SIGNIFICANCE OF PERIOPERATIVE PAIN MANAGEMENT
Management of acute postoperative pain and its morbid transition to chronic postsurgical pain (CPSP) continue to be major health care challenges. CPSP is defined as pain that develops after surgery and persists for at least 2 months, with exclusion of other causes and preexisting problems.1 Recent surveys indicate that postoperative pain remains inadequately treated2; this being especially true in procedure- and condition-specific at-risk populations.3,4 Inadequate postsurgical analgesia may predispose patients to a number of postsurgical complications with subsequent increases in negative perioperative outcomes and unnecessary costs.3 A patient’s pain experience has also been reported as the second most important factor in his or her recommendation of an institution.5
Of the approximately 80 million annual inpatient and outpatient surgical procedures currently performed in the United States,6 it is estimated that between 10% and 70% of patients will develop some degree of CPSP depending on the type of surgery performed (Table 1),1,7 and up to 5% will develop severe CPSP with chronic functional disability and psychosocial distress.8 Therefore, CPSP is the second largest group of patients presenting to chronic pain treatment centers9 and represents a significant portion of the United States estimated approximately $635 billion chronic pain-related health care costs.10
Furthermore, surgical patients with preexisting chronic pain and opioid tolerance are a challenging and growing population who not uncommonly experience negative perioperative outcomes with associated increased costs.3 There are no published data on the prevalence of such surgical patients. However, an internal audit of our preoperative evaluation clinic noted 15% to have preexisting chronic pain and opioid tolerance.
Effective surgical pain management is a widely recognized fundamental human right and ethical principle11 and an important health care quality metric. Perioperative pain management in the United States is currently substandard and is criticized due to its variable and fragmented care, high costs, and low value.6,12 Postoperative pain should not simply be reactively addressed as a byproduct of surgery, it should be cohesively and proactively managed throughout the entire perioperative experience.
In this Open Mind article, we describe how a comprehensive perioperative pain service (PPS) can be integrated into a Perioperative Surgical Home (PSH) model, thereby improving outcomes and reducing costs in surgical patients at risk for poorly controlled postoperative pain and CPSP. We also discuss how the specialty of anesthesiology may contribute to and benefit from this new practice model. Lastly, we present a viable financial model for such a PSH-integrated PPS.
Identification, assessment, and management of cohorts at risk of moderate to severe postoperative pain are challenging. A better understanding of associated (“predictive”) factors will help to identify patients likely to benefit from additional care. Current evidence suggests that preoperative pain,3,13 increased pain sensitivity,8 and vulnerable psychosocial3,8 (anxiety, depression, catastrophization, and stress symptoms), physical3,8,14 (younger adults, female gender, obesity, and deconditioning), and genetic features8 are considered important factors associated with acute postoperative pain. In turn, acute postoperative pain and its associated factors, along with the type of surgical procedure being performed, are generally considered important factors associated with CPSP.3,15 A recent review of procedure-specific CPSP demonstrated that the prevalence of CPSP after surgeries (Table 1)1,7 performed in the thoracic and breast area approximates 30%–35%; that of bone and joint surgeries approximates 20%; and that of surgeries on abdominal visceral structures approximates 10%–14%,16,17 with a reported 10% overall rate of severe CPSP 1 year after surgery.7 The complexity of the sensory and emotional aspects of pain makes it highly unlikely that one single measure could predict all aspects of acute or more persistent postoperative pain, and accordingly, multivariate prediction models may prove valuable. One such analysis showed a sensitivity of 60% and a specificity of 83% based on 5 multivariate predictors: capacity overload, preoperative pain in the operating field, other chronic preoperative pain, postsurgical acute pain, and comorbid stress symptoms.1 There exists a real and sizeable proportion of patients presenting for surgery with condition-specific and/or procedure-specific risk factors who could benefit from a comprehensive PPS model.
THE FRAGMENTED PERIOPERATIVE PAIN EXPERIENCE AND BARRIERS TO THE CURRENT ACUTE PAIN SERVICE MODEL
Perioperative care in the United States is criticized due to its variable and fragmented care, high costs, and low value,6,12 paralleling recent data seen from acute pain service (APS) reviews.5,18 Current APS teams vary widely in structure and function across institutions. Most provide care in the postoperative phase and primarily focus on management of epidural and peripheral nerve catheters, with a few services offering assistance in the intradischarge and postdischarge phases.5 As a result, the majority of postsurgical pain, even for at-risk patients, is typically managed by surgeons who commonly use only single-agent therapy such as intravenous patient-controlled analgesia.
The current pain service model neglects many components of optimal perisurgical pain control, beginning in the preoperative phase, a critical phase ideal for identification and implementation of standardized assessment and patient-centered management plans for at-risk populations. The intraoperative phase is another area in which patient-centered decisions are often not discussed, and pain management guidelines or protocols are not followed due to disorganization and/or disengaged APS teams. Without a postdischarge phase, much needed follow-up assessments and services cannot be provided. Lastly, without an APS encompassing the full perioperative pain experience, effective measurement of pain-related health care metrics is difficult, and the ability to provide proactive, comprehensive, individually tailored care is significantly hindered.
Despite major health care measures and generally agreed-upon provisions of a dedicated pain service, APS teams continue to face obstacles.19 Reasons for this vary between organizations; nonetheless, the general census remains that pain services are encumbered with significant fiscal and operational barriers. For instance, postoperative and postdischarge analgesia in the United States is traditionally managed by the surgical team and is the present-day model largely because this care service is included in its global professional fee. This is relevant because within this existing payment system, it makes it fiscally problematic for an expert team to provide postoperative pain management to at-risk patients. Further compounding the issue is that despite the benefits of a dedicated postoperative pain service, recent systematic reviews have demonstrated insufficient evidence to suggest its cost-effectiveness or ability to impact outcomes.8,18 Explanations for this suggest that the variability in structure and function of pain services across facilities make it difficult to draw unequivocal conclusions,5 and that most studies are limited by partial economic analyses.19
There are many conflicting elements involved in the development, implementation, and operational management of APS teams, and given the expenses of such a service, what are the incentives for hospitals and anesthesiologists to participate? Whether an APS is cost-effective likely depends on multiple factors, such as procedure- and condition-specific populations,5,20 and the achievability of an integrated, comprehensive, standardized, rehabilitation pain program21 that involves all phases of perioperative care.
THE SOLUTION: A PERIOPERATIVE PAIN SERVICE?
Effective surgical pain management is a fundamental human right and ethical principle.11 Current views of postoperative pain must change from being an afterthought of surgery to a proactive, integral component of the entire perisurgical episode, beginning with the decision to operate. Role expansion of the APS into the preoperative and postdischarge phases, so as to embrace the entire perioperative episode, can provide patients at risk for postoperative pain with comprehensive and continuous perioperative pain management. This new proactive PPS model attempts to provide patient-centered, value-based health care and may improve health outcomes and produce cost savings for at-risk populations. This is similar to what has occurred in terms of reducing perioperative infections by surgeons now focusing on prevention rather than treatment after the fact.
Rationalistic data in support of a PPS are paralleled in recent reviews from the Patient-Centered Medical Home (PCMH),22 integrated care pathways (ICPs, ie, enhanced recovery after surgery),23 and standardized clinical assessment and management plan (SCAMP)24 models. Collectively, these care delivery models have demonstrated better outcomes and improved health care value than traditional methods. Furthermore, the implementation of a PPS within the PSH is in alignment with the Institute of Healthcare Improvement Triple Aim for surgical health care reform, which comprises (1) improving the individual experience of care, (2) improving the health of populations, and (3) reducing per capita costs of care.6
THE SALIENT ELEMENTS OF A PERIOPERATIVE PAIN SERVICE
By harnessing the anesthesiologist-led PSH as the platform, an APS can fulfill the transition to becoming an all-encompassing PPS (Figure 1). Akin to the PSH, a PPS emphasizes continuity, coordination, and integration of perioperative care, with a greater focus on patient-centeredness and shared decision making, ultimately aiming to improve health care quality and cost outcomes. As such, many of the benefits recognized within the PSH will likely be applicable to a PPS model. Also, by having a PSH platform for pain services, at any time in a patient’s surgical episode should they be experiencing inadequate pain relief with standard surgical ward measures, the PPS team can systematically assimilate this patient into their standardized management care structure. In doing so, a PPS will inherently address the postoperative management phase of the PSH, a challenging phase based on our current care model. Lastly, as does the PSH, a PPS will further enhance the visibility and value of the anesthesiology department within a hospital. This is becoming increasingly relevant in today’s mounting health care-wide financial pressure, evolving hospital-physician economic collaborations and changing payment paradigm.
The principal goal of a PPS model will be to reduce variability, an overarching element of many innovative health care reforms. As in the PSH model, a PPS will be responsible for the integrative management of both condition-specific SCAMPs and procedural-specific ICPs, often times concurrently for each patient. With this level of organization, patients can be stratified into low-variability, high-throughput, protocol-based systems that optimizes resource utilization while improving patient care.23,24 Key to variability reduction will be early intervention by the PPS, particularly in the preoperative phase (Table 2). This is a crucial phase where predictive risk factors of acute postoperative pain and its morbid transition to CPSP can be better understood and at-risk patients identified and assessed in a standardized fashion. Additionally, important patient-provider relationship building, education, expectation setting, and preemptive optimization of medical, psychological, and physical factors begin in the phase, as well as perioperative pain management planning, including discussion on intraoperative regional and neuraxial techniques.
Additional phases of care unique and essential to an all-encompassing PPS, and that are especially important for patients showing increased and prolonged postsurgical pain, are the postoperative transition planning and postdischarge follow-up phases. At these key junctures, integrative, patient-centered care-coordinated provisions are made with outpatient teams, pain medication regimens are optimized with appropriate tapering strategies, and where applicable, referrals to chronic pain medicine specialists are made available. Particularly, there is increasing evidence that majority of surgical patients do not utilize most of the opioid prescriptions provided by surgeons for postdischarge pain management. In addition, exposure to opioids during postoperative pain management is the first step for many patients who end up getting dependent on or abusing this group of medications.25,26 Therefore, an anesthesiologist-led PPS is ideally positioned to help reduce the rampant opioid abuse/diversion epidemic in the United States by taking the lead in managing (or advising surgeons on) postoperative analgesic regimens.
Another vital function of the PPS model will be in its capacity to effectively administer and measure pain-relevant health care metrics, thus embracing a key element of a learning health care system. In doing so, perhaps a PPS could at last statistically demonstrate cost-effectiveness and enhanced value while improving outcomes through comparative effectiveness research (CER). As with the PSH, CER within the PPS model will aim to enhance patient-centered care, increase clinician adherence to evidence-based practice, improve patient quality and safety, and reduce overall costs. Ideally, a national PPS outcome database designed to measure risk-adjusted outcomes and CER of pain management interventions so as to compare results between institutions should be developed, much akin to the surgeon’s National Surgical Quality Improvement Program.27 Through envelopment of the entire perioperative process with a dedicated pain service, a faithful adaptation of a learning health care system with regard to perioperative pain management can be achieved.
DISSEMINATION AND IMPLEMENTATION OF A PERIOPERATIVE PAIN SERVICE
Dissemination and implementation of a PPS will not be without challenges. Foremost, considering the PSH is the ideal platform for anesthesiologist-led perioperative care, a variation of this surgical home model should either be in place or in parallel development with a PPS. As with the PSH model, dissemination and implementation of a PPS require a broad set of stakeholders who are willing to collaborate and push for this innovation28; this includes providers (anesthesiologists, surgeons, nurses, and pharmacists, with respective departmental fiscal officers), payers, and policymakers. Depending on institutional infrastructure and unforeseen external forces, there will likely be multiple effective variants of a PPS fashioned in an evolutionary-type manner with different institutions adopting different elements at different rates. Dissemination and implementation science should be incorporated throughout the process of creating a PPS; this includes efficacy and effectiveness trials followed by CER not only for validation and improvement but for economic and political leveraging capacity.6
Key to dissemination and implementation of a PPS within the PSH will involve a multidisciplinary collaboration of health care providers. This is paramount considering the expanded perioperative care responsibilities that a PPS model will assume in addition to the subsequent expansion in patient volume with increased health care personnel and resource requirements. Not surprisingly, dissemination and implementation science will likely determine that the ideal PPS organizational structure will center on an integrative team of midlevel providers supervised by anesthesiologists. Midlevel providers can effectively apply highly efficient, evidence-based perioperative pain protocols and pathways, thereby enabling anesthesiologists to focus on a patient’s evolving diagnoses and to tailor an individualized treatment plan.29 Additionally, the task of developing local institutional perioperative pain SCAMP/ICP amalgamation pathways for at-risk acute postoperative pain and CPSP populations should also be accomplished by a multidisciplinary team of health care providers and performed similarly to previous descriptions in the literature using evidence-based guidelines and protocols.24
Highly important to the successful dissemination and implementation of a PPS includes adequate education and training among anesthesiologists and midlevel providers. Not only will they need to become clinically proficient in perioperative pain management, especially for at-risk postoperative pain populations, but they will need to educate themselves on the general dissemination and implementation process, including its science, team building, and change management,12 to competently develop and implement a PPS with SCAMP/ICP amalgamation pathways. Just as importantly, continuous feedback and learning from CER will also be key to the successful dissemination and implementation and maintenance of a PPS. With the goal of creating a comprehensive proactive PPS with PSH-integrated clinical pathways, as suggested in the PSH literature,12 residency programs should provide training that incorporates the perioperative encounter into a multiphase continuum.
PAYING FOR A PERIOPERATIVE PAIN SERVICE
In the current expensive health care system, funding a PPS integrated into a PSH presents significant financial barriers. The compensation structure of the US health care system is shifting away from the traditional, volume-based, fee-for-service model toward bundled payments that include performance and care coordination payments. In view of this, creation of an anesthesiology-led PPS will encourage important hospital-wide visibility and add expected cost-effective value to the global perisurgical arena, thereby helping to defend the undesirable outcome of anesthesia provisions being locked only into the intraoperative phase with commodity rate compensations.
Central questions yet to be adequately answered to achieving a PPS are: (1) how does one finance the dissemination and implementation of the service; and (2) how does one receive compensation for maintenance of the service? To help answer the first question, resource capacity utilization will need to be determined and patient selection criteria matched, that way patient volume will approach full resource capacity. Given that an anesthesiologist-led PSH will be the support structure of an overlying PPS, determination of initial cost will also vary depending on the PSH infrastructure already in place at a particular institution. Furthermore, an existing APS will help institutions offset the start-up cost. As described in the PSH literature,6,12 financing a PSH-integrated PPS will require local institutional stakeholders to purchase the presumed value created by this care model. That said, the brunt of the initial investment may lie with anesthesiologists until the hospital and third-party payers appreciate the improved outcomes and added value of the service.
As described in the PCMH literature and used as a guide for the PSH, current health care initiatives depend on a combination of 4 basic compensation elements: fee-for-service, criteria-met bonus, pay-for-performance, and care coordination payments.6 Local institutional APS and PSH compensation structures will serve as guides for a PPS.
At our institution, we trialed reimbursement payments during the dissemination and implementation of our PPS and discovered that anesthesiologists can receive compensation for seeing patients preoperatively who are at risk for postoperative pain and CPSP, collect in-hospital daily rounding fees, as well as receive payments for coordinating discharge plans and for a postdischarge follow-up visit. During the dissemination and implementation process, we used the time-driven activity-based costing method (Figure 2), work pioneered by Harvard Business School professors Michael Porter and Robert Kaplan, to design a perioperative care delivery process pathway for at-risk postoperative pain patients, predict the purchasing cost of implementing this service, and characterize opportunity to reduce perioperative cost for this group of patients. The time-driven activity-based costing method is a bottom-up approach of estimating health care delivery costs based on direct assessment of actual clinical and administrative processes. This method engaged health care providers at our institution in understanding the processes and costing activities of health care delivery and provided a unique platform to design and integrate a PPS in an optimized, cost-conscious manner.
Adequate management of iatrogenic surgical pain is a fundamental ethical principle, highly recognized by the medical profession and health authorities, and an important component of many measures of hospital quality. With the advent of the anesthesiologist-led PSH, the opportunity to create a proactive, comprehensive, and standardized PPS that embraces the entire perisurgical episode while serving as a learning health care system through CER may confirm improved health outcomes and cost savings, as paralleled in PCMH, ICP, and SCAMP care delivery models, for surgical patients at risk for increased acute postoperative pain and CPSP. The success of a PPS requires collaboration of health care providers, local institutions, and payers all functioning in alliance across the perioperative care continuum. We believe the specialty of anesthesiology will benefit from this practice model, and the implementation of a PPS will help meet the postoperative demands of the PSH and is adequately in alignment with the Institute of Healthcare Improvement Triple Aim for surgical health care reform.
Name: Michael P. Zaccagnino, MD.
Contribution: This author helped conceive/design and collect/analyze the data, draft, critically revise, and approve the final manuscript.
Name: Angela M. Bader, MD.
Contribution: This author helped conceive/design and analyze the data, draft, critically revise, and approve the final manuscript.
Name: Christine N. Sang, MD.
Contribution: This author helped conceive/design and collect/analyze the data, draft, critically revise, and approve the final manuscript.
Name: Darin J. Correll, MD.
Contribution: This author helped conceive/design and collect/analyze the data, draft, critically revise, and approve the final manuscript.
This manuscript was handled by: Richard Brull, MD, FRCPC.
Acting EIC on final acceptance: Thomas R. Vetter, MD, MPH.
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