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@EMARIANOMD
Pain Medicine and the
Pathway to Better
Surgical Care
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

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@EMARIANOMD
Financial Disclosures
 None currently.
 Past (>1 year): 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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@EMARIANOMD
Health Care Is Changing

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@EMARIANOMD
Focus on the Facts

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@EMARIANOMD
Kurtz S, et al. JBJS 2007 Apr;89(4):780
FACT: Arthroplasties Are Increasing

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@EMARIANOMD
Kurtz S, et al. JBJS 2007 Apr;89(4):780
FACT: Arthroplasties Are Increasing
Now Over 1,000,000 THA
and TKA Cases Annually

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FACT: “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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FACT: “Precision” Medicine

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FACT: The Opioid Epidemic
https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

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FACT: MACRA Passed in 2015

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FACT: MIPS Started in 2017
https://qpp.cms.gov/

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FACT: The Newest Subspecialty
X

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@EMARIANOMD
Overview
 Defining the Perioperative Surgical Home
 The role of pain medicine
 Thinking beyond blocks

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@EMARIANOMD
Overview
 Defining the Perioperative Surgical Home
 The role of pain medicine
 Thinking beyond blocks

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@EMARIANOMD
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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@EMARIANOMD
Perioperative Surgical Home
Anesthesiology 2015;123:A23
We started
in 2010!

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@EMARIANOMD
Perioperative Surgical Home

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@EMARIANOMD
How Do I Think of PSH?

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@EMARIANOMD
Overview
 Defining the Perioperative Surgical Home
 The role of pain medicine
 Thinking beyond blocks

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@EMARIANOMD
 Prospective study comparing opioid-naïve,
low and high opioid cohorts for TKA
 Perioperative multimodal analgesia
Aasvang & Kehlet, et al. Acta Anaes Scand 2016;60:529

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@EMARIANOMD
Elements of Pain Medicine in PSH
PSH: Comprehensive Literature Review, www.asahq.org/psh

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

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@EMARIANOMD
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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@EMARIANOMD
HCAHPS Questions on Pain
Mariano, et al. Adv Anesthesia 2013;31:119

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@EMARIANOMD
 “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

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@EMARIANOMD
Overview
 Defining the Perioperative Surgical Home
 The role of pain medicine
 Thinking beyond blocks

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

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@EMARIANOMD
Remember Multimodal Analgesia
Anesthesiology 2012;116:248

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@EMARIANOMD
Continuously Improve
Mudumbai & Mariano, et al. Healthcare 2016;4:334

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@EMARIANOMD
Avoid “Never” Events
Federal Register May 3, 2007

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@EMARIANOMD
Anesth Clinics 2014;32:853

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@EMARIANOMD
Prevent Persistent Pain
Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients
Normal
Persistent Pain
Neuropathic Pain

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@EMARIANOMD
Primary Care
Conservative mgmt
failed
Surgery considered as
treatment option
Preop Consult
Initiated by primary care
E-consult or phone consult
to anesthesiology
Alternative treatments
considered
Establish common preop
“ready” criteria:
http://www.becertain.org/st
rong_for_surgery/hospitals
Referral to
Surgeon
Patient evaluated
Images/tests reviewed
Decision Made to
Proceed with
Surgery
Preop Visit
Review protocols and
instructions
Focus on education and
preview of OR experience
Day of Surgery
Surgery proceeds as
scheduled; or
surgery is cancelled
Rethink Preop Preparation

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@EMARIANOMD
Deliver Highly Reliable Care

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@EMARIANOMD
2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016

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@EMARIANOMD
Be Change Agents

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@EMARIANOMD
Helpful Resources
 https://www.asahq.org/psh
 https://www.asra.com/pain-
resource/category/27/practice-
management
 https://www.asahq.org/quality-and-
practice-management/macra/macra-
modules
 https://qpp.cms.gov/