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The Pediatric Perioperative Surgical Home: The Emperor’s New Clothes?

Davis, Peter J. MD

doi: 10.1213/ANE.0000000000000703
Editorials: Editorial

From the Department of Anesthesia, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Accepted for publication January 23, 2015.

Funding: Not funded.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Peter J. Davis, MD, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, One Children’s Hospital Dr., 4401 Penn Ave., Main Hospital Fl. 5, Pittsburgh, PA 15224. Address e-mail to davispj@anes.upmc.edu.

The article by Ferrari et al. in this issue of the journal articulates a position in support of the pediatric Perioperative Surgical Home (PSH) model of care. This concept aligns anesthesia practice models with health care reform goals and the “triple aim” of the Institute for Healthcare Improvements: a high quality of care, a focus on population health, and a reduction in health care expense. The article promotes the leadership role of pediatric anesthesiologists in implementing measureable goals, standardizing care pathways, and coordinating care for pediatric patients who require surgery or other procedures requiring anesthesia or sedation. Thus, the anesthesiologist’s scope of practice increases, the stature of the specialty is enhanced, and patient care becomes standardized, more comprehensive, and more integrated. As a result of this model, patient outcome, patient care, resource utilization, and quality all improve.1

Perioperative Surgical Home has become a popular buzzword. The May 2014 issue of Anesthesia & Analgesia highlighted this concept,2–12 and the 2014 American Society of Anesthesiologists’ Annual Meeting in New Orleans promoted the topic as well by showcasing relevant articles and lectures. As a pediatrician and an anesthesiologist who has spent his entire career advocating for children, it is hard to argue against this concept. This is especially true today because medicine is often practiced in silos despite increasing patient and procedural complexity. A more rational and comprehensive approach is needed to create and standardize a specific surgical service line and surgical procedures, with efforts focused on coordinating and integrating all aspects of perioperative care of a patient. A PSH for pediatrics would not only encompass the anesthetic management of the patient but also involve optimization of comorbidities via a full-service preoperative assessment, consultation, and treatment clinic directed by anesthesiologists.13

The well-written The Open Mind article by Ferrari et al. promotes generalizations and noble concepts that are difficult to argue against. However, the authors neither provide details nor offer specific information on how the pediatric PSH would operate, except to imply that the leadership role or driving force would be in the specialty of anesthesiology. Although the devil is in the details, I am personally bedeviled by the lack of detail.

Even with 4 years of medical school education and 4 years of residency training, most anesthesiologists are not (nor want to be) trained to deal with issues outside the immediate perioperative area. Because the pediatric perioperative anesthesiologist will be managing and directing both the preoperative and postoperative care of the patient, this will be a significant culture change for young physicians entering our specialty.

For most anesthesiologists, the concept of long-term care equates to an operating room case that lasts >3 hours. If anesthesiologists are to take on this role in the pediatric PSH, we will need to rethink the educational training model for anesthesiologists. As with the advanced pediatric anesthesia fellowship model, it is likely that the prescription for a pediatric PSH will be disruptive.14 Creating anesthesiologists with knowledge and experience in pediatric medicine may require changes in resident selection as well as changes in resident training paradigms. Anesthesiology trainees will require more clinical exposure to pediatric and adult clinical medicine and surgery. The training programs will need to emphasize longitudinal care, evidence-based medicine, biostatistics, process improvement, statistical control, and operations management as a part of their curriculum. Dual residencies (i.e., anesthesia/pediatrics), possibly combined with training in health care management, may offer a platform to appropriately train anesthesiologists who can lead the pediatric PSH. This will be expensive!

As opposed to adults, who frequently have significant underlying comorbid diseases, most pediatric patients are generally healthy or have well-controlled medical issues. Children with severe disabilities and/or children with complex medical issues are the ones who truly need a pediatric PSH. As noted by Ferrari et al.,1 children with special needs represent 15% of the population of children <18 years of age. However, meeting the real needs and the true value of a pediatric PSH for these children requires an individual to coordinate their care. Is the pediatric anesthesiologist the right person to do this?

Even when it is not about the money, it is about the money. Cost containment is a major issue in contemporary medicine. Who will pay for the time and effort needed to train the pediatrician-anesthesiologist? Who will remunerate this individual to perform care coordination? Editorials and articles in the May 2014 issue of Anesthesia & Analgesia question whether cost reductions can be achieved. Do the cost savings of the program produce overall cost savings when the costs of implementing the program are included? Why should health systems pay high-priced anesthesiologists to perform the task when less expensive, equally bright physicians could also provide this service? Furthermore, why shouldn’t care coordination be the role of a midlevel provider (e.g., nurse practitioner, physician assistant, medical social worker) or a well-trained registered nurse? How much of this could be replaced by “bot-work,” intelligent computers managing the trajectories of the patient, optimizing the timing of services to achieve the triple aim. The ability of less expensive providers, or software algorithms, to manage the PSH is especially true if clinical guidelines can be established for patient care pathways. Because most pediatric specialty care involves coordinating care, it seems to make more sense that the person coordinating care be a midlevel provider rather than the more expensive anesthesiologist. Finally, if payments to physicians and institutions become bundled, will surgeons be willing to be remunerated less in order for anesthesiologists to do what they, the surgeon, may perceive they are already doing?

This article has well-articulated goals. I believe this is the right direction for perioperative pediatric health care. However, I keep stumbling on the idea that anesthesiologists are presently adequately trained to manage pediatric patients and their chronic medical problems both before and after surgery. If we keep advocating ourselves as the leaders of these efforts to establish pediatric PSHs, we will need a strategy to train us to provide optimum patient care. At present, we have no details on how accomplished anesthesiologists can evolve into the leadership and management roles for the pediatric PSH. In addition, it is not clear if the model of the pediatric PSH is economically feasible.

Without details, it will be hard to convince others of our value, and we will be relegated to a modern day version of the Hans Christian Anderson tale “The Emperor’s New Clothes.” This is a childhood story about 2 weavers/swindlers who promise an emperor a new set of magnificent clothes that are invisible to those either unfit for their position, stupid, or incompetent. On the day the emperor displayed his “new” clothes, it took a child to state the obvious. Without details, without strategy, the pediatric PSH will become the emperor’s new clothes.

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DISCLOSURES

Name: Peter J. Davis, MD.

Contribution: This author wrote the manuscript.

Attestation: Peter J. Davis approved the final manuscript.

This manuscript was handled by: Steven L. Shafer, MD.

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