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ERAS and regional anesthesia at PGA 2015

Do we need regional in ERAS?

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ERAS and regional anesthesia at PGA 2015

  1. 1. Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPC Professor and Chair of Anesthesiology University of Ottawa Head of Anesthesiology The Ottawa Hospital Scientist, Ottawa Hospital Research Institute Enhanced Recovery and Regional Anesthesia: Do we need regional?
  2. 2. Conflicts of Interest  Consultant for Teleflex Medical  I will not be discussing off-label or investigative uses of commercial devices
  3. 3. Objectives  Describe the place of enhanced recovery in perioperative care  Learn the place of regional anesthesia in enhanced recovery  Examine the current evidence to support regional anesthesia within the enhanced recovery process  Look at the future of regional anesthesia in ERAS
  4. 4. Summary  ERAS pathways have become common for colorectal and orthopedic surgical pathways  Regional anesthesia techniques are used in many pathways but use has suffered due to educational and other barriers  Regional anesthesia has demonstrated several benefits for patients in ERAS pathways  As healthcare spending becomes further constrained we need to align our outcome measures with those being used to justify funding for our interventions
  5. 5. Enhanced Recovery after Surgery  Largely influenced by work of Professor Henrik Kehlet (Denmark)1  Integrated coordinated bundles of care with a focus on multimodal techniques and interdisciplinary care  Major focus on colorectal and orthopedic surgery  Regional anesthesia often included 1Kehlet H BJA 1997; 78: 606-17
  6. 6. Enhanced Recovery after Surgery  Less use of ERAS pathways outside colorectal and orthopedic surgery  Barriers to implementation in many centres  Regional anesthesia use often limited  Specific focus on evidence-base for regional within ERAS not available 1Kehlet H BJA 1997; 78: 606-17
  7. 7. Concepts within ERAS  Standardization of care  Evidence-based care  Multimodal care pathways based on best evidence  Multidisciplinary (focus on the team)
  8. 8.  Many reviews of efficacy of enhanced recovery protocols  Little written about specific place of RA with ERAS protocols  Scoping review to examine area Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
  9. 9.  Scoping review: a rapid gathering of evidence in a given clinical area with an aim to accumulate as much evidence as possible and map the results  Focus on triple aim outcomes Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
  10. 10. Institute for Healthcare Improvement Triple Aim in Healthcare
  11. 11.  Searched for all articles that examined regional anesthesia within an enhanced recovery pathway (ERP)  EMBASE, MEDLINE, CENTRAL, CDSR, PROSPERO and the NHS Evaluation Database  Inception to May 2015 Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA 2015
  12. 12.  695 unique citations; 446 excluded after title review, 249 full text review with 191 excluded  58 unique studies for data extraction  67% RCTs and one non-randomized trial  14 controlled before-and-after studies, 5 retrospective cohort studies and one prospective cohort Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
  13. 13.  >50% of studies examined colorectal surgery  Orthopedic (21%) and other types of non- colorectal general surgery (29%)  Regional techniques: Epidural, SAB, TAP block and lower limb PNB techniques Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
  14. 14. Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
  15. 15.  Good news! Strong evidence that RA provides: – Improved pain control – Improved organ function and mobility – Reduced PONV, length of stay and adverse events  Bad news: little focus on triple aim outcomes Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press
  16. 16.  Elective colon resection  64 patients randomized to epidural or PCA  Primary outcome: 6 MWT  Secondary outcome: HRQoL: SF-36
  17. 17.  Both groups had decrease in 6MWT and SF-36 3 and 6 weeks following surgery  Significantly greater decrease in the PCA group (p<0.01)
  18. 18.  Clinical pathway including multimodal analgesia and continuous PNBs  Reduced length of stay, hospital costs and improved pain control
  19. 19. Bad News  Poor translation of current evidence into practice  Little focus on Triple Aim
  20. 20. Wong PA, McCartney CJ et al Pain Medicine: In press
  21. 21.  382,000 patients  25% neuraxial  Neuraxial associated with less mortality, length of stay, in-patient morbidity Anesthesiology 2013
  22. 22.  120 patients randomized to spinal vs TIVA for TKA  Primary outcome: LOS  No opioid (intrathecal or other) in spinal group  Both groups received LIA
  23. 23. The KT Gap and RA? Patient factors System factors Education factors
  24. 24. Barriers to RA  Patient education  Surgeon education  Anesthesiology education  Administrative barriers
  25. 25. Patient education  Patients don’t like needles  Patients don’t like being awake in the OR  Patients don’t like postoperative pain
  26. 26. Importance of good acute pain control to patients Apfelbaum JL A&A 2003
  27. 27. Surgical education Masursky D et al A&A 2008
  28. 28. Anesthesiology education  Anesthesiologists remain poorly trained in regional anesthesia  Anesthesiologists fear risk of failure and complications  Leadership and support must come from the top of every department
  29. 29. Administrative Barriers  Anesthesiology leadership and leadership in perioperative medicine  Hospital funding silos  Overfocus on RCT evidence and lack of larger population-based evidence
  30. 30. Anesthesiology Leadership  We need to leading perioperative teams in our hospitals  Invest in our ability to care for patients from admission to discharge  Realize that anesthesiologists are the key perioperative physicians  Understand the threat to our patients if we do not step up
  31. 31. Funding Silos  Inability to leverage total hospital savings against possible increase in OR costs  No incentive to save costs in our current system  Funding of innovative but unproven therapy at expense of “less sexy” proven methods
  32. 32. Overfocus on RCT evidence  RCTs constitute <25% of all patients  Strict inclusion/exclusion criteria  ? Reflect real practice  Pragmatic trials possibly the answer  Good quality case control or cohort studies  Definition of standardized outcomes across studies  More focus on longer term outcomes
  33. 33.  382,000 patients  25% neuraxial  Neuraxial associated with less mortality, length of stay, in-patient morbidity Anesthesiology 2013
  34. 34. Bad News  Poor translation of current evidence into practice  Little focus on Triple Aim
  35. 35. Importance of Triple Aim  Used increasingly by government agencies to allocate funding: – US: Centre for Medicaid and Medicare Services – Canada: Provincial Funding Model and Quality-Based Procedures – UK: CQUINS: Commissioning for Quality and Innovation Payments
  36. 36. What outcomes do we need to study?
  37. 37. What is patient experience?
  38. 38.  “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
  39. 39. 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
  40. 40. What measures should we use? Phase of recovery Definition Time Frame Threshold Outcomes Example of measures Early OR to PACU discharge Hours Safety (to go to ward) Physiological Aldrete Score Intermediate PACU to hospital discharge Days Self-care Symptoms and impairment of IADL Quality of Recovery score Late Discharge to return to normal function Weeks to months Return to normal Function and HRQoL 6MWT CHAMPS SF-6D Lee L et al Surgery 2014
  41. 41. What can we focus on? Process vs Outcome Measures  Timing of antibiotic administration and SSI  Patient warming and CVS events  Use of neuraxial anesthesia  Use of multimodal analgesia and effective early pain control and rehabilitation
  42. 42. What can we focus on? Process vs Outcome Measures  Focus on quality of care for individual patients. Smaller RCTs and QA processes  Focus on standards of care for populations of patients. Larger pragmatic and population based studies to determine broad guidelines for care e.g. AAOS, HQO
  43. 43. Summary  ERAS pathways are common for colorectal and orthopedic surgical pathways  Regional anesthesia techniques are used in many pathways but use has suffered due to educational and other barriers  Regional anesthesia has demonstrated several benefits for patients  Align outcome measures with Triple Aim to ensure funding of valuable interventions
  44. 44. Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPC Professor and Chair of Anesthesiology University of Ottawa Head of Anesthesiology The Ottawa Hospital Scientist, Ottawa Hospital Research Institute Enhanced Recovery and Regional Anesthesia: Do we need regional? Yes
  45. 45. What do we need?  Studies of RA that focus on outcomes relevant to patients and the system  Studies examining non-colorectal and orthopedic populations  A system that facilitates use of best treatments  Invest in our own clinical, education and research leaders looking outside our own institutions  Don’t forget about the importance of pain control, care after discharge and care of each individual
  46. 46. Winterlude Anesthesia 2016 January 30-31, Ottawa http://www.med.uottawa.ca/anesthesia/eng/06_winterlude.html

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Do we need regional in ERAS?

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