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Pain Medicine and the Pathway to Better Surgical Care

Pain Medicine and the Pathway to Better Surgical Care

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Healthcare around the world is changing. In the United States, healthcare reform has been focused on achieving the “triple aim". This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists that may serve as an integrator to help hospitals achieve the triple aim. PSH is defined as “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.” Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation.

Healthcare around the world is changing. In the United States, healthcare reform has been focused on achieving the “triple aim". This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists that may serve as an integrator to help hospitals achieve the triple aim. PSH is defined as “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.” Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation.

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Pain Medicine and the Pathway to Better Surgical Care

  1. 1. @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
  2. 2. @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.
  3. 3. @EMARIANOMD Health Care Is Changing
  4. 4. @EMARIANOMD Focus on the Facts
  5. 5. @EMARIANOMD Kurtz S, et al. JBJS 2007 Apr;89(4):780 FACT: Arthroplasties Are Increasing
  6. 6. @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
  7. 7. @EMARIANOMD FACT: “The Triple Aim” Berwick et al., Health Aff (Millwood) 2008;27:759 Vetter et al., Anesth Analg 2014;118(5):1131
  8. 8. @EMARIANOMD FACT: “Precision” Medicine
  9. 9. @EMARIANOMD FACT: The Opioid Epidemic https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0
  10. 10. @EMARIANOMD FACT: MACRA Passed in 2015
  11. 11. @EMARIANOMD FACT: MIPS Started in 2017 https://qpp.cms.gov/
  12. 12. @EMARIANOMD FACT: The Newest Subspecialty X
  13. 13. @EMARIANOMD Overview  Defining the Perioperative Surgical Home  The role of pain medicine  Thinking beyond blocks
  14. 14. @EMARIANOMD Overview  Defining the Perioperative Surgical Home  The role of pain medicine  Thinking beyond blocks
  15. 15. @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
  16. 16. @EMARIANOMD Perioperative Surgical Home Anesthesiology 2015;123:A23 We started in 2010!
  17. 17. @EMARIANOMD Perioperative Surgical Home
  18. 18. @EMARIANOMD How Do I Think of PSH?
  19. 19. @EMARIANOMD Overview  Defining the Perioperative Surgical Home  The role of pain medicine  Thinking beyond blocks
  20. 20. @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
  21. 21. @EMARIANOMD Elements of Pain Medicine in PSH PSH: Comprehensive Literature Review, www.asahq.org/psh
  22. 22. @EMARIANOMD Mariano, Walters, Kim, Kain. A&A 2015;120:1163 Walters, Mariano, Clark. Pain Med 2015;16:1666.
  23. 23. @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
  24. 24. @EMARIANOMD HCAHPS Questions on Pain Mariano, et al. Adv Anesthesia 2013;31:119
  25. 25. @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
  26. 26. @EMARIANOMD Overview  Defining the Perioperative Surgical Home  The role of pain medicine  Thinking beyond blocks
  27. 27. @EMARIANOMD Develop Patient Care Pathways Hebl JR, et al. JBJS 2005;87 Suppl 2:63
  28. 28. @EMARIANOMD Remember Multimodal Analgesia Anesthesiology 2012;116:248
  29. 29. @EMARIANOMD Continuously Improve Mudumbai & Mariano, et al. Healthcare 2016;4:334
  30. 30. @EMARIANOMD Avoid “Never” Events Federal Register May 3, 2007
  31. 31. @EMARIANOMD Anesth Clinics 2014;32:853
  32. 32. @EMARIANOMD Prevent Persistent Pain Lavand’homme, et al. CORR 2014;472:1409 TKA Patients Normal Persistent Pain Neuropathic Pain
  33. 33. @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
  34. 34. @EMARIANOMD Deliver Highly Reliable Care
  35. 35. @EMARIANOMD 2017;42:368 http://www.edmariano.com/archives/1196 27%! J Arthroplasty 2016
  36. 36. @EMARIANOMD Be Change Agents
  37. 37. @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/

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