A Better Pathway to Acute Care

flying cadeuciiWhen patients need acute interventional care, coordinating the transitions away from and back to primary care is a challenge. The common pathway for these patients, no matter what their diagnosis, is an encounter with anesthesiology. But it often happens too late in the process. If we’re involved earlier, physician anesthesiologists can help reduce procedure risk, control costs, and improve the long-term health of this high-risk, high-spend population.                    

The numbers haven’t changed significantly in several years—only five percent of the U.S. population consumes a full 50 percent of annual health care spending, and just one percent is responsible for nearly 23 percent of spending.

Within the top 10 percent of high spenders, most (nearly 80 percent) are age 45 or older. About 42 percent are persistent high consumers year after year, while the majority requires high spending only on an occasional basis. These episodes of high health care consumption often involve surgery or other invasive procedures in the older patient population.

The experience of undergoing surgery inevitably disrupts a patient’s normal routine of care, even if the surgery is a common elective procedure such as a total joint replacement. Too often, the primary care physician may be unaware that the patient has actually undergone surgery.

Even if the patient’s primary physicians are informed of the plan for elective surgery, they may be left out of the loop regarding discharge planning, the need for post-acute care and rehabilitation, and any changes made to the patient’s medication and diet regimen. Lapses in care and deterioration of chronic medical conditions may result, with the frail, older patient population clearly at highest risk.

Why we should rethink current practices

Within every community population, a subset of patients will be in need of procedural care at any point in time. This care may involve an operation. Or it may involve a substantial, invasive procedure for diagnosis or treatment, such as ablation of cardiac arrhythmia, ERCP (endoscopic retrograde cholangiopancreatography), or insertion of an endovascular stent.

The common pathway for this entire population subset, regardless of the diagnosis or any other factors, is an encounter with anesthesiology before, during, and after the procedure. Today, that encounter often begins way too late in the process.

The role of physician anesthesiologists in perioperative care has evolved significantly over the past 20 years. A number of academic departments have expanded their titles to “Anesthesiology and Perioperative Medicine” to reflect this expansion of scope.

Anesthesiologists are interested in population health as a means to improve outcome and control costs in the high-risk surgical/procedural population. If we can improve the health of patients before invasive procedures, and improve the management of the inevitable transitions of care, we have the potential to bend the cost curve of the “high spenders”.

For these positive effects to happen, we need to place a new focus on building bridges between primary care and anesthesiology, recognizing that anesthesiologists will be managing any chronic medical conditions throughout the acute episode of care.

If the planned procedure is a same-day or short-stay encounter, it’s unlikely that a hospitalist or internist will be involved. Yet high-risk patients whose chronic medical conditions aren’t under optimal control may experience exacerbations of COPD or CHF, blood glucose spikes, or other problems that may lead to unplanned admissions, increased length of stay, or costly 30-day readmissions.

We need to undertake a major remapping of the pathway for surgical/procedural care, as it currently exists in most health systems. Typically, once it is decided that a patient should have an invasive procedure, it is scheduled relatively soon, depending on the availability of the surgeon or proceduralist. There is seldom time for a thorough reassessment of the patient’s underlying health problems, taking into account the systemic perturbations that are likely to result from the stress of the operation.

In a scenario that happens all too often, the patient and the anesthesiologist meet only on the day of the procedure, and the chart contains a scrawled note on a prescription pad that reads, “Cleared for surgery.”

Optimize health, then schedule the procedure

Instead, these high-risk, high-spend patients would benefit from anesthesiology consultation as soon as an elective procedure is considered, and before it’s actually scheduled. Physician anesthesiologists in many centers have expanded the function of preoperative clinics to include optimization of chronic medical conditions in anticipation of the added stress of surgery.

Patients may be motivated to improve their diabetes control when they understand that they will lower their risk of wound infections. Some patients are willing to stop smoking—finally—when they understand the increased risk of postoperative pneumonia and impaired wound healing. Anticoagulant, diuretic, or steroid dosing may need to be modified. Treatment of anemia before major surgery can reduce the risk and cost of transfusions. Chronic pain and poor nutritional status are risk factors for postoperative complications, and should be addressed well in advance of surgery whenever possible.

As the patient’s health issues are addressed, there is opportunity for education of the family about what to expect during the postoperative course. This is the time to anticipate and plan for post-acute care needs, and for a smooth transition back to the primary medical neighborhood.

For patients who have had little motivation to improve their health, or who have had little access to care for social reasons, an acute episode of care may be an entry point into the health system, a wake-up call, and an opportunity for better long-term health management.

The elective operation or procedure should be scheduled only after the patient is in the best attainable condition. During and after surgery, today’s evidence-guided anesthesiology care emphasizes enhanced recovery pathways, optimized fluid management, and techniques to reduce the incidence of postoperative delirium. Multimodal pain management, often utilizing regional anesthetic nerve blocks, reduces narcotic-related complications and length of stay.

The most forward-thinking anesthesiology departments are extending their involvement into the post-acute care period, recognizing that postoperative patients may return to the emergency room and even be readmitted due to pain and other non-surgical issues. The ability to manage these issues preemptively, in a clinic rather than hospital setting, has the potential to improve patient satisfaction and reduce costly readmissions.

A new model for transitional care

The traditional preoperative assessment clinic should receive health system support to evolve into a multidisciplinary transitional care clinic, where high-risk patients can be seen prior to procedures for health optimization, and afterward for improved follow-up. This arrangement would provide a robust opportunity for research and data collection, and allow for standardized assessment of clinical and patient-reported outcomes. It would also facilitate communication back to the patient’s primary medical neighborhood, and eliminate lapses in care from problems as basic as the inability to pick up medication refills.

As clinically integrated networks proliferate, and the connectivity of electronic health records (we hope) improves, the barriers separating primary care and acute care physicians may diminish. The goal of improving the health of populations is one that we share, and the subset of patients in need of acute interventional care deserves priority as a high-risk, high-spend cohort.

Physician anesthesiologists are an underutilized resource in optimizing the health of this population prior to interventions, reducing costly perioperative complications, and managing transitions of care. Policy and systems changes should be made to increase early communication and consultation between primary care and anesthesiology, and to improve transitional care afterward, whenever high-risk patients need major procedures.

Karen Sibert is an anesthesiologist in Los Angeles.

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2 replies »

  1. high-risk, high-spend patients must receive an anesthesiology consultation ASAP

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  2. Sounds great! It will require a shift in how anesthesiology departments are set up, though. At the hospitals I deal with, it is very hard to get hold of anyone in the anesthesia department. You would have to make yourselves available to external customers, have someone answering the phone, watch for incoming faxes etc. I agree with you that with so much surgery being same-day, the hospitalist aren’t the ones to involve for perioperative concerns.