How to Achieve Value-based Ambulatory Anesthesia Care
Author: Senthilkumar Sadhasivam, MD, Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.
Peer Reviewer: Ronald B. Berggren, MD, Professor Emeritus, Surgery, The Ohio State University College of Medicine, Columbus.
Value-based care is essentially the best patient outcome achieved at a reasonable cost.1,2 The percentage of surgical procedures being performed on same-day basis has significantly increased during the last decade. In this era of value-conscious perioperative care, the cost of a drug or practice to benefit a surgical patient is a significant factor; anesthesiologists must pursue quality improvement through collaborative efforts to improve quality of care and minimize costs.
Health care is the only major industry that lacks metrics to objectively define the quality of its services, and this fundamental deficiency has led to the use of price as the de facto scale for patient contracting.3 The personal bond between patient and medical groups has been transformed into an economic relationship driven chiefly by the price of health care services.4 Drug acquisition costs are only one element in a large and complex equation.
Concentrating on acquisition drug cost alone may be dangerous, even naïve, if we fall prey to knowing the cost of everything but the value of nothing.5 The answer to cost containment is not simply to cut or cap, but to manage and modify practice while accommodating changing needs.3 To re-establish the autonomy of medical decision, we must organize to assume the financial risks for our patients’ health, using objective, clinical information to deliver superior quality outcomes.6
Despite the clear and universal concern about quality, most health care negotiations continue to be dominated by cost considerations. This preoccupation with cost has transformed health care negotiations into a zero-sum game in which each stakeholder attempts to shift costs and accountability to one or more of the others.7 One of the ways to add value to health costs is value-based cost management, which directly links cost accounting, processes, clinical outcomes, and patient and employee satisfaction.8 Value-based cost management links health care costs and quality improvement to clinical outcomes through added value, and it accomplishes this integration by linking several measures with three financial tools: activity-based costing, value-added analysis, and cost of quality.9
From Cost to Value
We need to promote more cost-efficient perioperative care by balancing economic pressures and the ability to deliver high-quality care in this value-conscious environment.10 We should analyze the downstream clinical and economic benefits [such as patient satisfaction, fast-tracking time, duration of postoperative care unit (PACU) stay, frequency of post-discharge symptoms, unanticipated admissions, and emergency department (ED) visits] rather than the direct costs alone of more aggressive perioperative management — even if the direct cost of treatment is more.
Better perioperative planning and more aggressive management of perioperative pain and postoperative nausea and vomiting (PONV) are expected to decrease delayed PACU discharges, unanticipated admissions, post-discharge morbidities, and ED visits, and thereby improve the quality of perioperative care and the value of health care dollars. The unplanned hospital admission rate following same-day surgery is an example of a typical outcome measure of quality. Following ambulatory surgery, PONV with dehydration and severe postoperative pain are the two leading causes for delayed PACU discharges and unanticipated hospital admissions,11,12 which adversely affect the quality/value of health care delivery and increase perioperative costs significantly. A useful concept with value-improving and cost-reducing potential during ambulatory anesthesia is fast tracking, which is transferring patients directly from the operating room to the less labor-intensive step-down unit.13,14
Understanding costs is crucial to evaluate performance, strategic planning, managed care contract negotiations, and to minimize costs while maintaining the quality of patient care.15 Costs also are important for resource allocation, cost control, departmental budgeting, and staffing decisions.16 There is no doubt that cost will continue to be an important factor in health care transactions. Value-based care does not imply an elimination of cost considerations, but rather helps to move a health system toward a better understanding of how costs and benefits affect the system. With our inherent ability to add value, we clinicians should enhance the value of the two of the most powerful relationships in health care: clinician-patient and clinician-health plan.7
The emerging concerns about quality suggest that, instead of a preoccupation with costs, we should seek ways to broaden our understanding and more clearly define the various factors that constitute value.7 It is difficult to measure health care delivery benefits such as quality of care and improved health status. We need additional and different information for value-based decision making. Because four stakeholders (patients, doctors, health plan, and payer) engage in transactions in the health care marketplace,17 it is difficult to integrate nonfinancial benefits into health care negotiations across the entire set of relationships. Thus, when quality and satisfaction are discussed, it is often in the context of ensuring that basic quality standards are met. While this clearly is important, it leads to a narrow view of the benefits that the health care system can deliver and thus may miss the specificity necessary to add real value.7 To create the value equation, we must go beyond the specification of benefits and ask, "What costs will stakeholders need to incur to achieve their desired benefits?" The answers, when combined for all stakeholders, will lead to a set of value equations.7
We should not restrict the use of superior drugs based on acquisition cost alone, especially since drugs are such a small portion of the total costs.3 Downstream clinical and economic benefits may more than compensate for the additional direct cost of aggressive therapy.18 We must consider entire perianesthetic experience — preoperatively, intraoperatively, and postoperatively — to assess the cost benefit and other implications of our management. Otherwise, we risk being penny-wise and pound-foolish.18
To accurately evaluate the cost of an anesthetic, it is necessary to identify all the hidden drug-related costs, including wastes, as well as the costs due to perioperative factors not under the anesthesiologist’s control. It also is important to identify changes in the costs associated with patient preparation and recovery care that are affected by the choice of anesthetic agents and techniques.19,20
Anesthesia supply direct costs are only 5.6% of total hospital costs, and it is easy to miss the larger personnel costs involved.21 The more complex "indirect costs," which refers to all expenses for administrating, supporting, and maintaining a facility, can range anywhere from an additional 50% to 1,000% the direct costs for some surgical procedures.22 If the change in anesthetic drug/practice results in delayed PACU discharges, staffing costs could skyrocket and become much greater than the potential savings from such a change. PACU economics are more affected by the peak number of patients admitted to the unit rather than the choice of anesthetic drugs.23 Thus, if the patient can go directly from the operating room to the phase II recovery unit (fast tracking), there is a potential for significant cost savings.23 Efficient use of the operative room and recovery room time is very important in the overall financial success of a hospital-based ambulatory anesthesia program24 because it has been estimated that 70% of a hospital’s expenses are labor costs.25 The majority of costs in a hospital or operating room are labor-related, so efficient use of staff is essential.26 Thus, when evaluating a change in practice, it is important to account for all of the costs associated with the potential changes that will occur in the functioning of the facility.
Value-based Care and Outpatient Anesthesia
Application of value-based care principles1 to ambulatory anesthesia care should aim to achieve the following goals for ambulatory general anesthesia27 to add value to the health care dollars spent:
- rapid induction without side effects;
- smooth maintenance with good physiologic control and adequate amnesia without excessive depth to prolong awakening and recovery;
- rapid awakening and discharge, with a minimum of post-anesthetic sequelae;
- rapid return to normal activities.
The benefits of anesthetic agents for ambulatory surgery are defined by these recovery goals. We should try to avoid anesthesia-related factors that hinder reaching these goals, which will add up a huge amount of indirect cost on the facility practice in addition to the simple costs of the drugs themselves.
Suitable Anesthetic Drugs and Practices
There are potent anesthetic agents with high degrees of pharmacologic specificity and selectivity. Short-acting anesthetics facilitate earlier postoperative discharges because of the more reliable and early return of preoperative cognitive function. These agents minimize the need for prolonged recovery periods and intensive observation and monitoring, and they also may be associated with a lower incidence of postanesthesia complications.
Propofol has achieved widespread popularity as an induction agent for ambulatory anesthesia for three main reasons: the rapid dissipation of its effect; the lower incidence of PONV and the high degree of patient satisfaction, due to the rapid return to a preoperative mental state; and minimal side effects. Other intravenous induction agents have limited acceptability for ambulatory anesthesia. Induction of anesthesia in children for ambulatory procedures can be best accomplished with inhalational techniques, using sevoflurane or halothane.
In the same-day surgery setting, fentanyl is the most commonly used and the least expensive opioid. Unfortunately, the duration of fentanyl-induced nausea appears to outlast the analgesia. Fentanyl-induced PONV is dose-related and is more resistant to antiemetic treatment. It is, therefore, important to limit the perioperative dose of fentanyl, especially in patients with higher risk of PONV. The use of sufentanil in ambulatory anesthesia is limited by its relatively high acquisition cost. Alfentanil, a short-acting fentanyl analog, also exhibits the typical opioid side effects including PONV. Remifentanil is an ultrashort-acting opioid that can be highly useful for ambulatory anesthesia when used appropriately.28 Remifentanil does cause PONV, but it is of shorter duration.28 With intraoperative sole remifentanil analgesia, it is important to ensure adequate postoperative analgesia, by local or regional blocks, or by using longer-acting analgesics. Remifentanil, with its kinetic and cost advantages, may well replace alfentanil as the opioid infusion for maintenance of ambulatory procedures.
The development of total intravenous anesthesia (TIVA) and newer agents greatly have increased the ease and safety of ambulatory anesthesia and significantly reduced costs, especially because of faster patient recovery. Infusions of hypnotics (propofol or midazolam) can be combined with infusions of short-duration opioids (alfentanil or remifentanil) for TIVA. Propofol and remifentanil appear to be better choices for the hypnotic and opioid components of TIVA respectively for ambulatory anesthesia, as both agents do not delay patient recovery and reduce costs of PACU time.
The use of propofol and remifentanil may increase the cost of the individual anesthetic, but may have indirect cost savings based on rapid emergence, rapid turnover, and decreased time to discharge.29,30
Low-flow desflurane, with its cost advantage, is particularly useful for the anesthetic maintenance of longer ambulatory procedures. Advantages of sevoflurane are its lack of airway pungency, rapid induction, and smooth maintenance of anesthesia. Sevoflurane and desflurane provide faster recovery and lower incidence of nausea than isoflurane.31 Desflurane is more expensive than isoflurane at 3 L per min of fresh gas flow (FGF), but when FGF is decreased to 1 L per min, desflurane costs become comparable.20 N2O reduces the amount of potent inhalant needed to provide anesthesia and is the least expensive inhaled anesthetic, and, therefore, its use greatly reduces the cost of inhalant anesthesia at any FGF. Another factor that influences the choice to include or exclude N2O is its possible role in PONV.32
Succinylcholine still remains a good relaxant for intubation during ambulatory procedures because of its rapid, predictable action and its lower costs. Its drawbacks include the side effect of particular concern for ambulatory surgery patients: the postoperative myalgia. The advantage of mivacurium, a nondepolarizing muscle relaxant (NDMR), with its duration of action corresponding to the length of many ambulatory procedures, is that the routine use of neuromuscular reversal agents is not necessary, and this may reduce the potential for neostigmine-associated PONV. Differences appear to be small among the intermediate-duration NDMR for ambulatory procedures. The use of long-acting NDMR such as pancuronium should be limited to lengthier procedures only.
Regional anesthesia is enjoying increased popularity for ambulatory surgery because of its advantages over general anesthesia (GA), which include superior postoperative analgesia, minimal PONV, and attenuation of the surgical stress response.33 Of particular importance is the ability of regional anesthesia to provide a predictable intra- and postoperative course, thus facilitating a smooth recovery with anticipated early discharge. This is in contrast to the use of GA, with its associated risks of delayed discharges and unplanned admissions due to complications (particularly PONV, pain, and drowsiness).
A comparative study of interscalene block vs. GA for ambulatory shoulder arthroscopic surgery showed that 8% of the patients receiving GA required unanticipated admission vs. none of the patients receiving interscalene block.34
Cost constraints are encouraging the performance of an increasing number of intrusive procedures on an ambulatory basis. Multimodal pain treatment regimens, including local anesthetics, have made possible procedures previously associated with moderate postoperative pain to be satisfactorily performed on an ambulatory basis. In one study, which evaluated multimodal pain treatment that included femoral nerve block for outpatient endoscopic anterior cruciate ligament (ACL) reconstruction, there were no unanticipated admissions or emergency department visits for pain management.35 In another study, following outpatient knee surgery, regional anesthesia provided an earlier recovery than recovery after GA,36 which confirmed the cost-saving potential of regional anesthesia. The number of unanticipated hospital admissions also was less in the regional anesthesia group (1.2%) than in the GA group (2.9%).36,37 These advantages were attributed to the lack of PONV and pain associated with regional anesthesia.
Postoperative pain management is best initiated intraoperatively. Infiltration of the operative site with local anesthesia prior to incision is likely to make postoperative pain easier to control.38 The use of a long-acting local anesthetic such as bupivacaine or ropivacaine can provide analgesia for many hours after discharge. Alternatively, regional anesthesia alone or used adjunctively can control postoperative pain. The intraoperative administration of intramuscular ketorolac, a nonsteroidal anti-inflammatory drug, has an opioid-sparing effect and provides moderate analgesia for two to six hours following administration. For a patient to be eligible for an early discharge, postoperative pain must be well controlled. A case-control study of unanticipated hospital admissions following ambulatory surgery identified pain as one of the most common reasons for unplanned admission (18%).11 Young males, American Society of Anesthesiologists (ASA) Physical Status-1 patients, and patients with a high body mass index were most likely to experience severe pain.39 Certain types of surgery (inguinal herniorrhaphy, orthopedic surgery, hand surgery, and varicose vein surgery) were more likely to experience moderate to severe pain.40 These patients with potential for severe pain should be particularly aggressively managed to avoid unanticipated admissions.
PONV has been described by patients as more debilitating than pain after surgery.41 Patients incurring PONV have longer PACU stays, and this might be the most important determinant of prolonged PACU stay.42 Comparative studies of regional vs. GA have shown significantly decreased incidences of PONV in patients receiving regional anesthesia.43 It is very important clinically and economically to aggressively manage PONV and pain to improve true outcomes and value of care.32,44
Regional anesthesia, GA, and postoperative narcotic analgesia may result in urinary retention. Mandating voiding before discharge routinely creates unnecessarily longer and expensive PACU stays. Only in selected high-risk groups (such as urinary surgery patients) is voiding before the discharge recommended.45
Although central neuraxial blocks are easy to perform, drawbacks such as unpredictable offset, possible urinary retention, and (if opioid adjuvants are used) PONV, and pruritus may occur, all of which may prolong PACU stay and increase cost. Recently, the need for rapid offset of effect has rekindled interest in ambulatory spinal anesthesia. Comparative studies of spinal and GA have dispelled the myth that spinal anesthesia decreases OR efficiency.46 When central neuraxial techniques are needed (pelvic or perineal surgery), combinations of agents are used to allow the lowest possible effective dose of local anesthetic (e.g., ropivacaine 5 mg in 5% dextrose plus fentanyl 20 mcg intrathecally for perirectal surgery) in hope of providing early postoperative ambulation and discharge. Novel manipulation of baricity and dose has resulted in significant reduction of unwanted motor block using conventional spinal anesthesia.47 Lumbar plexus, sciatic, paravertebral,48 and popliteal blocks are ambulatory procedure-friendly blocks with superior postoperative analgesia and a lower incidence of PONV. All nerve blocks need to be performed in a monitored holding area to enhance block success, patient satisfaction, and OR efficiency (by eliminating the need for the induction time of GA). When time actually spent in the OR corresponds closely to surgical time, OR efficiency is increased and OR utilization is maximized. The accelerated recovery and fast-track eligibility afforded by the proper use of regional techniques markedly shorten PACU stays.
Identification of specific patient groups that are susceptible to major complications in an ambulatory setup is important to avoid longer PACU stays and unplanned admissions, which increase the cost dramatically and adversely affect the quality/value of care. Patients in an unhealthy preoperative state, sleep apnea, a concomitant major procedure, or an inappropriate social environment for postoperative care have been identified as high-risk patients for unanticipated admissions following outpatient tonsil and adenoid surgery.49 Other high-risk conditions for unanticipated admissions following ambulatory tonsillectomy and adenoidectomy include morbid obesity, sleep apnea, pickwickian syndrome, airway compromise, congenital heart disease, previous anesthesia complication, and mental retardation.50 Factors associated with an increased risk for ambulatory surgery should be managed with proper anticipation and planning.45,51
Cost and convenience are driving the growth and success of ambulatory surgery. Anesthesiologists must assume responsibility for quality, patient safety issues, and continue to demonstrate high-quality outcomes even when resource consumption is constrained. We need to modify our practices and assume greater responsibility and flexibility to add more value to our practice. As practitioners, it is our primary responsibility to ensure that each patient’s values and preferences are considered in the clinical decision making, as it is our important duty to provide the best possible care for our patients.52,53
References
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CE/CME Objectives
After participating in this CE/CME activity, the participant will be able to:
• define value-based care;
• list the common complication(s) following same-day surgery that affect the quality/value of anesthetic care the most;
• list ways to improve value of care for same day surgery;
• be able to identify which item costs more in perioperative health care delivery.
CE/CME Questions
1. What is value-based care?
A. Health care that improves the quality of care
B. Health care delivery that reduces the cost of care
C. The best patient outcome achieved at a reasonable cost
D. All of the above
2. What is the common postoperative complication following same-day surgery that affects the quality/value of anesthetic care the most?
A. Urinary retention
B. Vomiting
C. Headache
D. Drowsiness
3. Ways to improve value of care for same-day surgery include all of the following, except:
A. avoidance of expensive medications.
B. better preoperative planning and proper patient selection.
C. efficient use of operating room.
D. fast tracking.
4. Which of the following costs more in perioperative health care delivery?
A. Direct drug costs
B. Labor costs
C. Equipment costs
D. General endotracheal anesthesia
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