PowerPoint Presentation
Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCChair of
Anesthesiology and Pain MedicineUniversity of OttawaHead of
Anesthesiology and Pain MedicineThe Ottawa HospitalScientist,
Ottawa Hospital Research InstituteOutcomes after Surgery: Can
Regional Anesthesia make a difference?
1Good morning. My name is Colin McCartney and I am an
anesthetist and consultant in chronic pain management from Toronto
Western Hospital.
Conflicts of InterestNone
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: Value
of CareOur specialty: expertise in perioperative and pain
medicine
After Breakfast QuotesWe have to be leading the evaluation of
outcomes in our specialtyIf we are not at the table we might be on
the menuIf we dont like change we are going to like irrelevance
even less
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
From the patients perspective?Two TKA procedures five years
apartFirst TKA-GA + PCANausea, painDifficulty in mobilisingMental
effects of continuous pain Next knee-no chance!
From the patients perspective?2nd TKASpinal + multimodalBetter
pain controlMuch faster ambulationMental wellnessGA patients were
easy to identify
RAPM 2011
What are other benefits of RA?Reduced respiratory
dysfunctionFaster return GI functionReduction in surgical site
infectionReduced critical care utilizationFaster dischargeReduced
readmissionReduced chronic painReduction in cancer
recurrenceReduction in mortality
Regional and Respiratory
Regional and GI function
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
Evidence: How Much is Enough?Small RCTsLarge RCTsQualitative
studiesSurveysSystematic reviewLarge database studies
Shaughnessy and Slawson BMJ 2004
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
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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
Berwick DM et al 2008
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
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
RA and Cost of Care
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 arthroplastiesFrom:
HOAC
55
OR Overtime(* cancellations)Thanks: HOAC and Dr. Susan Belo
56
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 Thanks: Dr. Jeffrey Gollish
Data from Brians studyRCDB 50 patients undergoing TKAcFNB or
placeboMultimodal analgesiaTime to achieve three distinct discharge
criteria
58
59
Ilfeld et al 2008
60
RA and Cost of Care
Reduced LOS and reduction in readmission with PNB for TKANo
difference in falls
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 outcome 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
AimWe need to be at the table: clinically, administratively and
academicallyCourage and persistence required to make fundamental
changes
To improve is to change, to be perfect is to change oftenWS
Churchill
[email protected]