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Ambulatory Anesthesiology and Perioperative Management

A Primer on Population Health Management and Its Perioperative Application

Boudreaux, Arthur M. MD; Vetter, Thomas R. MD, MPH

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doi: 10.1213/ANE.0000000000001357
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Around the world, rising health care costs are claiming a larger share of national budgets.1 This has resulted in strategies being implemented to control health care system costs through the more efficient use of health care resources not only in the United States, but also in Canada, England, France, and Germany.1 In England, recent reductions in health care expenditure (i.e., budget cuts) have also included reducing the use of targeted surgical procedures, deemed to be ineffective, overused, or inappropriate.2 Efforts are likewise underway in the United States and several other member countries of the Organization for Economic Cooperation and Development to implement value-based cost-sharing, whereby patients are encouraged to use providers, health care services and delivery systems, and medications, which offer better value than other available options.3

With the 2015 Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), the U.S. federal government “finally euthanized the sustainable growth rate formula.”4 Ironically, MACRA also ushered in a new and likely truly sustainable era of value-based reimbursement by the Centers for Medicare and Medicaid Services and attendant greater financial risk sharing by providers.4

Specifically, MACRA “put in motion (2 Centers for Medicare and Medicaid Services) policies to transform physician payments from a system that rewards volume to one that recognizes value.”5 The Merit-Based Incentive Payment System allows physicians to continue to be reimbursed under traditional fee-for-service but with payments adjusted annually upward or downward based on their performance on the 4 domains of clinical quality, meaningful use of health information technology, resource use, and practice improvement.5 The alternative payment model program is intended for physicians who choose to participate in alternative practice models (e.g., Accountable Care Organizations or Patient-Centered Medical Homes [PCMHs]) and thereby accept financial risk for the quality and effectiveness of patient care.5

Population health management will play a central role in physicians—and the facilities in which they practice—successfully adopting and adapting to governmental and nongovernmental payer initiatives. This will include in the United States responding to either the Merit-Based Incentive Payment System or the alternative payment model and their robust value-based strategies (e.g., financial risk sharing) and metrics.6 However, for many anesthesiologists, population health management is a new or even foreign concept. We thus present here a primer on population health management and its potential perioperative application.

DEFINING POPULATION HEALTH MANAGEMENT

Arriving at a widely agreed-on definition of population health management is a prerequisite to applying and studying its principles in the perioperative setting. This can be accomplished by first deconstructing the term into its 3 components, each of which has its own important meaning.7

Population

A population “refers to a group of individuals, in contrast to the individuals themselves, organized into many different units of analysis, depending on the research or policy purpose.”7 Although many health interventions and programs—including the majority of current acute medical and surgical care—focus exclusively on individuals, population-level management, policy, and research concentrate on the aggregate health of groups of individuals.8

Health

Many definitions of health are available.9 The most commonly quoted definition of health is that presented by the World Health Organization in 1946 as “a complete state of physical, mental, and social well-being and not merely the absence of disease or infirmity.”10 However, critics have argued that this World Health Organization definition of health is utopian, inflexible, and unrealistic.9,11 A more contemporary and pragmatic definition of health is “a dynamic state of well-being characterized by a physical, mental, and social potential, which satisfies the demands of a life commensurate with age, culture, and personal responsibility.”12 This latter definition takes into account the changing health care needs, especially in relation to an individual’s age, culture, and personal responsibilities.9

Population Health

The term population health has been viewed by some as a field of study primarily of health determinants (i.e., an extension of traditional public health). However, a broader and more applicable definition is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”7

Figure 1.
Figure 1.:
A schematic framework for population health planning and management (reproduced and modified with permission from David Kindig, PhD). SES = socioeconomic status.

The dialog and debate about population health has included other terms such as outcomes, disparities, determinants, and risk factors. These related terms are often used imprecisely and interchangeably, especially by the divergent disciplines of medicine, epidemiology, economics, and sociology. Nevertheless, in this broader context, population health innately includes these domains of health outcomes, disparities, determinants, and risk factors (Fig. 1).7,13

Population Health Management

Although it certainly continues to evolve, population health management can be broadly defined as the specific policies, programs, and interventions directed at optimizing population health (Fig. 1).13 Population health management provides a useful rationale for patients, providers, payers, and policymakers to move collectively away from the traditional system of individual, siloed providers to a more integrated, coordinated, team-based approach, thus creating a holistic view of the patient population.14a

The Population Health Alliance (formerly the Care Continuum Alliance) has created a particularly cogent conceptual framework that identifies the key components of population health and its management (Fig. 2).15,16 The core of this framework is the continuum of care and patient-centered interventions. The framework is predicated on organizational interventions (culture/environment), provider interventions, and family and community resources. The interconnected and very useful population health process model (also created by the Population Health Alliance) sequentially includes the following:

Figure 2.
Figure 2.:
Population health conceptual framework (reproduced with permission from the Population Health Alliance15).
  • Population monitoring and identification
  • Health assessment
  • Risk stratification
  • Enrollment and engagement strategies
  • Communication and intervention delivery modalities
  • Patient-centered interventions across the health continuum
  • Impact evaluation across multiple short- and moderate-term outcome domains

Lastly, there is a strong reiterative, continuous quality improvement component based on process learning and outcome evaluation.15,16 This continuous quality improvement can be readily performed by applying Plan-Do-Study-Act cycles or closely related Plan-Do-Check-Act cycles.16,17

Of note, this Population Health Alliance conceptual framework has been transformed into an analytical framework in which a set of indicators can be operationalized to measure the impact of population health management in terms of the Institute for Healthcare Improvement (IHI) Triple Aim. This will also allow evaluation and comparison of several population health management initiatives and sites across regions and even countries.16

The goal of population health management is to keep the targeted patient population as healthy as possible, thus minimizing the need for costly interventions such as emergency department visits, acute hospitalizations, laboratory testing and imaging, and diagnostic and therapeutic procedures.18 Doing so not only reduces direct and indirect medical costs, but also redefines health care as activities that encompass more than acute, episodic care.

Population health management focuses heavily on the sickest and thus highest risk patients, who generate the majority of health care costs. However, it also systematically addresses the preventive care of every patient, thus reducing subsequently needed chronic care. Because the prevalence and severity of health risks change over time, the objective of population health management is to modify the factors that produce or exacerbate disease or illness.19

An Example of a Population Health Management Strategy

Among health care systems in the United States, Partners HealthCare in Boston has pioneered the development and implementation of a system-level population health management strategy.b Their comprehensive approach to population health management has incorporated 5 major elements: (1) primary care; (2) specialty care; (3) nonhospital care; (4) patient engagement; and (5) analytics and technology (Fig. 3).

Figure 3.
Figure 3.:
Major elements of a prototypic population health management program being developed and implemented at Partners HealthCare in Boston, Massachusetts. *Content derived from Partners HealthCare: Population Health Management. Available at: http://www.partners.org/Innovation-And-Leadership/Population-Health-Management/. Accessed January 24, 2016.
Table 1.
Table 1.:
Factors Contributing to a Successful Population Health Management Strategy16 , 20

To improve the quality of health care for chronic conditions, such a successful population health management strategy is predicated on a series of macro-level, meso-level, and micro-level factors (Table 1).16,20

THE TRIPLE AIM, PCMH, AND PERIOPERATIVE SURGICAL HOME

Guiding Principle of the Triple Aim

The Triple Aim of Healthcare was first espoused in 2008 by Berwick et al.21 and the IHI. In their 2012 book, “Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs,” Bisognano and Kenney22 at the IHI further refined the IHI Triple Aim of Healthcare:

  • Improving the experience of care—providing effective, safe, and reliable care—to every patient, every time
  • Improving the health of a population, reaching out to communities and organizations, focusing on prevention and wellness, managing chronic conditions, and so forth
  • Decreasing per capita costs

In 2015, drawing on their 7 years of collective experience, Nolan, Whittington, and colleagues at the IHI identified 3 major principles that guided the organizations and communities working on implementing the Triple Aim: (1) creating the right foundation for population management; (2) managing services at scale for the population; and (3) establishing a learning system to drive and sustain the work over time.23 The IHI Triple Aim thus continues to serve as a major guiding principle in efforts to maximize the value of health care from the perspective of all its stakeholders.

Tenants of the PCMH

The PCMH model has been developed in the primary care practice setting. The PCMH has been described as comprising 4 elements: “(1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; (2) new ways of organizing practice; (3) development of practices’ internal capabilities; and (4) related health care system and reimbursement changes.”24 These 4 elements are intended to improve the health of individuals, families, communities, and populations and to increase the value of health care.24

Tenets of the Perioperative Surgical Home

The Perioperative Surgical Home (PSH) represents a paradigm shift aimed at remedying the currently highly fragmented and overly costly perioperative care in the United States.25,26 The PSH is a patient-centered approach to the surgical patient with a strong emphasis on process standardization, evidence-based clinical care pathways, and robust coordination and integration of care. This new model of care guides the patient and their family members through the complexities of the perioperative continuum, especially during transitions of care, from the decision for surgery to the postdischarge phase.27

Needless to say, the success of any variant of the PSH model is predicated on an appreciation of the local infrastructure, resources, and internal/external forces and a high degree of collaboration among all of its institutional stakeholders.25,28

Parallels Between the PSH and the PCMH

Both the PCMH and the PSH concepts are platforms or mechanisms by which to undertake population health management (Fig. 4).

Figure 4.
Figure 4.:
Patient-Centered Medical Home and the Perioperative Surgical Home are platforms or mechanisms by which to undertake population health management.

Akin to the PSH, the PCMH has been fittingly described as “a journey, not a destination, and requires ongoing evolution of medical models and attention to patient preferences.”29

However, also similar to the PSH, a recent systematic review concluded that “the PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine the effects on clinical and most economic outcomes.”30

Specifically, the preliminary research on the PCMH, and on the PSH, reflects both the wide variation in how such models are being designed and implemented in practice and in how researchers are evaluating the design and implementation of the PCMH and the PSH. Thus, a continued evolution of PCMH-related and PSH-related evaluative research is needed.31

It is likely that a comprehensive, mixed qualitative–quantitative method can best provide insights about how these transformative medical and surgical care models impact critical outcomes by achieving meaningful, patient-centered, high-quality, and cost-effective sustainable changes among diverse care practices.32,33

The Vital Role of Perioperative Population Health Management

The PSH essentially seeks to transform perioperative care by achieving the IHI Triple Aim.25,26,34 Successfully achieving all 3 aims will undoubtedly become more important with the noted unrelenting expansion of value-based perioperative care involving more rigorous pay-for-performance metrics and a greater share of reimbursement predicated on shared financial risk by providers.6,35 Specifically, the PSH specifically seeks to achieve the IHI Triple Aim of improving the health of the surgical population. The success of the PSH model is thus largely predicated on anesthesiologists, surgeons, and other clinicians understanding and applying the principles of population health management.

APPLYING POPULATION HEALTH MANAGEMENT IN THE PERIOPERATIVE SETTING

The scope of population health management is admittedly so expansive that it can present challenges and appear understandably daunting to health care systems/hospitals, group practices, and individual clinicians seeking to successfully achieve it. Therefore, it has been recommended that subsets or subpopulations of patients be identified and targeted.16,20 One example of dividing or grouping a population of patients cared for by a specific health system might include levels of severity of disease and utilization of services.

The Medical Expenditure Panel Survey is a federal survey that can produce nationally representative estimates of health care expenditures associated with medical conditions for the U.S. civilian population. Using Medical Expenditure Panel Survey data, an analysis of the variations in medical expenditures for people with chronic medical conditions was performed. Not surprisingly, health care expenditures increased substantially with the number of chronic medical conditions being treated (Fig. 5).36 The Nationwide Inpatient Sample is the largest all-payer inpatient database in the United States. Using Nationwide Inpatient Sample data, a similar pattern was observed, in which a greater number of chronic medical conditions was associated with higher mortality, use of health care services, and average cost.37

Figure 5.
Figure 5.:
The inverse relationship between health care expenditures and the number of chronic medical conditions being treated.36

An analysis of the character and demographics of each health care delivery system would necessarily differ based on geography, socioeconomics, and other factors. Nevertheless, the principles of population health management can be modified and applied to surgical patient subpopulations. For instance, an orthopedic specialty hospital treating younger patients with sports-related injuries would differ from a community hospital serving a general surgical population in an inner city. The population of patients presenting for surgical care can be divided into 4 distinct groups. Certain targeted interventions in these subpopulations may influence outcomes.

The first and largest group is comprised of healthy patients with minimal or no comorbidities, suffering an acute need for surgical care because of an injury or short illness. This group utilizes a comparatively small number of health care services. Population health strategies for this group might include wellness and disease prevention programs that might take a longer timeframe to show a return on investment.

The second group is comprised of patients who are at risk for chronic diseases because of lifestyle, cultural, or genetic issues. This group utilizes more health care services. If the trajectory of this group of patients is not altered, they will progress to the next level of severity. Targeted interventions for this group may include smoking cessation, weight loss and exercise programs, and patient education efforts.

The third group is comprised of patients with established chronic diseases requiring regular maintenance. This group experiences more frequent episodes requiring hospital care or surgery because of their disease states. Patients in this group might benefit from coordination and frequent monitoring of care, like in a PCMH setting, and the use of specialist expertise in management for conditions that are difficult to control and optimize.

The fourth group is comprised of patients with severe or frequently decompensated chronic diseases or end-stage illnesses and thus near the end of life. This group predictably utilizes considerable resources and requires frequent or intense acute care episodes. This usually represents the highest cost subpopulation. Acute decompensation requiring hospitalization occurs frequently in this group. A large data analysis of Medicare patients showed that only 10% of emergency department visits and acute care admissions to the hospital were possibly preventable. This high-cost group comprised only 10% of the Medicare population but was responsible for >70% of all acute care costs in the Medicare program.26

Although we may not be able to reduce the number of acute episodes of surgical care in any of these groups, we can certainly improve how we deliver that care. Provision of evidence-based best practices, with decreased variation/increased standardization, better coordinated and integrated care, and more effective postacute care, can reduce costs and provide better outcomes. This type of patient-centered, coordinated, integrated, and standardized care is promoted by the PSH model2 and in Enhanced Recovery After Surgery protocols.38 The subpopulations of patients with stable chronic disease(s) or those who are at risk for progression toward unstable and/or multiple chronic diseases are groups in which targeted interventions may be beneficial in a shorter timeframe.

Postacute care expenditures comprise a large segment of spending in the Medicare program. This segment of care has tremendous variation in utilization of services but without a relationship to efficacy or effectiveness. Potential changes in payment schemes, quality and medical necessity analyses, and better defined discharge planning may standardize care and alter costs.39 Utilization of telemedicine for early and convenient postoperative follow-up visits,40 and perhaps postdischarge physiologic monitoring (e.g., pulse oximetry or capnography), may reduce unnecessary readmissions while providing a more patient-centric focus that improves care and the patient experience.

THE ROLE OF ANESTHESIOLOGY IN A PERIOPERATIVE POPULATION HEALTH MANAGEMENT STRATEGY

Population health management strategies are increasingly more important to leaders of health care systems because the health of populations for which they care, especially in a strong cost risk-sharing environment, must be optimized. Most population health management efforts rely on a patient-centric team approach, coordination of care, effective communication, and robust outcomes data analysis. Anesthesiologists have an opportunity to help lead these efforts in concert with their surgical and nursing colleagues.

Because anesthesiologists provide acute surgical care for the entire spectrum of patients, targeted interventions for each identified group of patients (i.e., stratified by American Society of Anesthesiologists physical status score) may be implemented and add value from the population health perspective (Fig. 6). In well-organized preoperative evaluation and treatment clinics, we can prospectively identify groups of patients who will benefit from better presurgical preparation (i.e., prehabilitation). Delaying the timing of surgery will allow for targeted interventions that may improve outcomes and thus add value.

Figure 6.
Figure 6.:
Perioperative population health management as targeted interventions across the perioperative continuum for patients stratified by American Society of Anesthesiologists physical status score.

For instance, patients undergoing major surgery who have iron deficiency anemia preoperatively are at a higher risk for blood transfusion, complications, and mortality. Anemia management programs that treat patients with short courses of iron and erythrocyte-stimulating agents, when used in patients undergoing major procedures with higher blood loss such as total hip arthroplasty and total knee arthroplasty, have shown promise to reduce risks and improve outcomes in these patients.41

Patients who take numerous prescription medications and who have multiple comorbidities are at risk for worse outcomes. The Comorbidity-Polypharmacy Score, a simple summation of the number of preoperative medications and comorbidities, is predictive of worse outcomes in the trauma patient population.42 Optimizing medications before elective surgery may reduce the likelihood of drug interactions and improve outcomes.

Geriatric patents are at risk for numerous complications when having intermediate- or high-risk surgery. Postoperative delirium is associated with higher morbidity and mortality in elderly patients having surgery. Prospectively identifying these subpopulations with simple screening tools such as the MiniCog examination and frailty index scores might allow for targeted interventions such as preoperative referral for a geriatric medicine consultation and arrangement for the patient to be treated in an acute care for the elderly unit in the postoperative period.43

Patients who have nutritional deficiencies, identified specifically by low serum albumin and prealbumin levels, have worse overall outcomes. A short-course preoperative nutritional supplementation may improve postoperative outcomes, especially in patients having cancer resections.44,45

These are just a few examples of how anesthesiologists can risk-stratify patients and institute appropriate preoperative therapy or work in concert with other physicians to improve the chance for better outcomes for patients. Anesthesiologists can work to improve the health of all surgical patients by applying evidence-based care with a reduction in variation throughout the entire surgical continuum. Effective multimodal analgesia plans, critical care management, and discharge planning are all elements of a comprehensive PSH model. Implementation of quality and safety programs and working to lead high-reliability teams are important measures to ensure the best outcomes possible, especially in the high-risk patient populations.

CONCLUSIONS

Population health management is crucial to successfully achieving the IHI Triple Aim of (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing per-capita costs of care.21,23,46 Many health care delivery systems and many clinicians (including anesthesiologists) are just beginning their population health management journeys. However, by doing so, they are preparing to navigate a much greater risk-sharing landscape, where these efforts can create greater financial stability by preventing major financial loss. Anesthesiologists can and should be leaders in this effort to add value by improving the comprehensive continuum of care of our patients.

DISCLOSURES

This manuscript was handled by: T. J. Gan, MD.

This Special Article was prepared at the invitation of Dr. Jean-Francois Pittet.

This manuscript was not screened for plagiarism.

FOOTNOTES

aMcKesson Corporation: Population Health Management. Available at: http://www.mckesson.com/population-health-management/population-health-management/. Accessed January 24, 2016.

bPartners HealthCare: Population Health Management. Available at: http://www.partners.org/Innovation-And-Leadership/Population-Health-Management/. Accessed January 24, 2016.

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