The focus of health care finance reform in the United States has moved to the perioperative arena where the problem of cost control is particularly pressing. Approximately 30 million inpatient surgeries are performed annually in the United States1–5 with surgical care estimated to account for 52% of hospital admission expenses.6 In addition, postdischarge payments have been shown to account for 36% of overall episode payments.7 It is widely recognized that the current system of perioperative care is fragmented, and lapses in expected standards of care and operational inefficiencies increase cost, expose patients to potential harm, and adversely affect patient experience.3,6,8–10 Stakeholders are now faced with the challenge and the opportunity of creating effective systems to integrate perioperative care delivery. Anesthesiologists, with a strong history of leadership in patient safety,11,12 systems management experience, and an intimate understanding of perioperative medicine, are health care providers uniquely qualified to help with this transformation.13
The Perioperative Surgical Home (PSH) is a new innovative clinical model in the United States with similarities to Enhanced Recovery After Surgery (Table 1) that is aimed to transform surgical care through improved coordination from decision for surgery until 30 days after discharge. This model strives to optimize patients for surgery and reduce variability in the perioperative care provided.5,8,9 Implementation of the PSH is expected to improve quality of clinical care, enhance service to patients and health care providers, and decrease the cost of care.9,14 Proof of concept has been established in a limited number of academic centers,8,10,14 but the question of widespread adoption remains to be proven.
The perceptions of anesthesiologists of US health care finance reform and perceptions of the expanded practice roles proposed in the nascent PSH model are germane to informing the future of our specialty. In 2013, Tilburt et al.15 surveyed the views of a large sample of US physicians about containing health care costs. Physicians in the survey reported having some responsibility to control health care costs and expressed enthusiasm for cost-containment strategies that focus on the quality of care but less enthusiasm for substantial financial reforms.15 Although the study sheds light on the views of US physicians as a whole, the views of physician subspecialists, including anesthesiologists, were not addressed.
The aim of this study was to assess the views of anesthesiologists of their own importance in cost-reduction strategies.2,5,10 To achieve this, we revised the survey developed by Tilburt et al.15 with a specific focus on enthusiasm for cost-containment strategies, professional role in cost containment, and perceived consequences of cost-conscious practice. To validate the primary outcome, we took advantage of the American Society of Anesthesiologists’ (ASA) recent focus on the PSH to ask a series of related questions as comparators.
Development of Survey
This study was reviewed by the University of California, IRB and deemed exempt. A survey instrument (Supplemental Digital Content 1, http://links.lww.com/AA/B182) was developed by a task force of a group of selected anesthesiologists and internists who closely examined the validated tool by Tilburt et al.15 with the intention of adapting it for use in this study. The group performed a literature review, conducted focus groups, and developed questions pertinent to our revised study goals. Where possible, questions were adapted or incorporated verbatim from Tilburt et al.15 The instrument was piloted by testing 25 anesthesiologists, and revisions were made based on the analysis of responses and feedback. Two types of scales were used in the study, both categorical responses indicating either degree of responsibility attributable (major, minor, none) or agreement with statement (strongly agree, agree, disagree, strongly disagree). In all survey questions, lower scores (1–2) constituted stronger agreement or more responsibility, whereas higher scores indicated disagreement or lack of responsibility (3–4).
Primary Outcome: Responsibility for Reducing Cost and Cost-Reduction Strategies
Respondents were asked to indicate what level of responsibility they perceive stakeholders (employers, government, hospitals, insurance companies, patients, pharmaceutical companies, professional societies, technology companies, and trial lawyers) to have in reducing the cost of health care and perioperative care delivery. Respondents were then asked to describe their relative enthusiasm for cost-reduction strategies (bundled payment model, eliminate fee- for-service model, pay for performance, Medicare payment cuts, and compensation reform). As noted earlier, given the central role of anesthesiologists in the PSH, the primary outcome of interest was anesthesiologists’ views of their own importance in cost-reduction strategies.
Validation: Perioperative Surgical Home and Future Practice Roles
Respondents were asked a series of questions related to the PSH, including self-reported understanding of the PSH, which perioperative time frames anesthesiologists should coordinate patient care, and potential benefits (reduced cost of care, length of stay, readmission rates, etc.) pertinent to each perioperative time frame, and asked to rate their level of agreement. Among these questions, respondents were presented with specific cost-containment or quality improvement strategies, which were used to provide validation points for the primary outcome.
Study Participants and Data Collection
A power analysis assuming a random uniform distribution of responses for each survey question showed that 750 respondents would result in an approximate precision for point estimates of ±3.2% with 99.7% confidence. We assumed a 12.5% response rate, indicating 6000 surveys would need to be sent.
Members of the ASA were randomly chosen for recruitment into this survey. Respondents who were not currently practicing at the time of the survey were excluded. In March, April, and May of 2014, the recruitment script and link to an online survey tool (Qualtrics, Salt Lake City, UT) was distributed through email. Participants were presented with the study information sheet and prompted to indicate understanding before proceeding. A 20-question survey titled “Views of United States Anesthesiologists about Health Care Costs and Future Practice Roles Survey” (Supplemental Digital Content 1, http://links.lww.com/AA/B182) was administered, and deidentified data were collected to ensure confidentiality.
Reponses to questions designed to measure the primary outcome were first analyzed by simple quantification (number and percentage of respondents choosing each option) for each question. Two subtypes of construct validity were examined with regards to the primary outcome: discriminant validity (the relationship between questions designed to measure the primary outcome and other questions not expected to correlate) and convergent validity (the relationship between questions designed to measure the primary outcome and other questions that are expected to correlate), both of which were compared with the PSH survey questions using Spearman rank correlation (ρ).
In consideration of external validity, we sought to determine the demographic variables (Table 2) collected that were associated with a stronger perspective that anesthesiologists had responsibility in controlling costs (the primary outcome variable) via simple linear correlation coefficients. First, each demographic variable was correlated with the primary outcome to see which were independently associated. After this, we performed a stepwise comparison, wherein we took the strongest independently correlated variable and added it as a controlled-for variable in a partial correlation, then re-ran the other remaining independent variables again against the primary outcome. This process was continued until all of the variables initially found to be statistically significantly associated were either included in the corrected correlations or found nonsignificant in light of the already included variables. We then examined whether this final set of associated predictors were variables for which the ASA had data on the population of anesthesiologists practicing in the United States. Finally, to test the sensitivity of the process to sequence, we also performed a backward stepwise comparison in which all independently correlated variables were initially included as controlled and each one tested sequentially against the primary outcome. The least significant factor was then removed iteratively until only significant factors remained, and this final set was compared with that resulting from the forward process.
Statistical tests were performed using SPSS version 11.0 (SPSS Inc., Chicago, IL) and Microsoft Excel (Microsoft, Redmond, WA). Point estimates (percentages) for multinomial proportions are reported as percent (95% confidence interval [CI]), where CI is calculated by using the method of Sison and Glaz.16 This test provides simultaneous CIs while controlling the overall (familywise) coverage at 95%. Spearman correlation coefficients are reported with 95% CI calculated by nonparametric bootstrap (1000 sets by simple resampling with replacement).
Of the 6000 anesthesiologists solicited, 871 (14.5%) completed the survey with 12 partial responses (Table 2).
Primary Outcome: Health Care Finance Reform
Health care finance reform responses are summarized in Table 3. Thirty-eight percent (95% CI, 35–42) of respondents indicated that physicians bear “major responsibility” for cost reduction, 58% (55–61) indicated that physicians bear “some responsibility,” and 4%, only a small fraction (0.7–7.5), indicated that physicians bear "no responsibility.” Respondents also indicated that other entities bear “major responsibility” for cost reduction, including hospitals (57% [95% CI, 54–61]) and insurance companies (54% [51–57]).
Construct Validity: Comparison with Perioperative Surgical Home and Future Practice Roles
Self-reported understanding of the PSH model is shown in Table 4. Data regarding the specific roles of anesthesiologists at each perioperative phase, comfort with those care phases, and opinions about litigation risk are presented in Tables 5 and 6. Most respondents were “not enthusiastic” about Medicare payment cuts (93% [95% CI, 91–95]).
In terms of convergent validity of the primary outcome of physician role in reduction of health care costs, there was a positive correlation between stronger belief that physicians have responsibility to reduce costs and belief that anesthesiologists should take costs of tests into account in the preoperative (ρ = 0.17; 95% CI, 0.10–0.23) and intraoperative (ρ =0.23; 95% CI, 0.16–0.30) settings; and anesthesiologist participation in care would in fact reduce costs in the preoperative (ρ = 0.14; 95% CI, 0.08–0.21), intraoperative (ρ = 0.20; 95% CI, 0.13–0.27), and postoperative (ρ = 0.15; 95% CI, 0.08–0.22) care phases with P < 0.00001 for all correlations. Similarly, there was a negative correlation between those who believed physicians had a major role in health care costs and those who believed anesthesiologists should only play a role in the intraoperative care phase (ρ = −0.12; 95% CI, −0.19 to −0.06; P < 0.0003). However, there was no correlation with reported understanding of the surgical home (ρ = 0.03; 95% CI, −0.04 to 0.10; P = 0.42) or belief that the PSH would improve patient outcomes (ρ = 0.05; 95% CI, −0.01 to 0.12; P = 0.13), while we might have expected some relationship between these items and interest in cost reduction.
In terms of discriminant validity, there was no significant correlation between belief that physicians had a major role to play in cost reduction and self-reported comfort managing intraoperative (ρ = 0.05; 95% CI, −0.01 to 0.11; P = 0.12) and postoperative care (ρ = 0.001; 95% CI, −0.06 to 0.08; P = 0.87). However, there was an association between belief that physicians play a role in cost reduction and the belief that operating room patient management should use decision support (ρ = 0.19; 95% CI, 0.13–0.26; P < 0.00001), fluid management strategies (ρ = 0.14; 95% CI, 0.07–0.20; P = 0.00004), that effective management should reduce length of stay (ρ = 0.16; 95% CI, 0.09–0.22; P < 0.00001), and several questions related to litigation risk; these latter in particular would not necessarily be expected to be linked to belief in physician cost responsibility.
External Validity: Demographics Associated with Feelings of Physician Responsibility
Several demographic or practice-related characteristics were independently associated with belief that physicians play an important role in cost management in health care. Younger age (ρ = −0.17; 95% CI, −0.23 to −0.11; P < 0.00001), fewer years in practice (ρ = −0.20; 95% CI, −0.26 to −0.14; P < 0.00001), practice in a community hospital (ρ = 0.10; 95% CI, 0.04 to 0.17; P = 0.003), higher patient volume (ρ = 0.08; 95% CI, 0.01 to 0.14; P = 0.02), more liberal political beliefs (ρ = −0.12; 95% CI, −0.18 to −0.05; P = 0.0002), and no fellowship training (ρ = 0.09; 95% CI, 0.02 to 0.15; P = 0.008) were all associated with a stronger belief that physicians played a major role in cost containment. After forward stepwise correction for fitted variables, only years in practice, political beliefs, and work in a community hospital remained significant (each P ≤ 0.015); the independent effects of age, fellowship training, and volume of patients seen were nonsignificant once the other factors were corrected for (all P ≥ 0.4). Backward stepwise comparisons yielded the same 3 factors as significant (years in practice, political beliefs, and work in community hospital, each P ≤ 0.015), suggesting that these results are not sensitive to order of inclusion or exclusion.
This study surveyed anesthesiologists’ views of their own importance in cost-reduction strategies. With respect to health care finance reform, respondents identified hospitals and insurance companies as having a major responsibility in cost reduction. Respondents were not enthusiastic about Medicare payment cuts, eliminating the fee-for-service model, and adoption of a bundled payment model as strategies for cost containment.
In response to questions about future practice roles, a majority of US anesthesiologists surveyed reported fair or good understanding of the PSH. A majority of respondents agreed with the vision of anesthesiologist-lead coordination of care from surgery scheduling until hospital discharge. There was more agreement about preoperative management becoming the standard of care and relatively less agreement about postoperative management becoming the standard of care. Similarly, respondents reported feeling more comfortable and perceived less exposure to litigation with management of preoperative care compared with postoperative care. However, a substantial majority of respondents agreed that anesthesiologist coordination of postoperative care will improve patient outcomes, reduce the overall cost of care, length of stay, and readmission rate. Anesthesiologists surveyed overwhelmingly agreed with incorporation of key components of the PSH model such as decision support technologies, evidence-based protocols, and fluid-management strategies.
Responses to questions about future practice roles illustrate the need for additional education. Although a majority of respondents reported fair or good understanding of the PSH, a full 25% reported poor understanding. The survey queried perceived understanding of the PSH, but did not attempt to objectively measure understanding. It is reasonable to assume that some respondents may have perceived understanding, yet need more education. However, it is encouraging that the PSH has achieved a high degree of recognition in a brief time frame. It is not surprising that respondents reported relatively less comfort with anesthesiologist-lead coordination of postoperative care. This may reflect unfamiliarity with or confusion over this new practice role rather than a belief that this role should not be performed. Indeed respondents believed that anesthesiologist involvement with postoperative care will positively impact quality and cost indicators. Further education about the vision of postoperative roles in the PSH model as well as refresher courses in postoperative management should be considered. Our colleagues who practice critical care medicine or acute pain management are well positioned to lead these efforts.
Our study presents some limitations. First, our response rate (14.5 %) remained low, and this may have been responsible for response bias, which we were not able to completely eliminate. This is a common limitation to online or email surveys, which has been well documented.17,18 One way of bypassing this limitation is to use a professional mailing list to reach a specific target population18 as we did in this study. Second, despite the relatively large size of our sample, it might not have reflected the demographic of the ASA members. To extrapolate our results to the population of US anesthesiologists (and correct for nonresponders in our study), we would need to correct our results for differences between the respondent population and the general population on these variables. Unfortunately, political preference was found to be a strong predictor of results, and this is not a demographic tracked by the ASA, making generalization by this method infeasible.
In conclusion, we found that US anesthesiologists surveyed perceived hospitals and insurance companies as having a major responsibility in cost reduction. Furthermore, they were not enthusiastic about substantial financial reform such as cuts to Medicare payments. This study illustrates the need for additional education about the PSH model among anesthesiologists, particularly with regard to anesthesiologists’ future practice role in coordinating postoperative care.
Name: Darren R. Raphael, MD, MBA.
Contribution: This author helped design the study, conduct the study, analyze the data, and prepare the manuscript.
Attestation: Darren R. Raphael approved the final manuscript and is the archival author.
Name: Maxime Cannesson, MD, PhD.
Contribution: This author helped design the study, analyze the data, and prepare the manuscript.
Attestation: Maxime Cannesson approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.
Name: Joseph Rinehart, MD.
Contribution: This author helped analyze the data and prepare the manuscript.
Attestation: Joseph Rinehart approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.
Name: Zeev N. Kain, MD, MBA.
Contribution: This author helped design the study, analyze the data, and prepare the manuscript.
Attestation: Zeev N. Kain approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.
RECUSE NOTEMaxime Cannesson is the Section Editor for Technology, Computing, and Simulation for the Anesthesia & Analgesia. The manuscript was handled by Dr. Franklin Dexter, the Statistical Editor and Section Editor for Economics, Education, and Policy for the Anesthesia & Analgesia, and Dr. Cannesson was not involved in any way with the editorial process or decision.
1. Blumenthal D, Stremikis K, Cutler D. Health care spending—a giant slain or sleeping? N Engl J Med. 2013;369:2551–7
2. Butterworth JF, Green JA. The anesthesiologist-directed perioperative surgical home: a great idea that will succeed only if it is embraced by hospital administrators and surgeons. Anesth Analg. 2014;118:896–7
3. Chen C, Ackerly DC. Beyond ACOs and bundled payments: Medicare’s shift toward accountability in fee-for-service. JAMA. 2014;311:673–4
4. Dexter F, Wachtel RE. Strategies for net cost reductions with the expanded role and expertise of anesthesiologists in the perioperative surgical home. Anesth Analg. 2014;118:1062–71
5. Vetter TR, Ivankova NV, Goeddel LA, McGwin G Jr, Pittet JFUAB Perioperative Surgical Home Group. UAB Perioperative Surgical Home Group. . An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology. 2013;119:1261–74
6. Vetter TR, Boudreaux AM, Jones KA, Hunter JM Jr, Pittet JF. The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg. 2014;118:1131–6
7. Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res. 2014;472:188–93
8. Garson L, Schwarzkopf R, Vakharia S, Alexander B, Stead S, Cannesson M, Kain Z. Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg. 2014;118:1081–9
9. Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The perioperative surgical home as a future perioperative practice model. Anesth Analg. 2014;118:1126–30
10. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol. 2013;13:6
11. Agarwala AV, McCarty LK, Pian-Smith MC. Anesthesia quality and safety: advancing on a legacy of leadership. Anesthesiology. 2014;120:253–6
12. Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ. 2000;320:785–8
13. Masursky D, Dexter F, Nussmeier NA. Operating room nursing directors’ influence on anesthesia group operating room productivity. Anesth Analg. 2008;107:1989–96
14. Raphael DR, Cannesson M, Schwarzkopf R, Garson LM, Vakharia SB, Gupta R, Kain ZN. Total joint Perioperative Surgical Home: an observational financial review. Perioper Med (Lond). 2014;3:6
15. Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS, Liebow M, Hurst S, Danis M, Goold SD. Views of US physicians about controlling health care costs. JAMA. 2013;310:380–8
16. Sison CP, Glaz J. Simultaneous confidence intervals and sample size determination for multinomial proportions (vol 90, pg 366, 1995). J Am Stat Assoc. 1995;90:366–9
17. Mavis BE, Brocato JJ. Postal surveys versus electronic mail surveys. The tortoise and the hare revisited. Eval Health Prof. 1998;21:395–408
18. Braithwaite D, Emery J, De Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract. 2003;20:545–51