, those presenting for surgery are more likely to be American Society of Anesthesiologists (ASA) Physical Status 3 and 4 patients. Although this patient group is naturally more vulnerable to perioperative complications, new provider payment systems – so-called ‘bundled payments’ – will have limited tolerance; in other words, it will not be willing to pay for these events. At the same time, a growing percentage of surgical services are being provided as ambulatory surgery, wherein preanesthetic evaluations are often cursory and the role of the anesthesiologist in postoperative follow-up is generally absent. Although these trends are not entirely unique to the USA, the fragmented
healthcare financing and delivery system in this country adds additional layers of complexity to the problem and any proposed solutions that are not present in countries with centralized insurance and healthcare systems. In response to these emerging developments, the ASA has outlined a paradigm for the delivery of perioperative services called the surgical home. This article describes this model and the healthcare trends it was intended to address.
Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Natalie F. Holt, MD, MPH, Staff Anesthesiologist, Medical Director, Ambulatory Procedures Unit, Veterans Affairs Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, Connecticut 06520, USA. Tel: +1 203 654 1677; fax: +1 203 865 2586; e-mail: [email protected] Curr Opin Anesthesiol 2014, 27:371–376 DOI:10.1097/ACO.0000000000000064
0952-7907 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-anesthesiology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anesthesia and medical disease
US population by age, 2000 and 2050 (projected)
KEY POINTS Changes in population demographics and health policy are converging that will have a significant impact on the practice of anesthesia in future decades. By 2050, the proportion of the US population older than 65 years is expected to be 20%, meaning that the population of patients presenting for elective surgery will be sicker and at greater risk for perioperative complications.
Population (millions)
250 000 % change, 32.9% 200 000 150 000 % change, 135.4%
100 000 50 000
% change, 349.8% 0
At the same time, partially for economic reasons, there will be continued demand to perform surgeries in the ambulatory setting, wherein preoperative evaluation and follow-up are often cursory. In the USA, the CMS has introduced ‘bundled payments’ for episodes of care in order to align incentives among hospitals and providers toward maximizing patient outcomes and eliminating unnecessary expenditures. In response to these developments, the ASA has introduced the concept of the perioperative surgical home in which the anesthesiologist serves as leader of the patient’s care team from the preoperative through the postoperative phase to maximize patient outcomes, while maintaining safety and efficiency.
CHANGING POPULATION DEMOGRAPHICS Improved medical management of chronic conditions such as cardiovascular disease, combined with the aging of Americans portend that in the coming decades, the population of patients presenting for elective surgeries will be sicker and at greater risk for perioperative complications. In the four decades from 2010 to 2050, the US population older than 65 years is projected to more than double – from 40 million to 88.5 million, or approximately 20% of the total population (Table 1, Fig. 1) [1,2]. These changes are occurring in most industrialized countries. In fact, compared with the USA, most
Table 1. US population by age, 2000 and 2050, projecteda Age (years) 16–64
2000
2050
% change
177 974
236 602
32.9
65þ
34 835
81 999
135.4
85þ
4312
19 352
349.8
Reproduced with permission from [2]. a Population in millions
372
www.co-anesthesiology.com
16–64
65+
85+
Age
FIGURE 1. US population by age, 2000 and 2050, projected. In the coming decades, the working age population of the United States is expected to increase by only about 33%. At the same time, the number of people older than 65 years is expected to more than double and the number of people more than 85 years of age is expected to increase at an even higher rate. This will mean that sicker patients will be presenting for elective surgery. Additionally, it portends additional burden on public programs such as Medicare that are already in financial distress. Data from [2].
Western European countries already have a relatively higher proportion of their population older than 65 years (Table 2) [3]. As expected, older people more commonly present with chronic medical conditions. According to data from the 2009 Behavioral Risk Factor Surveillance System conducted in the USA, 35.7% of adults aged 60–69 years reported at least one chronic medical condition; 33.8% reported two or more such conditions. Furthermore, the majority of older individuals with chronic illness also testify to a concomitant functional limitation [4]. As a result, in all industrialized nations, about 35–45% of all healthcare dollars are spent on elderly care (Table 3) [3]. It is becoming clear that older patients presenting for surgery are not only at higher risk for perioperative complications, but also that common postoperative complications often have unique manifestations in this age group. Delirium is relatively common after moderate to high-risk surgery, occurring in nearly 50% of patients presenting for open heart surgery and 20–40% of patients presenting for orthopedic, vascular, and colorectal surgery [5]. Furthermore, the development of postoperative delirium is itself a risk factor for subsequent complications [6], prolonged hospital stay [6,7], poorer functional recovery [8,9], and increased short-term mortality [7,8]. Age is also associated Volume 27 Number 3 June 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Trends in US healthcare and the perioperative surgical home Holt Table 2. Percentage of total population age 65 and older and age 80 and older in eight countries, 1980–2000 Percentage age 65 and older percentage increase 1980–2000
2000–2020
Australia
26
39
Canada
36
43
France
14
26
5
32
Japan
89
54
New Zealand
17
34
6
24
12
33
Germany
UK USA
Other common postoperative complications may present themselves differently in older patients, increasing the risk of missed or late diagnosis. For example, confusion may be the first manifestation of infection, rather than leukocytosis. In addition, myocardial ischemia is estimated to be silent in 80% of elderly patients [5]. Furthermore, management of complications is more complex. Although thromboembolic events disproportionately affect the elderly [10], so too do bleeding complications related to anticoagulant use [11,12]. Subtle preoperative renal dysfunction may become florid in the face of polypharmacy or dehydration postoperatively. Therefore, the margin for error in this population is narrow.
Percentage age 80 and older Percentage increase 1980–2000 Australia
2000–2020
66
30
Canada
74
42
France
23
45
Germany
30
76
170
107
New Zealand
65
24
UK
52
22
USA
39
14
Japan
Adapted with permission from [3].
with an increased risk for venous thromboembolism, likely as a result of the presence of a greater number of risk factors in this population, including immobilization and atherosclerotic disease. It is estimated that over 90% of all pulmonary emboli occur in patients over age 50 years [5].
Table 3. Health spending for the elderly in eight countries, 1993–1995 Percentage of total health spending on the elderly
Estimated percentage of GDP spent on health for the elderly
Australia (1994)
35
3.0
Canada (1994)
40
3.6
France (1993)
35
3.4
Germany (1994)
34
3.5
Japan (1994)
47
3.4
New Zealand (1994)
34
2.5
UK (1993)
43
2.8
USA (1995)
38
5.0
Country
GDP, gross domestic product. Adapted with permission from [3].
TRANSITION TO AMBULATORY SURGERY In contradistinction to the growing complexity of the patient population presenting for surgery is the trend to push the boundaries between hospitalbased and ambulatory medicine, in favor of outpatient care. Currently, about 67% of elective surgical procedures are performed on an outpatient basis, and this number is estimated to increase over the next decade [13]. Ambulatory surgery centers (ASCs) have the benefit of offering patient and provider convenience, as well as enhanced efficiency. For this reason, they are often profit centers for hospitals and physicians. Medicare and private insurance companies often save money when procedures are performed in an ASC relative to a hospital setting. For this reason, over the past several years, the Centers for Medicare & Medicaid Services (CMS) has adopted criteria that allow more procedures to be covered in an ASC. This presents a challenge for anesthesiologists, who will be faced with a sicker patient population now coming for more complex surgical procedures, yet still tasked with maintaining outcomes and safety comparable with the inpatient setting. It is not entirely clear how best to achieve these standards. The value of preanesthetic evaluations has been contested in general; they are especially controversial for patients presenting for outpatient surgeries. In a National Surgical Quality Improvement Program review of preoperative testing, abnormal test results were found in 61% of patients, yet serious postoperative complications occurred in only 0.3% of patients and were not predicted by preoperative test abnormalities [14]. Nevertheless, although most anesthesiologists agree that too many preoperative tests are currently ordered, few agree that their complete elimination is the answer [15]. Research involving cataract surgery patients, who represent an older cohort with more comorbid
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conditions, has also shown that although preanesthesia evaluations identify new medical issues in approximately one in five patients, these issues rarely lead to delays or change surgical outcomes [16]. However, although day of surgery outcomes might not have been changed, the impact of the new findings on the patients’ overall health was not well addressed by this research and might have been significant. As with inpatient care, the incentive to maintain high standards in the outpatient setting is now being translated into financial terms. In 2012, CMS began requiring that ASCs report on specific quality measures, including prophylactic antibiotic administration, wrong site surgery, and unexpected hospital admission or transfer. Those not reporting face a 2% reduction in reimbursement effective in 2014. Anesthesiologists have experience from inpatient practice to make a positive impact on quality management and patient safety in the ambulatory surgery setting; although they have not traditionally been the leaders in these practice environments, developing new collaborations with surgical colleagues may be a future trend.
MOVE TO BUNDLED PAYMENTS Bundled payments are payments for episodes of medical care. This payment structure is replacing the long-established practice of paying providers for individual services rendered during the course of a single illness (a.k.a. fee-for-service care). The purpose of this unified payment system is to align incentives among hospitals, physicians, and other practitioners toward maximizing patient outcomes, creating a motivation to eliminate unnecessary perioperative expenditures and prevent costly – and ostensibly preventable – complications. In January 2013, CMS began testing the bundled payment system for a defined set of Diagnostic Related Group codes across a specific set of healthcare facilities [17 ]. These include surgical procedures such as joint replacement and coronary artery bypass surgery. There are several models of bundled payment currently being tested – some that include only acute care services, others that include only postacute care services, and others that combine both acute and postacute care services. Interestingly, early experience with the bundled payment system suggests that, in many cases, Medicare payments in the 90 days following an acute care hospitalization are just as high as for the initial hospitalization [18]. &
PERIOPERATIVE SURGICAL HOME MODEL In 2011, the ASA developed the Committee on Future Models of Anesthesia Practice (CFMAP) 374
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designed to address the role of anesthesiologists in emerging models of healthcare intended to confront the reality of bundled payments [19 ]. Ultimately, the CFMAP conceived of the perioperative surgical home. Purported benefits of the perioperative surgical home model (data from Reference [19 ]) are as follows: &
&
(1) Reduced preoperative testing and consultative services (2) Reduced day of surgery cancellations (3) Improved clinical outcomes (4) Improved compliance with healthcare metrics (e.g., Surgical Care Improvement Project) (5) Development of clinical initiatives for pre and postprocedure care (e.g., postoperative nausea and vomiting prophylaxis, anticoagulation management) (6) Reduced postoperative complications (7) Cost reduction (through reduced testing, reduced postoperative complications, decreased postanesthesia care unit, ICU, and hospital stays) (8) Improved care coordination and discharge planning. In the perioperative surgical home model, a coordinated, multidisciplinary team led by an anesthesiologist is responsible for the care of patients from the preoperative period through the postdischarge phase. When possible, evidencebased protocols drive decision-making. Preoperative evaluations are conducted in an anesthesia-run clinic. Decisions regarding preoperative lab testing, the need for specialty consultation, and changes in medication management prior to surgery are made by the consulting anesthesiologist, not a surgeon or primary care physician. Patient education, including the anesthesia plan and expectations about postoperative pain management, is also discussed during the preanesthetic interview. And perhaps most importantly, rather than be managed only by a surgical team, an anesthesia-intensivist remains involved in the postoperative care of the patient, overseeing decisions regarding, for example, glycemic control, venous thromboembolism prophylaxis, as well as pain management (Table 4). The concept of the surgical home was an extension of the medical home, a term first introduced by the American Academy of Pediatrics in 1967 and conceived of by Dr Calvin Sia, based primarily on his experience working with at-risk families and children with special needs [20]. Unlike the surgical home, the medical home is a fairly well established concept. In 2009, the Accreditation Association for Ambulatory Healthcare issued specific accrediting Volume 27 Number 3 June 2014
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Trends in US healthcare and the perioperative surgical home Holt Table 4. Traditional care vs. perioperative surgical home
Preoperative
Traditional care
Perioperative surgical home
Surgeon orders preoperative lab work and chest x-ray when the surgery is booked
Anesthesiologist orders preoperative lab work, chest x-ray, and other tests as needed after preanesthesia interview
Surgeon orders blood products to be available for day of surgery
Anesthesiologist considers strategies for medical optimization (e.g., statins, anticoagulation, diabetes control, treatment of anemia) Anesthesiologist conducts routine screening of high-risk patient groups and considers plan to prevent complications (e.g., dementia/delirium, substance abuse) Anesthesiologist outlines intraoperative and expected pain management plan
Intraoperative
Anesthesiologist makes management decisions based on personal judgment of the patient’s medical readiness for surgery
Anesthesiologist establishes patient readiness according to criteria outlined during preanesthesia visit Anesthesiologist conducts anesthesia and pain management plan according to course established in preanesthesia visit (to the extent appropriate)
Postoperative
Surgeon is dominant physician in the OR
Anesthesiologist becomes the OR team leader, facilitating decisions such as disposition of postoperative patient
Surgical team manages patient’s medical/surgical care during hospitalization
Anesthesiologist-intensivist manages patient’s medical care during hospitalization Anesthesiologist applies evidence-based protocols and checklists are used where appropriate (e.g., DVT prophylaxis, ventilator weaning, antibiotic discontinuation)
DVT, deep vein thrombosis; OR, operating room.
guidelines for organizations wishing to be designated medical homes. Several state governments and large self-insured companies, including IBM, have begun to use the medical home concept, particularly in the management of patients with chronic diseases [20]. Furthermore, early evidence suggests that implementation of the medical home can improve quality of care while simultaneously reducing costs and acute care visits [21,22]. In several European countries, such as Denmark and the UK, although the term medical home is not used, the gate-keeping role of the general practitioner in the care of patients serves an analogous function [23]. To date, the surgical home is an untested concept. However, at some institutions, its practical application is being tested. At the Keck Medical Center at the University of Southern California, a surgical home concept has been utilized in the anesthesia ICU for over 30 years. In a retrospective trial, investigators compared outcomes of patients who had the same anesthesiologist for intra and postoperative care vs. those whose care was managed by different anesthesiologists. They found that both ICU days (2.72 vs. 4.85 days, P < 0.001) and hospital days (6.87 vs. 10.1 days, P ¼ 0.004) were significantly reduced in patients who had been managed according to the surgical home model.
In addition, ICU readmission rates were significantly less among patients in the surgical home group (1.65 vs. 15%, P < 0.001). Furthermore, mortality among patients managed in the surgical home was also significantly reduced (3.79 vs. 8.33%, P ¼ 0.005) [24]. The role of the anesthesiologist in the surgical home is somewhat analogous to the hospitalist. Once resisted by primary care physicians as encroaching upon their ‘territory’, hospitalists are now increasingly embraced by those same physicians, who now see it as a way for them to enhance efficiency allowing them to focus on outpatient care [25]. Medical co-management of high-risk surgical patients by hospitalists is indeed not a new concept. Although some studies suggest such practice can lead to lower mortality and shorter hospital length of stay [26–28], others have shown no significant outcomes effects [29,30]. However, anesthesiologists have the advantage over hospitalists of already being familiar with the surgical issues of the patient. Therefore, they are arguably better equipped to oversee perioperative medical issues than the hospitalist. There are some elements of the surgical home that are easier to operationalize than others. In the inpatient setting and for patients in the ICU especially, anesthesia-led patient care management is a fairly easy transition. The role of the
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anesthesiologist in posthospital follow-up care is a far less well developed concept. Furthermore, adaptation of the surgical home to the outpatient setting has yet to be described, but clearly warrants attention, as more than two-thirds of surgeries now take place in that environment.
CONCLUSION Hospital–physician collaborations will increasingly be needed in light of the obligatory risk-sharing implied by a bundled payment system. The development of the surgical home requires buy-in not only from surgeons but also from hospital administration. Improvement in patient outcomes and net reduction in hospital costs will be the best forms of evidence that the model is a success. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Vincent GK, Velkoff VA. The next four decades. The older population in the United States: 2010 to 2050. Current Population Reports. Washington, D.C., USA: Census Bureau; 2010; pp 25–1138. 2. Wiener JM, Tilly J. Population ageing in the United States of America: implications for public programmes. Int J Epidemiol 2002; 31:776–781. 3. Anderson GF, Hussey PS. Population aging: a comparison among industrialized countries. Health affairs 2000; 19:191–203. 4. Pearson WS, Bhat-Schelbert K, Probst JC. Multiple chronic conditions and the aging of america: challenge for primary care physicians. J Prim Care community Health 2012; 3:51–56. 5. Lagoo-Deenadayalalan SA, Newell MA, Pofahl WE. Common perioperative complications in older patients. In: Rosenthal RA, Zenilman ME, Katlic MR, editors. Principles and practice of geriatric surgery. Volume 2. New York: Springer Science Business Media, LLC; 2011. pp. 361–376. 6. Olin K, Eriksdotter-Jonhagen M, Jansson A, et al. Postoperative delirium in elderly patients after major abdominal surgery. Brit J Surg 2005; 92:1559– 1564. 7. Robinson TN, Raeburn CD, Tran ZV, et al. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg 2009; 249:173–178.
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8. Edelstein DM, Aharonoff GB, Karp A, et al. Effect of postoperative delirium on outcome after hip fracture. Clin Orthop Relat Res 2004; 422:195– 200. 9. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc 2000; 48:618–624. 10. Kim V, Spandorfer J. Epidemiology of venous thromboembolic disease. Emerg Med Clin North Am 2001; 19:839–859. 11. Di Minno G, Tufano A. Challenges in the prevention of venous thromboembolism in the elderly. J Thromb Haemost 2004; 2:1292–1298. 12. Jaffer AK, Brotman DJ. Prevention of venous thromboembolism in the geriatric patient. Clin Geriatr Med 2006; 22:93–111; ix. 13. U.S. Outpatient Surgeries on the Rise. CDC National Center for Health Statistics Press Release. Available at http://www.cdc.gov/media/pressrel/ 2009/r090128.htm, January 28, 2009. 14. Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg 2012; 256:518–528. 15. van Gelder FE, de Graaff JC, van Wolfswinkel L, van Klei WA. Preoperative testing in noncardiac surgery patients: a survey amongst European anaesthesiologists. Eur J Anaesthesiol 2012; 29:465–470. 16. Phillips MB, Bendel RE, Crook JE, Diehl NN. Global health implications of preanesthesia medical examination for ophthalmic surgery. Anesthesiology 2013; 118:1038–1045. 17. Bundled Payments for Care Improvement Initiative. Centers for Medicare & & Medicaid Services Fact Sheet. Available at http://innovation.cms.gov/initiatives/bundled-payments/, September 30, 2013. This fact sheet describes the concept of the bundled payment and how CMS plans to roll-out the new payment structure. 18. Mechanic R, Tompkins C. Lessons learned preparing for Medicare bundled payments. N Engl J Med 2012; 367:1873–1875. 19. Schweitzer M, Fahy B, Leib M, Rosenquist R, et al. The perioperative surgical & home model. ASA Newsletter 2013; 77:58–59. This article outlines the ASA’s concept of the perioperative surgical home. 20. Backer LA. The medical home: an idea whose time has come...again. Fam Pract Manag 2007; 14:38–41; Available at http://www.aafp.org/fpm/2007/ 0900/. 21. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs 2010; 29:835–843. 22. Steiner BD, Denham AC, Ashkin E, et al. Community care of North Carolina: improving care through community health networks. Ann Fam Med 2008; 6:361–367. 23. Solberg LI, Van Royen P. The medical home: is it a blind men and elephant tale? Fam Pract 2009; 26:425–427. 24. Atoian A, Haney M, Gabel E, et al. The evidence for a surgical home (abstract). ASA Practice Management 2013. January 25-27, 2013. Las Vegas, NV. Available at education.asahq.org/sites/education.asahq.org/files/users/pm20. pdf 25. Fuchs VR. Major trends in the U.S health economy since 1950. N Engl J Med 2012; 366:973–977. 26. Auerbach AD, Wachter RM, Cheng HQ, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Inter Med 2010; 170:2004–2010. 27. Phy MP, Vanness DJ, Melton LJ 3rd. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med 2005; 165:796–801. 28. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics 2009; 32:495. 29. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med 2004; 141:28–38. 30. Siegal EM. Just because you can, doesn’t mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med 2008; 3:398– 402.
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