regional anesthesia and bundled payments – opioid-sparing pain management for optimal outcomes
TRANSCRIPT
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5/9/2017 Confidential ©2014 Wellbe, Inc. – All Rights Reserved.
www.periopmed.org – Enter OSLCODE for Early Bird $100 off through tomorrow!
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2
Patient Engagement for ERAS Protocols
www.wellbe.me
• Assessment Forms• Optimization Education• Patient Preparation• Post-Op Follow Up• Outcomes Measurement
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Regional Anesthesia and Bundled Payments -
Opioid-sparing Pain Management
for Optimal Outcomes
Sonia Szlyk, MDDirector of Regional Anesthesia
North American Partners in Anesthesia,
Mid-Atlantic Division
INOVA Fair Oaks Hospital, VA
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Disclosure
• National Speakers’ Bureau- Halyard Health
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Large academic hospital
Private practice hospital
Freestanding Orthopedic ASC
My Perspective
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PATIENT & SURGEON SATISFACTION
BUNDLED PAYMENTS & OUTCOMES
REDUCING OPIOID USE
INCREASED DISCHARGE TO HOME
ERAS & FAST-TRACKING JOINTS
There’s a BLOCK for THAT!
IF YOU CARE ABOUT…
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Edvard Munch
What About the PAIN?!!!
I Know I Need Surgery, but…
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ThePerfectStorm
Narcotics
NauseaImmobility
Surgical Pain
Respiratory Depression
What Keeps Patients in the Hospital/ASC/Acute Rehab?
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Pain
Narcotics
Nausea
Respiratory Depression
Immobility
Regional Anesthesia Nerve Blocks
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The Era of Bundled Payments
PatientSatisfaction
PreventReadmissions
BetterOutcomes
CoordinateCare
LowerCost
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Average Target Cost:
469 ~ $50,000470 ~ $25,000
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Regional Anesthesia!
Pain controlOpioid-sparing
Reduced cognitive impactEarly ambulationDecreased LOS
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-Excellent pain control
-Minimize narcotics & nausea
-Decrease LOS
-High patient/surgeon satisfaction
-Complex cases as outpatient
-Complex patients as outpatient
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Benefits of Ultrasound-guided Nerve Blocks
• Improved Efficiency
– Faster block placement
– Faster onset
Liu, S. Ultrasound-Guided Regional Anesthesia and Analgesia. A Qualitative Systematic Review. Reg Anesth Pain Med 2009;34: 47 - 59.
Sites, B. et al. A comparison of sensory and motor loss after a femoral nerve block conducted with ultrasound versus ultrasound and nerve stimulation. Reg Anesth PainMed 2009; 34:508-513.
Choi, S. et al. Femoral nerve block does provide significant analgesia after anterior cruciate ligament reconstruction. Arthroscopy 2010; 26(11), 1416.
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Expectations are Everything
BUSY
1. Don’t delay my case2. Don’t hurt my patient3. It had better work4. Don’t slow down rehab
And...Don’t delay my case!
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Wulf, H. Femoral nerve block with ropivacaine or bupivacaine in day case anterior cruciate ligament reconstruction. Acta Anaesthesiol Scand 2010; 54:414-420.
Pain control
Quad weakness
Quad weakness involves multiple factors…
not always the local anesthestic to blame
• Preop dysfunction
• Tourniquet
• Pain limiting
Balancing Act
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Adductor Canal Catheter
ERAS for…
• Partial knee replacement
• Total knee replacement
• ACL repair
orthoinfo.aaos.org
Decreased LOS & readmission rate, Increased DC to home
Auyong DB, et al, J Arthroplasty (2015).
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Femoral Block
Saphenous Block
Adductor Canal or“Mid-thigh Femoral”
Block
Location is Everything!
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In-plane
SAFETY EFFICIENCY PRECISION
Sites, B. et al. A comparison of sensory and motor loss after a femoral nerve block conducted with ultrasound versus ultrasound and nerve stimulation. Reg Anesth Pain Med 2009; 34:508-513.
Choi, S. et al. Femoral nerve block does provide significant analgesia after anterior cruciate ligament reconstruction. Arthroscopy 2010; 26(11), 1416.
Adductor Canal Block
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Nerve Block Infusion Pump
• Connected in PACU by RN
• Lasts ~ 3 days
• Adjustable rate
• Pt removes at home
• Easy, no sharps
0.2% Ropivacaine @ 8 mL/hr550 mL reservoir
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Jaegar, P. Adductor Canal Block versus Femoral Nerve Block for Analgesia after Total Knee Arthroplasty. Reg Anesth Pain Med. 2013;38: 526–532.
ACBC preserved quad strength better than FNBC (52% vs 15% baseline)
NO differencemorphine consumption
pain at rest, flexionadductor muscle strength
n/v, antiemeticsmobilization ability
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Physical Therapists, Patients & Surgeons Rejoice!
Same-day Physical Therapy!
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• Decreased LOS (76.6 to 56.1 hrs)
• Increased DC to home (52% vs 27%)
• No increase in readmission
• Decreased 30-day readmission rate (3% post vs 7% pre-pathway)
Auyong DB, et al, J Arthroplasty (2015).
UPDATED ERAS PATHWAY
RESULTS• Mepivacaine spinal
• TXA
• Adductor canal catheter x 48 hrs
• PT DOS
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Secondary Functional Outcomes
• Increased ambulation distance POD 1-2
• Decreased falls (0% post vs 2% pre-pathway)
• Decreased transfusion • Decreased nausea
Auyong DB, et al, J Arthroplasty (2015).
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Adductor canal catheter
LMA or Spinal (no narcotics in spinal)TXA
20 mL 0.5% Ropivacaine
Adductor canal catheter
Celecoxib, Oxycontin, Percocet or VicodinDOS Physical Therapy
0.2% Ropivacaine @ 8mL/hr
TKR ERAS PATHWAY
Premed Celecoxib, Acetaminophen, Decadron
Preop Block Adductor canal catheter 20mL 0.5% Ropivacaine
ORSpinal (Mepivacaine, no narcotics) or LMATXA
Postop & Home
Adductor canal catheter0.2% Ropivacaine @ 8mL/hr
Celecoxib, Oxycodone/Acetaminophen, Ondansetron
DOS Physical Therapy
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Multimodal Premeds
• NSAIDs
- Improved pain score, decreased opioid requirements, improved ROM in physical therapy
- Cyclooxygenase inhibition (mitigate central and peripheral prostaglandin production)
• Acetaminophen
- Decreases 24-h usage of morphine and pain scores
- Inhibits central prostaglandin synthesis
• Gabapentin & Pregabalin
- Decreases opioid use over first 24 – 48 hrs, use beyond POD 4 is not supported
- Membrane stabilizers (inhibit x-2-delta subunit of L-type calcium channels)
Webb & Mariano. Pain Management (2015) 5(3). 185 – 196.
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Chronic Pain Patients
• Preoperative consult with existing pain specialist
• Continue chronic outpatient pain medications perioperatively
• Gabapentin 300 – 600 mg po preop
• Ketamine IV
- 0.5 mg/kg bolus then 0.25 mg/kg/hr infusion
• Set expectations and goals
- Baseline pain score
Webb & Mariano. Pain Management (2015) 5(3). 185 – 196.
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Fascia Iliaca Catheter
ERAS for…
• Hip fracture
• THR
• Hip arthroscopy
Mayo Foundation for Medical Education.
Decreased incidence and duration of delirium, LOS, pain score
Mouzopoulos, G. Fascia iliaca block prophylaxis for hip fracture patients. J Orthop Traumatol 2009 Sep 10(3): 127 – 33.Dulaney-Cripe E et al. A continuous fascia iliaca compartment block in hip fracture patients. J Clin Med Res. 2012 Feb;4(1):45-8.
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Fascia Iliaca Block
• Lateral femoral cutaneous
• Femoral
• Obturator
• “Anterior approach lumbar plexus”
• Less dense versus lumbar plexus
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Fascia Iliaca Block
• Compartment block = High volume
• 50 - 60 cc local anestheticFujihara. FICB. J Orthop Sci. 2013.
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Fascia Iliaca Block
• Compartment block = High volume
• 50 - 60 cc local anestheticSartorius
Internal Oblique
Iliacus
SUPERIOR INFERIOR
50 cc Compartment Block• 20 cc 0.2% Ropivacaine• 30 cc 0.5% Ropivacaine
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Incidence of Delirium 10.78%23.8%
Mean Duration of Delirium 5.22 days
FIBPlacebo
10.97 days
Hip Fracture
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Fascia Iliaca Block
No Block FIB cathPOD 0 Pain
POD 1 Pain
Ave LOS
4.1 1.7
2.9
5.9 days
1.4
4.8 days
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Neuraxial AnesthesiaLower 30-day mortality
Decreased length of stayDecreased cost
Lower in-hospital complications
Memtsoudis, S., et al, Anesthesiology 2013 May; 118(5): 1046 -1058.
Total Hip Arthroplasty
• >380,000 THR, TKR• 400 hospitals• GA vs Neuraxial
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Neuraxial AnesthesiaDecreased incidence of SSI
Zorrilla - Vaca, A. et al., Regional Anesthesia and Pain Medicine. 2016; 41: 555-563.
• 13 studies• n = 362,029• GA vs Neuraxial
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How Does Pain Management
Affect the Bottom Line?
SM
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Reduced PACU Time
Impact of Regional Anesthesia
30 minutes in Phase 1 PACU
$400
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Reduced Opioids
Impact of Regional Anesthesia
• 380 US hospitals • 320,000 inpatient surgeries
•12.2% of patients had an opioid-related adverse event (ORADE) •respiratory depression •nausea and vomiting •drowsiness, itching, altered mental status •constipation and paralytic ileus
Oderda, GM. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliate Care Pharmacother. 2013 Mar; 27(1):62-70.
Effect of opioid-related adverse events on outcomes in selected surgical patients.
Oderda GM1, Gan TJ, Johnson BH, Robinson SB.
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Decreased LOS
Ave Cost per Inpatient Day(non-profit hospital)
CA $2676
LA $1519
VA $1630
AZ $2092
MN $1929
CO $2329
US Average $2025
$405,000 savings/year
Decrease LOS 1 day
x 200 joints/year
http://www.beckershospitalreview.com/lists/average-cost-per-inpatient-day-across-50-states-in-2010.html
Impact of Regional Anesthesia
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Lower After-Hospital Costs
Impact of Regional Anesthesia
Home Health$100/day
Skilled NursingFacility
$700/day
Increased Discharge to HOME
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Decreased Readmissions
Impact of Regional Anesthesia
Hospital Readmission
THR $12,300TKR $10,200
ER
$1400 - $2000
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Success Drivers
• Index Admission: $13,000 - $15,000 Range
• Hospital Payment
• Surgeon and Anesthesia
• Other Hospital Professional Fees (Hospitalist for fracture)
• Home Health
• Physical Therapy
• Other Follow-up Care (Office Visits, Radiology, DME)
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Loss Drivers…Rehab
- Acute Rehab LOS 5 to 10 d $15,000 - $21,000
- SNF at Target LOS 8-10 d $8,000
- SNF with Long LOS 30+ d $17,000 - $28,000
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Loss Drivers…Readmission
- Hospital Ortho Surgical $20,000 (Hospital & Physician)
- Hospital Medical $7,500 (Hospital & Physician)
- Surgery/Medical Observ. $5,000 - $20,000
- Other Misc. Part B = High-Cost Drugs, Imaging, Diag. Tests
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• Patient satisfaction• Surgeon satisfaction• Ambulation• Physical therapy
participation• D/C to home
Decreased Increased
• Pain scores• PONV• LOS• PACU time• Opioids, ORADE• ER & Hospital
readmission• Need for SNF or
inpatient rehab
Positive Impact of RA on Bundled Payments
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It Takes a Village…
Surgeon
Hospital/ASC Administration
Anesthesiateam Patient
PhysicalTherapist
Pharmacy
Familymember
OR &PACU RN
Floor RN
RegistrationBlock RN
EPIC/EMR
Billing
Preop RN
Successful Regional Anesthesia Program
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Anesthesia Team
Patient
Surgeon
Nurses
Joint ReplacementAdvisory Board
CEO, CFO, CMO, CNO
Physical Therapist
Hospitalist
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Evaluation of Bundle Performance
Quarterly Review
PREPARE FOR THE NEW TARGET!
• Readmissions
• Discharge disposition
• Financial assessment
- Ave cost vs. target cost
- Examine high-loss cases
• Identify further cost savings
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In the Media… AAOS
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1.Adamson, et al. Hosp Pharm. 2011;46(6 Suppl 1):1-3.2.Alam A, et al. Arch Intern Med, 2012; 172(5): 425-30.3.Carroll I, et al. Anesth Analg, 2012; 115(3): 694-702.
A Growing Opioid Epidemic
• ˃70 million patients per year are prescribed opioids for postsurgical pain 1
• 1 in 15 will go on to long-term use or abuse 2,3
• Rapid proliferation of new opioid users coming from the acute care setting 2,3
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MAKES IT EASY to...
Do the Right Thing
for the Patient!
Regional Anesthesia
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Regional Anesthesia & Value-based Payments Overview
http://go.beckershospitalreview.com/revisiting-regional-anesthesia-a-pathway-to-optimal-patient-outcomes-surgeon-satisfaction-and-value-based-payment