The document discusses important outcomes in healthcare and how acute pain medicine can influence value-based care. It outlines key outcomes defined by patients, providers, governments in the US, Canada, and UK. The Triple Aim framework of improving patient experience, population health, and reducing costs is examined. The document argues acute pain medicine can impact these areas by reducing pain and adverse effects, improving efficiency through faster recovery and discharge, and potentially improving health outcomes. Regional anesthesia techniques are discussed as ways to positively influence value-based goals through improved recovery and resource utilization.
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Defining Outcomes That Matter for Perioperative Pain Medicine
1. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anaesthesia
University of Ottawa
Head of Anaesthesia
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Defining the Outcomes That
Matter for Perioperative Pain
Medicine
3. Overview
Important outcomes/who defines?
USA, Canada, UK
How can acute pain medicine influence
value based on the IHI triple aim?
4. Overview
Important outcomes/who defines?
USA, Canada, UK
How can acute pain medicine influence
value based on the IHI triple aim?
5. 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)
7. 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 will be 2% by 2017
9. 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
HCAHPS: Hospital Consumer Assessment of
Healthcare Providers and Systems
10. 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
11. 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.
12.
13. 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
14.
15.
16. 382,000 patients
25% neuraxial
Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013
17. Reduced postoperative pain, opioid
consumption, adverse effects
No difference in blood loss or TE events
No difference in mortality
18.
19. 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
20. Commissioning 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
24. “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
25. Patient Experience vs Satisfaction
Patient experience goes beyond patient
satisfaction and making patients happy
You may have a negative outcome but a positive
experience
You may have a positive outcome but a negative
experience
Patient experience is linked to staff engagement
Patients judge healthcare providers not only on
outcome but on compassionate and excellent
patient care
26.
27. Overview
Important outcomes/who defines?
USA, Canada, UK
How can acute pain medicine influence
value based on the IHI triple aim?
28. How can acute pain medicine
influence value
Triple aim: Quality, Health of populations
and Cost
Reduce pain: both acute and chronic
Reduces AEs related to opioid sparing
Reduction in cost: reduced overtime, case
cancellations, earlier discharge
Facilitate early rehabilitation
36. 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
37. 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
38. Overall lack of evidence with majority of
studies in colorectal surgery
Value-based outcomes (IHI related) were
rarely reported
Improved pain control, reduced adverse
events, faster mobility and enhanced
return of bowel function with RA
McIsaac D, Cole E, McCartney CJ BJA In Press
39.
40. Defining Value in Acute Pain Medicine
Improved pain control
Less adverse effects
Mortality and Morbidity Benefits
Greater Efficiency, Faster discharge,
Reduced readmission
41. Overview
Important outcomes/who defines?
USA, Canada, UK
How can acute pain medicine influence
value based on the IHI triple aim?
42. The Future
Greater involvement of patients and government
in determining healthcare funding allocation
Funding based on quality, effectiveness and
value
Individual provider and hospital metrics to look
at our own measures of quality (e.g. NSQIP)
Standardization of care to allow easier
measurement of outcomes (e.g. QBPs)
Movement of care back to the community
43. The Future
Better research across large numbers of patients
examining value-based outcomes
Get engaged in building the research base
Apply current evidence in practice
Use regional anesthesia but manage adverse
effects such as motor block
In this era of “Value-Based Medicine” make sure
we don’t decline to “Cost-Based Medicine”
Don’t confuse patient experience with patient
satisfaction
44. 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/