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Sanghvi J, Qian D, Olumuyide E, Mokuolu DC, Keswani A, Morewood GH, Burnett G, Park CH, Gal JS. Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America. Anesth Analg 2024:00000539-990000000-00734. [PMID: 38324349 DOI: 10.1213/ane.0000000000006763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.
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Affiliation(s)
| | | | | | - Deborah C Mokuolu
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aakash Keswani
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gordon H Morewood
- Department of Anesthesiology, Temple University Health System, Philadelphia, Pennsylvania
| | - Garrett Burnett
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chang H Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Matrka AK, Smith HM, Amundson AW, Duncan CM, Rueter MJ, Andrijasevic S, Hannon CP, Couch CG, Sanchez-Sotelo J, Trousdale RT, Abdel MP. Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project - Phase III Outcomes. J Arthroplasty 2022; 38:779-784. [PMID: 36403718 DOI: 10.1016/j.arth.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/27/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Our institution initiated the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies (OASIS) project in 2017 to improve the quality and efficiency for hip and knee arthroplasties. Phase III of this project aimed to: 1) increase same-day discharge (SDD) of primary total joint arthroplasties (TJAs) to 20%; 2) maintain or improve 30-day readmission rates; and 3) realize cost savings and revenue increases. METHODS All primary TJAs performed between 2021 and 2022 represented our study cohort, with those in 2019 (prepandemic) establishing the baseline cohort. A multidisciplinary team met weekly to track project tactics and metrics through the entire episode of care from preoperative surgical visit through 30 days postoperatively. RESULTS The SDD rate increased from 4% at baseline to 37%, with mean lengths of stay (LOS) decreasing from 1.5 to 0.9 days for all primary TJAs. The 30-day readmission rate decreased to 1.2 from 1.3%. Composite changes in surgical volume and cost reductions equaled $5 million. CONCLUSION Application of a multidisciplinary team with health systems engineering tools and methods allowed SDD to increase from 4 to 37% with a mean LOS <1 day, resulting in a $5 million incremental gain in profit at a major academic medical center. Importantly, patient safety was not compromised as 30-day readmission rates remained stable. LEVEL OF EVIDENCE III Therapeutic.
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Affiliation(s)
- Alexis K Matrka
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
| | - Hugh M Smith
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, Minnesota
| | - Adam W Amundson
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, Minnesota
| | - Christopher M Duncan
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, Minnesota
| | - Matthew J Rueter
- Mayo Clinic Practice Optimization and Acceleration, Rochester, Minnesota
| | - Sasa Andrijasevic
- Mayo Clinic Practice Optimization and Acceleration, Rochester, Minnesota
| | - Charles P Hannon
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
| | - Cory G Couch
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
| | | | | | - Matthew P Abdel
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
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Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Diabetes Mellitus Disparities. J Am Acad Orthop Surg 2022; 30:1017-1022. [PMID: 34534181 DOI: 10.5435/jaaos-d-21-00425] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/23/2021] [Indexed: 02/01/2023] Open
Abstract
This is one of a series of articles that focuses on maximizing access to total joint arthroplasty by providing preoperative optimization pathways to all patients to promote the best results and minimize postoperative complications. Because of inequities in health care, an optimization process that is not equipped to support the underserved can potentially worsen disparities in the utilization of arthroplasty. A staggering 10.5% of the American population lives with diabetes mellitus. Diabetes prevalence is 17% higher in rural communities compared with urban communities. Rates of diabetes are higher in African American, Hispanic, and American Indian populations. Barriers to health care are higher in rural areas and for vulnerable communities, positioning the management of diabetes at the intersection of risk. Poor glycemic control is a predictor of periprosthetic joint infection. Optimization tools include assessing for food security, knowledge of a social safety net and community resources, patient diabetic literacy, and relationships with primary care providers to ensure continuous check-ins as well as partnering with specialty endocrine diabetic clinics. Several strategic recommendations, such as healthcare navigators and promotores (Latinx population), are made to enable and empower, such as continuous glucose monitoring, the preoperative patient to reach a safe preoperative optimization goal for their TJA surgery.
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Letter to the Editor: "Same-day discharge to home is feasible and safe in up to seventy five percent of unselected total hip and knee arthroplasty". INTERNATIONAL ORTHOPAEDICS 2022; 46:1669-1670. [PMID: 35511276 DOI: 10.1007/s00264-022-05430-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 10/18/2022]
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Tsang AM, Jagannathan R, Amundson AW, Smith HM, Dankbar EC, Zavaleta KW, Abdel MP, Jacob AK. Defining the Value of Analgesia for Total Knee Arthroplasty Using Time-Driven Activity-Based Costing: A Novel Approach to Clinical Practice Transformation. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1042-1049. [PMID: 34765887 PMCID: PMC8572874 DOI: 10.1016/j.mayocpiqo.2021.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective To compare the relative value of 3 analgesic pathways for total knee arthroplasty (TKA). Patients and Methods Time-driven activity-based costing analyses were performed on 3 common analgesic pathways for patients undergoing TKA: periarticular infiltration (PAI) only, PAI and single-injection adductor canal blockade (SACB), and PAI and continuous adductor canal blockade (CACB). Additionally, adult patients who underwent elective primary TKA from November 1, 2017, to May 1, 2018, were retrospectively identified to analyze analgesic (pain score, opiate use) and hospital outcomes (distance walked, length of stay) after TKA based on analgesic pathway. Results There was no difference in patient demographic characteristics, specifically complexity (American Society of Anesthesiologists score) or preoperative opiate use, between groups. Compared with PAI, total cost (labor and material) was 1.4-times greater for PAI plus SACB and 2.3-times greater for PAI plus CACB. The addition of SACB to PAI resulted in lower average and maximum pain scores and opiate use on the day of operation compared with PAI alone. Average and maximum pain scores and opiate use between SACB and CACB were not significantly different. Walking distance and hospital length of stay were not significantly different between groups. Conclusion Perioperative care teams should consider the cost and relative value of pain management when selecting the optimal analgesic strategy for TKA. Despite slightly higher relative cost, the combination of SACB with PAI may offer short-term analgesic benefit compared with PAI alone, which could enhance its relative value in TKA.
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Affiliation(s)
- Alvin M Tsang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ram Jagannathan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Adam W Amundson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Hugh M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Eugene C Dankbar
- Department of Management Engineering and Consulting, Mayo Clinic, Rochester, MN
| | - Kathryn W Zavaleta
- Department of Management Engineering and Consulting, Mayo Clinic, Rochester, MN
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Amundson AW, Jacob AK, Duncan CM, Tsang AM, Zavaleta KW, Smith HM. Optimizing a Surgical Practice from Start to Finish. Adv Anesth 2021; 39:53-75. [PMID: 34715981 DOI: 10.1016/j.aan.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Adam W Amundson
- Department of Anesthesiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Adam K Jacob
- Department of Anesthesiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Chris M Duncan
- Department of Anesthesiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Alvin M Tsang
- Department of Anesthesiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Kathryn W Zavaleta
- Department of Management Engineering and Consulting, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Hugh M Smith
- Department of Anesthesiology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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