PowerPoint Presentation

Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of AnaesthesiaUniversity of OttawaHead of AnaesthesiaThe Ottawa HospitalScientist, Ottawa Hospital Research InstituteDoes regional anaesthesia have a place in modern perioperative care?

1Good morning. My name is Colin McCartney and I am an anesthetist and consultant in chronic pain management from Toronto Western Hospital.

Conflicts of InterestConsultant: Teleflex Medical

cmccartney@toh.ca

SummaryRegional anaesthesia (RA) has significant short, medium and long-term benefitsPressures in modern medicine are adversely influencing use of RARA and the Triple AimKey questions remain to be answered

Why I care about outcomes?Anaesthetist since 1993Regional Anaesthesia and Pain Medicine since 1994Research since 1999Head of Anaesthesia, The Ottawa Hospital since 2014Member of TOH Senior Management Team since 2014Exposure to practice in UK, Canada and US

Why should we care about outcomes?Our patientsOur system: cost:benefitOur specialty: expertise in perioperative and pain medicineWe need to invest in research and education

After Lunch QuotesIf we are not at the table we might be on the menuIf you dont like change you are going to like irrelevance even lessWe have to act like doctors, not technicians and be involved in evaluation of outcomes

SummaryRegional anaesthesia (RA) has significant short, medium and long-term benefitsPressures in modern medicine are adversely influencing use of RARA and the Triple AimKey questions remain to be answered

What are the key unquestioned benefits of regional anaesthesia?Pain controlReduction in adverse effects of opioid analgesia

Regional Anesthesia Reduces Pain

Anesthesia & Analgesia 2012

Value of RA on short term outcomes

What are the generally supported benefits of RA?Improved resp fnctn (Ballantyne et al)Faster return of GI function (Liu SS et al)Improved early ambulation (Ilfeld et al)Better sleep? (Riazi S et al)

Regional and Respiratory

Regional and GI function

What are the questionable benefits?Reduction in surgical site infectionReduced critical care utilizationFaster dischargeReduced readmissionReduced chronic painReduction in cancer recurrenceReduction in mortality

BMJ 2000

400 hospitals between 2006-10Data from primary hip/knee arthroplastySubgrouped by anesthetic technique30 day morbidity and mortality data

Anesthesiology 2013

382,000 patients25% neuraxialNeuraxial associated with less mortality, length of stay, in-patient morbidity

Anesthesiology 2013

SummaryRegional anaesthesia (RA) has significant short, medium and long-term benefitsPressures in modern medicine are adversely influencing use of RARA and the Triple AimKey questions remain to be answered

Regional and and Current Perioperative CareTake your time (as long as its not mine)Problems of budgetary silos and fundingRegional anaesthesia and educationRegional anaesthesia and complications

Take your Time: Barriers to RAPoorly taughtDifficult to learnPatients do not like needlesDelays surgery?Significant risk of failure?Risk of complications

Budgetary Silos

Barriers to RAPatient education

Surgeon education

Anesthesiology education

32

Risks of complications

SummaryRegional anaesthesia (RA) has significant short, medium and long-term benefitsPressures in modern medicine are adversely influencing use of RARA and the Triple AimKey questions remain to be answered

Institute for Healthcare Improvement Triple Aim in Healthcare

Value in HealthCareValue=Experience x Functional Outcome Cost (intensity x length of care)

Outcomes in Regional AnesthesiaBased on IHI Triple AimExperience of care: Pain, Function, AEsPopulation Health: Morbidity/Mortality benefitsCost of care: Efficiency, Early discharge, Reduction in readmission

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 efficiencyGovernment: More and more involved through incentive driven outcomes e.g. CQUINS (UK), QBPs (Ontario) and CMS (US)

Quality-Based Procedures and Cost-Per Weighted Case (Ontario)Ontario: 13.5 million peopleOHIP covers all medical care (tax-based system)Quality-based procedures being standardized based on best evidenceHospitals 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 pathwaysreduce practice variationattain cost efficienciescatalyze alignment of quality and funding.

How are guidelines developed?Expert consensusHealth Quality OntarioHip fracture/Hip and knee arthroplastyTry as much as possible to use evidence from the literatureOften evidence poor or not presentUnderlines importance of research in our specialty

382,000 patients25% neuraxialNeuraxial associated with less mortality, length of stay, in-patient morbidity

Anesthesiology 2013

Strengths/Limitations of QBPsStrengths: 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

Outcomes in Regional AnesthesiaBased on IHI Triple AimExperience of care: Pain, Function, AEsPopulation Health: Morbidity/Mortality benefitsCost of care: Efficiency, Early discharge, Reduction in readmission

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

Outcomes in Regional AnesthesiaBased on IHI Triple AimExperience of care: Pain, Function, AEsPopulation Health: Morbidity/Mortality benefitsCost of care: Efficiency, Early discharge, Reduced overtime and case cancellation, Reduction in readmission

Outcomes in Regional AnesthesiaBased on IHI Triple AimExperience of care: Pain, Function, AEsPopulation Health: Morbidity/Mortality benefitsCost of care: Efficiency, Early discharge, Reduced overtime and case cancellation, Reduction in readmission

OR Time

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

53

OR Overtime(* cancellations)

54

A Day in the OR OR time map with RA + block area: AT is outside the OR in the block area

ATPPDsurgeryout

TO

75 min

1562065% efficiencyOT = 0 min

Data from Brians studyRCDB 50 patients undergoing TKAcFNB or placeboMultimodal analgesiaTime to achieve three distinct discharge criteria

56

57

Ilfeld et al 2008

58

RA and Cost of Care

Reduced LOS and reduction in readmission with PNBNo difference in falls (McIsaac D unpublished)Reduction in SSI: Cost of SSI from $400 to $30,000 (Urban J 2006)

Outcomes in Regional AnesthesiaBased on IHI Triple AimExperience of care: Pain, Function, AEsPopulation Health: Morbidity/Mortality benefitsCost of care: Efficiency, Early discharge, Reduced overtime and case cancellation, Reduction in readmission

SummaryRegional anaesthesia (RA) has significant short, medium and long-term benefitsPressures in modern medicine are adversely influencing use of RARA and the Triple AimKey questions remain to be answered

What questions remain?Pain after discharge from hospitalIdentification and validation of novel measures of recovery after surgeryKnowledge translation and RAValue of RAPMImpact of RA on opioid utilization after surgery

SummaryRegional anaesthesia (RA) has significant short, medium and long-term benefits and has a major place in modern healthcarePressures in modern medicine are adversely influencing use of RARA and the Triple AimKey questions remain to be answered

ConclusionsGovernments talking about resource allocation based on Triple AimCurrently much talk about cost and less about valueRA costs money but improves value through all parts of the Triple Aim: Patient experience, Population Health and Per Capita CostSome courage required to make fundamental changes

To improve is to change, to be perfect is to change oftenWS Churchill