There has been a major impetus for American health care to adopt learning health care systems1,2 “in which knowledge generation is so embedded into the core of the practice of medicine that it is a natural outgrowth and product of the health care delivery process and leads to continual improvement in care.”3 The American Society of Anesthesiologists Perioperative Surgical Home Learning Collaborativea is fostering such learning health care systems. An ethics framework for such learning health care systems has been proposed to assess the ethical utility of their activities (Table 1).4,5
In this Open Mind article, we will first assert that, to be a disruptive innovation, the Perioperative Surgical Home should increase health care equity by expanding patient access to high-quality perioperative care. We will then focus on 4 other ethical opportunities. To fulfill the ethical tenets of a learning health care system (Table 1)4,5 and to be of greatest added value to the surgical population, this novel health care model must: (a) enhance patient-centered care, (b) embrace shared decision making, (c) increase health literacy, and (d) reduce futile surgery. Each of these represents a potential opportunity that must be validated with rigorous interdisciplinary health services research.
THE PERIOPERATIVE SURGICAL HOME AS A DISRUPTIVE INNOVATION
A sustaining innovation results in novel products and services that can be sold for higher profits to the best customers of the industry. A sustaining innovation does not create new markets but evolves existing ones, allowing firms to compete successfully in the existing market. Its value to society is limited to those who can access it.
Innovations in health care have predominantly sustained a system fraught with inaccessibility, inefficiency, and excess costs.6–8 As defined by Christensen et al.,6–8 a disruptive innovation also creates new products and services, but ones that are less expensive, simpler, more convenient, and more accessible. By creating a new market, a disruptive innovation eventually displaces the existing market. It also enables participation of a new set of customers previously ignored or shut out by the existing market. However, it should be noted that Christensen et al.’s theory of disruptive innovation is based largely on case examples and is applied retrospectively.
In 2000, Christensen et al.7 asked: “Will disruptive innovation cure health care?” Unfortunately, health care has remained expensive and inaccessible to many Americans.6,8 Disruptive innovation can improve health care, but only if it first disrupts an existing system in which “pharmaceutical companies, hospitals, physicians, device manufacturers, and insurers are able to ensure their financial health [prosperity] over patients’ financial or physical well-being.”9
Equitable health care requires the creation of patient-centered systems, systems responsive to a patient’s individual wishes and circumstances. Improving health care equity requires reallocation of resources and better alignment of capabilities with patients’ needs, particularly for patients who have been historically underserved.10 In its 2001 “Crossing the Quality Chasm,” the Institute of Medicine called for improvements in 6 dimensions of health care performance, including greater equity.11,12 In the interim, inequity in health and health care in the United States continues to be the norm.13 Recent health care reforms, including the Patient Protection and Affordable Care Act of 2010, offer an opportunity to create a more equitable American health care system. Specifically, financial incentives and penalties that make equity an element of value within a value-based health care model, including for surgical and anesthetic care, will reduce health care disparities and move the nation toward greater equity in health care.13
The nascent Perioperative Surgical Home model has been labeled by its innovators and early adopters as a disruptive innovation that creates disruptive alliances and transformative integrated care.14,15 However, to be a truly successful disruptive innovation, any variant of the Perioperative Surgical Home will need to provide perioperative care more simply, more accessibly, at lower cost, and thus within reach of more patients.16 One possible mechanism to achieve these goals with the Perioperative Surgical Home is by improving operational efficiency, thereby increasing operational margins. Greater efficiency would expand resource availability for patients who are currently underserved. Greater health care equity will thus result from the attendant broader and more equal patient access to high-quality perioperative care. This is especially critical among currently underserved and vulnerable racial and ethnic minorities, as well as individuals with lower socioeconomic status, who suffer poorer health outcomes because of chronic diseases and higher all-cause mortality.13,17
ENHANCING PATIENT-CENTERED CARE
Berwick18 defined patient-centered care as “the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.” Patient centeredness is manifested in the understanding that health care value, including for surgical and anesthetic services, is most validly assessed from the patient’s perspective.19–21
Patient-centered care is not simply capitulating to patients’ requests. Patient-centered health care is not a smorgasbord, offering patients what they want, when they want it, regardless of value or cost. Patient-centered care is not throwing information at patients and leaving them to sort it out on their own.22 Patient-centered care is teamwork by clinicians and patients, building healing relationships, and grounded in communication and trust among clinicians, patients, and patients’ families.22
Such teamwork and healing relationships are mandatory to achieve the potential benefits of the Perioperative Surgical Home. They are manifested in the Perioperative Surgical Home by robust patient education, engagement, and empowerment to expect surgical and anesthetic care that fulfills their individual needs, wishes, and context throughout the preoperative, intraoperative, and postoperative periods.23 If the Perioperative Surgical Home can enhance culturally sensitive patient-centered care, particularly among racial and ethnic minorities and individuals with lower socioeconomic status, this health care model will legitimately be a disruptive innovation that reduces health care disparities and increases health care equity.
EMBRACING SHARED DECISION MAKING
Shared decision making makes health care more patient centered. Shared decision making is a continuum.24 When a difficult medical decision needs be made, at their discretion, patients are encouraged to include friends, family, and other health care providers in examining how the outcomes of a particular medical or surgical decision align with the patient’s culture, values, and preferences.25
A recent study of the quality of informed consent found that, before major surgery, 13% of patients could not recall the procedure to be performed, its indications, risks, or alternatives.26 More striking, 33% of patients reported that the decision to proceed with surgery did not address their preferences, values, or goals. Populations at significant risk for concerns about fully informed consent were those speaking a different language and with lower educational levels, indicating a need for targeted interventions in these groups.
Addressing this deficiency in current practice, the Perioperative Surgical Home can foster communication among patients, their chosen confidants, and their clinicians to improve decision quality. The requisite preoperative assessment in the Perioperative Surgical Home is the appropriate venue to inform the patient and family about their clinicians’ professional opinions and consensus on the advisability of the planned procedure. Additionally, the creation and implementation of best practice informed consent can specifically address the needs of patient groups who are not adequately served by existing ad hoc informed consent processes.
Shared perioperative decision making is not intended to supplant the surgeon’s pivotal acumen, judgment, and role. It is also not intended to supplement the expert assessment of the anesthesiologist advising the patient before surgery and then preparing the patient for surgery. However, the Perioperative Surgical Home can facilitate a more consistently open communication among multiple providers to generate a clear clinical summary for the decision makers (patients, family members, and all clinicians). This clinical summary includes the necessity of the procedure, potential benefits, implications of possible complications, and clinicians’ recommendations for preoperative health optimization.
OPTIMIZING HEALTH LITERACY
Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”27,28 Health literacy is a requirement for perioperative patient-centered care and shared decision making. Many Americans with the greatest health care needs have the least ability to comprehend the information required to navigate the United States health care system.29 Increasing health literacy requires an investment by patients, health care professionals, and health systems.30
Inadequate health literacy has been associated with greater hospital utilization, poorer health status, and increased mortality.28,31–33 In 1 study, low health literacy was a significant, independent, and modifiable risk factor for hospital reutilization (readmission or return to the emergency department) during the 30 days after discharge.34 Improved health literacy has reduced chronic disease severity, decreased emergency department visits and hospitalizations, and improved patient satisfaction.35,36 In a recent study of 2026 general surgery patients in an urban setting in the United States, who had a mean of 10 years of education, only 19% possessed adequate health literacy.36 Lower health literacy is more common in individuals living below the poverty line, of an ethnic or cultural minority, living in the southern or western regions of the United States, with less than a high school education, or above the age of 65 years.28
Health care providers should take every opportunity to improve the public’s general literacy. This includes examining and modifying their own activities, assumptions, and environments to remove health literacy–related barriers that hinder access to information, navigation of services, and decision making.30 As a consistent nexus of the surgeon, anesthesiologist, medical consultants, and primary care physician, the Perioperative Surgical Home is an ideal opportunity to evaluate a surgical patient’s health literacy by using tools previously validated in the surgical population.37 Application of these tools can optimize health care literacy in the surgical population.38 This is especially important in those patients at greater risk of inadequate health literacy and poor decision quality.35 The Perioperative Surgical Home could also mitigate postdischarge events (e.g., patient medication errors, patient noncompliance with discharge instructions, and 30-day readmissions), decrease decisional regret, and possibly lessen the burden of malpractice litigation.36
AVOIDING FUTILE SURGERY
In 1999, the American Medical Association (AMA) recommended a process-based approach to determining medical futility, allowing institutions to circumvent an externally determined definition of futility and instead to apply a local case-by-case definition. This AMA framework incorporated patient centeredness and shared decision making as important elements39 consistent with the goals of the Perioperative Surgical Home. This AMA concept of medical futility has been subsequently summarized as follows:
It is not within the authority of the members of the medical profession to invade the patient’s physical integrity by performing a futile intervention, nor is it within the powers of the patient…to oblige a doctor to do so. This holds, in particular, for medical procedures that amount to a violation of the principle of beneficence, involving the infliction of iatrogenic harm without the prospect of markedly improving the patient’s condition.40
Another approach to medical futility has emphasized better communication and negotiation.41,42 Complexity of patients’ medical comorbidities must be balanced with the patients’ values and preferences.41 The 4 essential actions of principled negotiation are then ideally applied, including in the surgical patient (Fig. 1).41,43
Although the concept is quite controversial, qualitative futility is pertinent to the surgical patient. Qualitative futility refers to the scenario in which, even if technically successful, an intervention (e.g., a surgical procedure) may result in an outcome of insufficient or unacceptable functional status.42 Many elderly Americans undergo surgery in the year before their death. The rate varies regionally, suggesting discretion in clinicians’ decisions to intervene surgically at the end of life.44 Qualitative futility may be playing a role. Some 5% of patients seen in the preoperative assessment clinic of a tertiary care hospital died within 1 year of their procedure.45 Did these patients’ surgeries improve their remaining quality of life? Notably, in this same cohort of surgical patients, only 49% of these patients were aware of their planned intensive care unit admission, highlighting the need for better physician-patient communication.26
The Perioperative Surgical Home model is well suited to address this most challenging ethical issue. By reframing the futility of care of the surgical patient as resulting from inadequate physician-patient communication, Grant et al.42 have advocated methods of improving communication and strengthening the patient-physician relationship. To this end, a preoperative assessment clinic within a Perioperative Surgical Home can specifically facilitate determining surgical futility by providing the opportunity (a) to define futility for the patient and family, in terms of certain objective clinical criteria (e.g., the Model for End-Stage Liver Disease or MELD score46 and cancer prediction tools or prognostic nomograms from the Memorial Sloan Kettering Cancer Centerb) and subjective criteria (e.g., health-related quality of life) and (b) to foster communication and negotiation among the patient, family, and all clinicians, including the primary care physician, before the day of high-risk surgery.41,47 Delivering this communication as a scripted monologue will likely create professional animosity and patient confusion. The sensitive subject of surgical futility must be a dialogue that engages the patient, the family, and all caregivers.
Patients must weigh the possibility of the futility of their proposed surgery against palliative and supportive care. A robust Perioperative Surgical Home can be an important mechanism for improving access to palliative and supportive care across the trajectory of disease, helping inform this decision. This will likely require a new, consistently effective mechanism for dialogue among surgeons, anesthesiologists, medical consultants, and primary care physicians. All physicians must learn that informing a patient that there is no effective medical intervention does not constitute a dereliction of professional duty (i.e., patient abandonment).
The Perioperative Surgical Home can be a disruptive innovation within a learning health care system. The Perioperative Surgical Home has the potential to address complex patient care–related ethics issues that have not been adequately addressed in present models of perioperative care. This ability to achieve significant changes represents an opportunity to expand the scope and contribution of anesthesiologists, working in close concert with our surgical, medical, and primary care colleagues.
Name: Lee A. Goeddel, MD, MPH.
Contribution: This author helped write the manuscript.
Attestation: Lee A. Goeddel approved the final manuscript.
Name: John R. Porterfield, Jr., MD, MSPH.
Contribution: This author helped write the manuscript.
Attestation: John R. Porterfield, Jr., approved the final manuscript.
Name: Jason D. Hall, BA, BS, JD.
Contribution: This author helped write the manuscript.
Attestation: Jason D. Hall approved the final manuscript.
Name: Thomas R. Vetter, MD, MPH.
Contribution: This author helped write the manuscript.
Attestation: Thomas R. Vetter approved the final manuscript.
This manuscript was handled by: Steven L. Shafer, MD.
a American Society of Anesthesiologists: Perioperative Surgical Home Learning Collaborative. Available at: http://www.asahq.org/. Accessed December 16, 2014.
b Memorial Sloan Kettering Cancer Center: Prediction Tools—A Tool for Doctors and Patients. Available at: http://www.mskcc.org/nomograms. Accessed January 4, 2015.
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