Healthcare around the world is changing. In the United States, healthcare reform has been focused on achieving the “triple aim". This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists that may serve as an integrator to help hospitals achieve the triple aim. PSH is defined as “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.” Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation.

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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 Medicine
Chief, Anesthesiology and Perioperative Care
Veterans 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;27:759
Vetter 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;120:1163
Kain, 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;120:1163
Walters, 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.org
2. 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 mgmt
failed
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/st
rong_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/