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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/