This year’s second annual Perioperative Surgical Home (PSH) Summit, held on June 26-28 in Huntington Beach, California, drew 40 per cent more attendees than the inaugural meeting last year, reflecting the growing national interest in the PSH concept.
Though the weather at the waterfront was cool and cloudy—typical “June gloom” for the west coast—the conference at the Hyatt Regency Huntington Beach Resort attracted 426 registrants and 28 corporate exhibitors. The ASA and the University of California at Irvine’s Department of Anesthesiology and Perioperative Care jointly sponsored the event.
The PSH is a recently developed care model that may help organizations reduce avoidable costs and position themselves better under both current and future payment models. It offers detailed protocols at every stage of the surgical or procedural patient encounter, from preoperative through post-discharge care, aimed at delivering more coordinated, high-quality, and efficient service.
The entire first day preconference was dedicated to the topic of how to secure support for the PSH model from a broad group of stakeholders, including surgeons, nurses, case managers, and hospital administrators. Co-chairs Zeev Kain, MD, MBA, and Stan Stead, MD, MBA, opened the meeting by advising the group on how to lead the PSH process, identify their key stakeholders, and develop an “elevator pitch” about explaining the PSH concept in a few well-chosen words.
“Developing leading edge and coordinated care”
Amir Dan Rubin, MBA, the President and Chief Executive Officer at Stanford Hospital and Clinics, gave the keynote address at the start of the main meeting on Saturday morning. He told the audience that patients want more than just medical care. The key to an organization’s success, he said, is to ask the question: “Do all of our processes come together to deliver a great experience?”
Patients want to be known as individuals, with their background and preferences noted, Mr. Rubin said. Furthermore, they want to have their care coordinated for them, with same-day appointments if they need to see multiple specialists: radiology, anesthesiology, and surgery, for example. A patient wants Stanford to “know me, show me, and coordinate for me,” Mr. Rubin declared.
A great deal of consolidation is taking place in health care, Mr. Rubin said, with physicians moving from independent practice to large groups and health systems. But the experience for patients has been suboptimal, leading to a need to redesign primary care—what Stanford now calls “Primary Care 2.0”. He said that Stanford is moving toward personalizing care, with a patient portal that allows patients to review their own charts. Technology and smart phone apps have the potential to make checklists for patients easy to use, he said, with reminders, schedules, and step-by-step instructions for processes like pre-surgical instructions and stoma care.
Though the Centers for Medicare & Medicaid Services (CMS) is pushing hard to have most payments based on value rather than volume, Mr. Rubin said that value-based payments “probably won’t be the entire picture” any time soon. “Service-based and volume-based payments can still be a very efficient way to pay people,” he noted. “I think we’re all going to live in mixed models.” If bundled payments don’t do a good job of risk adjustment, he said, the result would be “to push centers to take only healthy patients.”
To be at the leading edge of health care, Mr. Rubin concluded, hospitals must “standardize processes, but treat each patient individually.”
Perioperative Medicine: moving beyond the OR
The University of California at Irvine (UCI) has led the way in early implementation of the PSH concept, and a number of UCI faculty members gave talks about their experience. Shermeen Vakharia, MD, MBA, spoke about the leadership skills needed for effective project management. Leslie Garson, MD, described the evolution of the preoperative assessment clinic into a setting geared toward optimizing the condition of the patient well before the day of surgery. Maxime Cannesson, MD, PhD, outlined the data showing that the use of goal-directed intraoperative fluid management can improve surgical outcome. UCI has expanded the role of anesthesiology in postsurgical care beyond the Post-Anesthesia Care Unit, and Scott Engwall, MD, MBA, described how this new perioperative medicine service is organized.
Both UCI and Stanford have recently started to offer perioperative medicine fellowships to train the next generation of anesthesiologists for a broader role in patient care beyond the operating room.
“Anesthesiologists are uniquely qualified to lead the PSH,” said Ron Pearl, MD, PhD, the chair of Stanford’s Department of Anesthesiology, Perioperative and Pain Medicine. Dr. Pearl believes that anesthesiology must expand to include postoperative oversight of surgical patients outside the areas of pain medicine and intensive care, and that anesthesiology residency curricula as well as fellowship training need to be adjusted accordingly.
“Postoperative complications are a more important determinant of long-term postoperative survival than either co-morbid diseases or intraoperative adverse events,” Dr. Pearl said. He quoted a 2009 study in the Annals of Surgery that blamed “failure to rescue” in the postoperative period as a major factor responsible for differences in mortality between hospitals.
Money and Harm: 30-Day Readmissions
Hospitals began to pay penalties in 2012 for Medicare patients who are readmitted within 30 days of discharge, and those penalties will reach an average of $400,000 per hospital by the end of this fiscal year, according to Douglas Merrill, MD, MBA, UCI’s Chief Medical Officer and Senior Associate Dean of Quality and Safety.
“Patients are paying attention” to this issue, Dr. Merrill said, as more of the bill for healthcare is being shouldered directly by patients. Nearly one in five Medicare patients is readmitted within 30 days, and as many as 75% of those readmissions may be preventable. The PSH, he believes, can play a key role in reducing surgical complications and readmissions.
Dr. Merrill recommends identifying frail patients, who are at higher surgical risk, early in the procedural care process. He said that the incidence of frailty is as high as 20% among patients over 65 years old, and that several simple measures can alert the PSH team:
- Gait speed
- Hand grip strength
- Ability to rise from a chair, walk, and return to the chair in less than 15 seconds
“It’s not survival, stupid!” Dr. Merrill claimed. Modern anesthesia care can get frail patients through surgery, but “the problem for these patients is that they never go home.” They go to long-term care or skilled nursing facilities (SNF), and then they come back to the hospital. “They go back to the SNF, maybe. Then they die,” he said. Families later say that if they had known this could happen, they would have refused surgery. The key is preoperative intervention, Dr. Merrill said, with better discussion of risks and benefits, and optimization with nutritional supplementation and exercise.
The Sunday morning sessions emphasized the economics of the PSH.
Dr. Stead discussed anesthesiology’s choices for the future in the world of bundled payments and value-based payment. He joined Mike Schweitzer, MD, MBA, and Marc Lieb, MD, JD, in a panel discussion about monetizing the PSH, co-management arrangements, and working with CMS and state government in PSH initiatives.
The ASA anticipates that information about next year’s PSH Summit will be available in December, and that the meeting site will be on the east coast.