How to Set Up an Acute Pain Service that Adds Value

@EMARIANOMD@EMARIANOMD

Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain MedicineProfessor of Anesthesiology, Perioperative & Pain Medicine

Stanford University School of MedicineStanford University School of MedicineChief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Financial DisclosuresFinancial Disclosures Halyard Health, B Braun – Halyard Health, B Braun –

Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

DisclaimerDisclaimer This presentation is intended for This presentation is intended for

educational purposes only and is not educational purposes only and is not meant to be reproduced or meant to be reproduced or redistributed for commercial redistributed for commercial purposespurposes

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Learning ObjectivesLearning Objectives Discuss the value-based purchasing Discuss the value-based purchasing

program and its componentsprogram and its components Identify aspects of the HCAHPS survey Identify aspects of the HCAHPS survey

that directly and indirectly relate to that directly and indirectly relate to inpatient pain managementinpatient pain management

Discuss strategies to provide high Discuss strategies to provide high quality pain management and quality pain management and minimize risks for postsurgical patientsminimize risks for postsurgical patients

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Let’s Go Back to 2004Let’s Go Back to 2004

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

The Most Important LessonThe Most Important Lesson

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Triple AimTriple Aim

Berwick et al., Health Aff (Millwood) 2008;27:759Berwick et al., Health Aff (Millwood) 2008;27:759Vetter et al., Anesth Analg 2014;118(5):1131Vetter et al., Anesth Analg 2014;118(5):1131

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Perioperative Surgical HomePerioperative Surgical Home

Anesthesiology 2015;123:A23Anesthesiology 2015;123:A23

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

PSH & Pain Medicine Go PSH & Pain Medicine Go TogetherTogether

PSH: Comprehensive Literature Review, www.asahq.org/pshPSH: Comprehensive Literature Review, www.asahq.org/psh

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Institute of Medicine 2012Institute of Medicine 2012

http://www.iom.edu/http://www.iom.edu/bestcarebestcare

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Authorized by the Affordable Care Act Authorized by the Affordable Care Act but has been around longerbut has been around longer

““Pays for care that Pays for care that rewards better value, rewards better value, patient outcomes, and innovations,patient outcomes, and innovations, instead of just volume of services”instead of just volume of services”

Funded by a 1.75% Funded by a 1.75% withholdwithhold from from participating hospitals’ Diagnosis-participating hospitals’ Diagnosis-Related Group (DRG) payments Related Group (DRG) payments (2% by (2% by 2017)2017)

Value-Based Purchasing Value-Based Purchasing (VBP)(VBP)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/downloads/Instruments/hospital-value-based-purchasing/downloads/HospVBP_ODF_072711.pdfHospVBP_ODF_072711.pdf

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Authorized by the Affordable Care Act Authorized by the Affordable Care Act but has been around longerbut has been around longer

““Pays for care that Pays for care that rewards better value, rewards better value, patient outcomes, and innovations,patient outcomes, and innovations, instead of just volume of services”instead of just volume of services”

Funded by a 1.75% Funded by a 1.75% withholdwithhold from from participating hospitals’ Diagnosis-participating hospitals’ Diagnosis-Related Group (DRG) payments Related Group (DRG) payments (2% by (2% by 2017)2017)

Value-Based Purchasing Value-Based Purchasing (VBP)(VBP)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/downloads/Instruments/hospital-value-based-purchasing/downloads/HospVBP_ODF_072711.pdfHospVBP_ODF_072711.pdf

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

FY2014 Value-Based FY2014 Value-Based PurchasingPurchasing

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/NPCSlides071112.pdfhospital-value-based-purchasing/Downloads/NPCSlides071112.pdf

*NEW*

*NEW*

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Satisfaction Isn’t EverythingSatisfaction Isn’t Everything

but we are scored on it!but we are scored on it!

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Assessing Patient Assessing Patient ExperienceExperience

Patients are surveyed using the Patients are surveyed using the Hospital Hospital Consumer Assessment of Healthcare Consumer Assessment of Healthcare Providers and Systems Providers and Systems (HCAHPS)(HCAHPS)11

32 questions32 questions Publicly reportedPublicly reported 4 times a year 4 times a year22

HCAHPS is administered to a random HCAHPS is administered to a random sample of adult inpatients between 48 sample of adult inpatients between 48 hours and six weeks after dischargehours and six weeks after discharge

1. http://www.hcahpsonline.org1. http://www.hcahpsonline.org2. 2. http://www.hospitalcompare.hhs.gohttp://www.hospitalcompare.hhs.govv

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

HCAHPS Questions on PainHCAHPS Questions on Pain

Mariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

How Do CA Hospitals How Do CA Hospitals Compare?Compare?

74%

http://http://www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov

Hosp#1 Hosp#2 Hosp#3 CA Avg US Avg

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

How Do CA Hospitals How Do CA Hospitals Compare?Compare?

86%

http://http://www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov

Hosp#1 Hosp#2 Hosp#3 CA Avg US Avg

Stanford Kaiser SC Wash Hosp CA Avg US Avg

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Scoring HospitalsScoring Hospitals

“Incentive” = How Much Withholding Hospitals Get Back

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Evolving Practice of Evolving Practice of AnesthesiaAnesthesia

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Avoid “Never” EventsAvoid “Never” Events

Federal Register May 3, Federal Register May 3, 20072007

Avoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) Events

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Cost Savings Benefit the Cost Savings Benefit the HospitalHospital

Increasing Phase I PACU bypassIncreasing Phase I PACU bypass Changing PACU nurse:patient ratiosChanging PACU nurse:patient ratios Decreasing unplanned hospital Decreasing unplanned hospital

admissionsadmissions Decreasing ER visitsDecreasing ER visits Shortening length of stay (e.g., joint Shortening length of stay (e.g., joint

replacement)replacement)

……Not You!Not You!

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Improve Time ManagementImprove Time Management Educate patients earlyEducate patients early

– Surgeons’ officesSurgeons’ offices– Online Online – Preanesthetic evaluation clinicsPreanesthetic evaluation clinics– Preoperative phone callsPreoperative phone calls

Centralize supplies Centralize supplies Teamwork with perioperative staff to Teamwork with perioperative staff to

get patients ready earlyget patients ready early Consider doing blocks outside the ORConsider doing blocks outside the OR

Mariano ER. Anesth Clin Mariano ER. Anesth Clin 2008;28:6812008;28:681

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Consider Making a “Block Consider Making a “Block Room” Room”

Dedicated space Dedicated space Standard ASA Standard ASA

monitors availablemonitors available Oxygen sourceOxygen source Resuscitation Resuscitation

equipmentequipment Not for every Not for every

practicepractice

Mariano ER. Anesth Clin Mariano ER. Anesth Clin 2008;28:6812008;28:681

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Develop Patient Care Develop Patient Care PathwaysPathways

Hebl JR, et al. JBJS 2005;87 Suppl Hebl JR, et al. JBJS 2005;87 Suppl 2:632:63

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Patients in the adductor Patients in the adductor canal group walked canal group walked 3737 (0-90) meters vs. (0-90) meters vs. 66 (0- (0-51) meters in the 51) meters in the femoral catheter group femoral catheter group ((p=0.003p=0.003). ).

Pain scores, opioid Pain scores, opioid consumption, and consumption, and hospital length of stay hospital length of stay were similar. were similar.

Promote Early Promote Early RehabilitationRehabilitation

Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2014;472:13772014;472:1377

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Practice Evidence-Based Practice Evidence-Based MedicineMedicine

30-day mortality was lower30-day mortality was lower for neuraxial and for neuraxial and neuraxial/GA vs. GA alone for TKAneuraxial/GA vs. GA alone for TKA

Most in-hospital complications were lower for Most in-hospital complications were lower for neuraxial and neuraxial/GA vs. GA aloneneuraxial and neuraxial/GA vs. GA alone

Transfusion requirements lowest for neuraxialTransfusion requirements lowest for neuraxial

Memtsoudis SG, et al. Anesth Memtsoudis SG, et al. Anesth 2013;118:10462013;118:1046

Mudumbai & Mariano, et al. Mudumbai & Mariano, et al. SubmittedSubmitted

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

TKA Protocol (VA Palo Alto)TKA Protocol (VA Palo Alto)PreopPreop 1.1. Adductor canal catheterAdductor canal catheter

2.2. Oral gabapentin if opioid-Oral gabapentin if opioid-dependentdependent

OROR Spinal anesthesia, LIA, IV Spinal anesthesia, LIA, IV acetaminophenacetaminophen

PostoPostopp

1.1. Continuous perineural infusion Continuous perineural infusion (0.2% ropivacaine 6 ml/h basal)(0.2% ropivacaine 6 ml/h basal)

2.2. Oral NSAID and acetaminophen Oral NSAID and acetaminophen ATCATC

3.3. Oral opioid ATC and PRNOral opioid ATC and PRN4.4. IV opioid PRN but no IV PCAIV opioid PRN but no IV PCAMariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Anesth Clinics 2014;32:853

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

OverviewOverview Think “big picture”Think “big picture” Continuously improveContinuously improve Reach for the starsReach for the stars

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Preoperative Preparation Preoperative Preparation TodayToday

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

A Vision for the FutureA Vision for the Future

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Mariano, Walters, Kim, Kain. A&A Mariano, Walters, Kim, Kain. A&A 2015;120:11632015;120:1163Walters, Mariano, Clark. Pain Med Walters, Mariano, Clark. Pain Med 2015;16:1666.2015;16:1666.

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

Prevent Persistent Pain?Prevent Persistent Pain?

Lavand’homme, et al. CORR Lavand’homme, et al. CORR 2014;472:14092014;472:1409

TKA Patients

Setting Up an Acute Pain ServiceSetting Up an Acute Pain Service

SummarySummary We discussed the value-based We discussed the value-based

purchasing program and its componentspurchasing program and its components We identified aspects of the HCAHPS We identified aspects of the HCAHPS

survey that directly and indirectly relate survey that directly and indirectly relate to inpatient pain managementto inpatient pain management

We discussed strategies to provide high We discussed strategies to provide high quality pain management and minimize quality pain management and minimize risks for postsurgical patientsrisks for postsurgical patients