Asra defining value may 2015
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Transcript of Asra defining value may 2015
Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of AnaesthesiaUniversity of OttawaHead of AnaesthesiaThe Ottawa HospitalScientist, Ottawa Hospital Research Institute
Defining Value in Regional Anesthesia:
What are the Important Outcomes and Who Gets to Define Them
Conflicts of Interest
None
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)
Institute for Healthcare Improvement
Triple Aim in Healthcare
USA
Centre for Medicaid and Medicare Services (CMS)
Best Care at Lower Cost 2012 Performance transparency between
providers and consumers Set % of withhold of payments based
on performance related payments Currently 1.25% and increasing each
year
Elements of Value-Based Purchasing
Patient Experience of Care
HCAHPS 32 questions Publicly reported 4 times per year 7 questions that directly or indirectly
relate to pain Acute pain medicine needed for
many reasons!
www.edmariano.com
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
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.
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
382,000 patients 25% neuraxial Neuraxial associated with less
mortality, length of stay, in-patient morbidity
Anesthesiology 2013
Reduced postoperative pain, opioid consumption, adverse effects
No difference in blood loss or TE events
No difference in mortality
Strengths/Limitations of QBPs
Strengths: first attempt to standardize practice across Ontario, Drives KT process, Drives further research
Weaknesses: based on limited evidence, opinion-based, limited input from patient experience of care, most funding remains based on geography/population base
Commisioning for Quality and Innovation Payments (CQUINS) UK Targets/Drivers for which hospitals
can obtain extra revenue Goal-directed therapy for major
abdominal surgery Time to surgery for hip fracture Dr. Foster-independent organization
measures and publishes outcome data across centres in England
CQUINS for 2014/15
Important outcomes: what are they?
Patient: pain, function, awareness, nausea
Physician: Quality and safety. Efficiency
Hospital: Patient experience, Q+S, Efficiency
Society: Quality and safety, Patient experience, Efficiency
What is patient experience?
“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
How can regional anesthesia influence value
Triple aim: Quality, Health of populations and Cost
Reduces pain: both acute and chronic Reduces AEs related to opioid
sparing Reduction in cost: reduced overtime,
case cancellations
Value of RA on short term outcomes
RA and short term outcomes
Reduced pain Reduced nausea Faster discharge Faster return of GI function Improved rehabilitation Reduced respiratory complications Reduced MI and CVS complications etc etc
23 RCTs in total Pooled 3 studies for epidural after
thoracotomy and 2 for PVB after breast surgery
Andreae MH et al BJA 2013
Value of RA in major outcomes?
382,000 patients 25% neuraxial Neuraxial associated with less
mortality, length of stay, in-patient morbidity
Anesthesiology 2013
How can regional anesthesia influence value
Increased efficiency: block room model, enhanced recovery, discharge, ambulatory care
Reduced readmission: better pain control
Population Health: reduced mortality and possible effects on other outcomes
A Day in the OR: pre-block room
OR time map
AT PPD surgery out TO
20 15 75 15 20
52 % efficiency
OT = 95 min
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
OR Time
KneesHips
Type
125
100
75
50
25
0
Mea
n S
urg
ical
Tim
e
Error bars: +/- 1 SD
2007
2004
Year
17% decrease in time for patient-in to patient-out from 2004 to 2007 in total knee arthroplasties18.6% decrease in time required from patient-in to patient-out for total hip arthroplasties
OR Overtime(* cancellations)
June July September October0
5
10
15
20
25
30
35
2004
2007
Ove
rtim
e (h
ou
rs)
*27
*14
*21*11
4
53
8
Defining Value in Regional Anesthesia
Improved pain controlLess adverse effects
Mortality and Morbidity Benefits
Greater Efficiency, Faster discharge
Further reading:
ACS Physician quality reporting system: https://www.facs.org/advocacy/regulatory/pqrs
Pay for Performance in periop pain: http://www.edmariano.com/archives/684
Triple aim: http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx
Dr. Foster: http://www.drfoster.com/about-us/