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@EMARIANOMD
Pain Medicine and the Pathway to Better
Surgical Care
Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System
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Financial Disclosures
None currently. Past (>1 year): Halyard Health, B Braun –
unrestricted educational program funding paid to my institution
The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.
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Health Care Is Changing
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Focus on the Facts
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Kurtz S, et al. JBJS 2007 Apr;89(4):780
FACT: Arthroplasties Are Increasing
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Kurtz S, et al. JBJS 2007 Apr;89(4):780
FACT: Arthroplasties Are Increasing
Now Over 1,000,000 THA and TKA Cases Annually
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FACT: “The Triple Aim”
Berwick et al., Health Aff (Millwood) 2008;27:759Vetter et al., Anesth Analg 2014;118(5):1131
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FACT: “Precision” Medicine
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FACT: The Opioid Epidemic
https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0
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FACT: MACRA Passed in 2015
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FACT: MIPS Started in 2017
https://qpp.cms.gov/
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FACT: The Newest Subspecialty
X
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Overview
Defining the Perioperative Surgical Home
The role of pain medicine
Thinking beyond blocks
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Overview
Defining the Perioperative Surgical Home
The role of pain medicine
Thinking beyond blocks
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Perioperative Surgical Home (PSH)
“a patient-centered, physician anesthesiologist-led, multidisciplinary team-
based practice model that coordinates surgical patient care throughout the
continuum from the decision to pursue surgery through convalescence.
Mariano, et al. A&A 2015;120:1163Kain, et al. A&A 2014;118:1126
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Perioperative Surgical Home
Anesthesiology 2015;123:A23
We started in 2010!
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Perioperative Surgical Home
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How Do I Think of PSH?
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Overview
Defining the Perioperative Surgical Home
The role of pain medicine
Thinking beyond blocks
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Prospective study comparing opioid-naïve, low and high opioid cohorts for TKA
Perioperative multimodal analgesia
Aasvang & Kehlet, et al. Acta Anaes Scand 2016;60:529
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Elements of Pain Medicine in PSH
PSH: Comprehensive Literature Review, www.asahq.org/psh
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Mariano, Walters, Kim, Kain. A&A 2015;120:1163Walters, Mariano, Clark. Pain Med 2015;16:1666.
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Patient Experience
Patients are surveyed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)1
32 questions
Publicly reported 4 times a year2
HCAHPS is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge
1. http://www.hcahpsonline.org2. http://www.hospitalcompare.hhs.gov
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HCAHPS Questions on Pain
Mariano, et al. Adv Anesthesia 2013;31:119
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“Unlike current questions, which ask about the efficacy of pain treatment, the new set will focus on the communication between doctor and patient about pain.”
http://www.nytimes.com/2016/08/05/health/pain-treatment-hospitals-emergency-rooms-surveys.html?_r=0
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Overview
Defining the Perioperative Surgical Home
The role of pain medicine
Thinking beyond blocks
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Develop Patient Care Pathways
Hebl JR, et al. JBJS 2005;87 Suppl 2:63
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Remember Multimodal Analgesia
Anesthesiology 2012;116:248
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Continuously Improve
Mudumbai & Mariano, et al. Healthcare 2016;4:334
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Avoid “Never” Events
Federal Register May 3, 2007
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Anesth Clinics 2014;32:853
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Prevent Persistent Pain
Lavand’homme, et al. CORR 2014;472:1409
TKA Patients
Normal
Persistent Pain
Neuropathic Pain
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Primary Care
Conservative mgmtfailed
Surgery considered as treatment option
Preop Consult
Initiated by primary care
E-consult or phone consult to anesthesiology
Alternative treatments considered
Establish common preop“ready” criteria:
http://www.becertain.org/strong_for_surgery/hospitals
Referral to Surgeon
Patient evaluated
Images/tests reviewed
Decision Made to Proceed with
Surgery
Preop Visit
Review protocols and instructions
Focus on education and preview of OR experience
Day of Surgery
Surgery proceeds as scheduled; or
surgery is cancelled
Rethink Preop Preparation
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Deliver Highly Reliable Care
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2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016
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Be Change Agents
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Helpful Resources
https://www.asahq.org/psh
https://www.asra.com/pain-resource/category/27/practice-management
https://www.asahq.org/quality-and-practice-management/macra/macra-modules
https://qpp.cms.gov/