Collaborative Decision Making and Perioperative Risk

Transcription

1 Collaborative Decision Making and Perioperative Risk Angela M Bader MD MPH Professor of Anaesthesia Harvard Medical School Vice Chair, Department of Anesthesiology, Pain and Perioperative Medicine,

2 No relevant disclosures.

3 Center for Surgery and Public Health at BWH SHARPP Research Group Drs. Zara Cooper and Angela Bader Collaboration between the Department of Surgery at Brigham and Women s Hospital, Harvard Medical School, and Harvard School of Public Health Research focused on SDM, appropriateness of care, and patient centered outcomes in geriatric, seriously ill, and terminally ill surgical patients

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5 Data on Surgical Shared Decision Making Available data is limited: Addresses only a few specific procedures Small sample sizes Inadequate scope to elucidate etiology of deficits in decision making

6 A Methodological Approach to Defining Appropriate Care Proposed Definition of Appropriate Care: Expected benefits outweigh the risks with sufficient margin to make the procedure worth doing despite the cost Patient has full understanding of risks/benefits and there is concordance between patient preferences and values and surgeon goals

7 Purpose: to provide a methodological approach to define and improve appropriateness of surgical care; with emphasis on high quality shared decision making RIGHT OPERATION The procedure is the best treatment for the disease Clinical Evidence RIGHT PATIENT The decision reflects the individual patient s Value and preferences High Quality Decision Certification, Privileging RIGHT PROVIDER The surgeon selected has the requisite skills to perform the procedure safely COE, Joint Commission RIGHT PLACE The healthcare facility chosen has all necessary resources Cooper, Sayal, Abbott, Neuman, Rickerson, Bader Anesthesiology, December 2015

8 Perspective: NEJM Redesigning Surgical Decision Making for High-Risk Patients Laurent G. Glance, M.D., Turner M. Osler, M.D., and Mark D. Neuman, M.D. N Engl J Med 2014; 370: Shared decision making incorporating patient preferences values and goals needs to be incorporated into pathways. Ensuring this particularly for high risk patients may require innovative interventions in a multidisciplinary framework of coordination; not done on an ad hoc basis

9 QUALITY METRIC: HEALTH CARE TRAJECTORIES

10 Shared Decision Making and the Triple Aim

11 HOSPITAL/PHYSICIAN RLATIONS/FORBES Managing the shift from volume to value Hospitals must be proactive, not reactive, in driving quality Joe Burns All the talk about moving healthcare reimbursement from volume to value sounds great, in theory. But how this shift takes place in practice is more complex than simply ending one form of payment and starting a new one.

12 Value =Quality/cost Vetter TR, Jones KA Anesth Clin 2015

13 DEFINING QUALITY METRICS THAT CAN SERVE AS RESEARCH OUTCOMES Traditional surgical and anesthesia outcomes (eg 30 day morbidity and mortality, giving antibiotics within 60 minutes of incision) do not equal patient centered outcomes. We often use process metrics and other metrics because they are easy to measure. What is the impact on health trajectory and patient centered outcomes?

14 Why is SDM/Appropriateness Important for Payment?

15 Shared Decision Making Our value in improving shared decision making and decreasing inappropriate surgery can be reflected in negotiations for payment models like bundles and ACO s We can help target hospital resources: (ensure high quality SDM, develop and implement specific high value perioperative pathways)

16 Are there criteria other than clinical indications in surgical decision making? Regional Variation in End of Life Surgical Care The intensity and variation of surgical care at the end of life: a retrospective cohort study Alvin C Kwok, Marcus E Semel, Stuart R Lipsitz, Angela M Bader, Amber E Barnato, Atul A Gawande, Ashish K Jha Lancet 2011; 378: Findings: The likelihood of receiving surgery at the end of life varied substantially by patient age and region Nearly 1/3 of elderly Americans had a surgical intervention during the last year of life Regions with high surgical intensity in patients in the last year of life have high (not low) death rates

17 Signed surgical informed consent does not equal high quality shared decision making.

18 Current research has identified patterns of deficiencies in shared decision making. Measuring Deficiencies in Shared Decision Making in Advanced Care Planning and Surgery Ankuda, C; Correll, DJ; Hepner, D; Cooper, Z; Block, S; Lasic M; Gawande, A; Bader, AM Patient Ed Couns: 2014 Methods: 1000 patients surveyed in the preoperative clinic after visit with surgeon and procedure scheduled; used factor analysis to identify patterns of deficiencies in shared decision making 50% patients scheduled for post operative ICU were not aware of this 50% of patients scheduled for post operative ICU had no advanced care directives 10% patients were conflicted about the decision to have a procedure; this correlated with physiciandirected decision making 10% patients incorrectly identified their scheduled procedure Of note, patients who were non white, non English speaking, and had lower levels of education were high risk groups for deficient shared decision making

19 Surgical Episode Pause Points Surgical Home Concept Referral from self, PCP, to surgeon Surgical office visit, Decision for surgery Informed consent signed Preop clinic visit Readiness for surgery Operation Post-Discharge

20 Ensuring High Quality Shared Decision Making: Identifying Groups at Risk Generating A Set of Basic Set of Appropriateness Triggers in the Preoperative Clinic Chan B, Arriaga A, Hassan S, Kidik, P, Silver, J, Hepner, D, Bader AM Objective: Can we use preoperative clinic data and literature review to generate a set of easily identifiable triggers associated with a increased likelihood of inappropriate care due to deficiencies in shared decision making? If so, can these be moved upstream in the surgical episode to generate discussion to improve quality of shared decision making? Disparities (language, socioeconomic class) Frailty Geriatric patients; particularly those with cognitive issues (current project) Inability to walk independently Living in assisted living facility Patients in the last year of life

21 Research area: Preoperative Cognitive Deficits

22 Vulnerable Group: Geriatric Patients Ironically, the brain, which is arguably the organ of greatest importance for informed decision-making, is often not formally evaluated preoperative Guidelines published by the American College of Surgeons and the American Geriatrics Society recommend preoperative cognitive assessment with a screening tool such as the MiniCog. The ASA has recently started a Brain Health Initiative. Most preoperative evaluations do not include routine cognitive evaluation and triage to pathways based on assessment results

23 Prevalence of Undiagnosed Cognitive Defects in a Preoperative Surgical Population METHODS: Geriatric patients were evaluated with the Minicog/Clock in the Box to determine the presence of undiagnosed cognitive dysfunction, evaluations were done by a trained research assistant. RESULTS: The age of consenting patients was 73.7 ± 6.4 (mean ± SD) years. Overall, 23% of patients met criteria for undiagnosed probable cognitive impairment. CONCLUSIONS: Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population. (Anesth Analg 2016;123:186 92) This work was supported by a grant from the Anesthesia Patient Safety Foundation and The Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Women s Hospital, Boston, MA

24 INCIDENCE OF UNDIAGNOSED COGNITIVE IMPAIRTMENT IN PATIENTS OVER AGE 65 PRESENTING FOR AN ELECTIVE SURGICAL PROCEDURE (OVERALL 29%) 80 % Patients This work was supported by a grant from the Anesthesia Patient Safety Foundation and The Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Women s Hospital, Boston, MA

25 INCIDENCE IS HIGHER IN THOSE OVER AGE 75(40%) THAN THOSE (24%) 100 % Patients This work was supported by a grant from the Anesthesia Patient Safety Foundation and The Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Women s Hospital, Boston, MA

26 Vulnerable Group: Geriatric Patients Can we implement routine cognitive testing during preoperative assessment? Are the results of stratification related to outcomes? How can we implement high value geriatric preoptimization targeting resources to those at highest risk to impact quality outcomes? Can we incorporate high quality shared decision making into these pathways?

27 RESULTS HealthStream Video Training & Assessment: Cognitive Screening in Older Surgical Patients

28 Sustainable Preoperative Cognitive Screening Brief video training program with on line quiz Measured percent of undiagnosed cognitive stratification No significant impact on visit length Results similar to those from previous research assistant performed study, validation and inter-rater reliability was very good.

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32 Vulnerable Group: Geriatric Patients Can we implement routine cognitive testing during preoperative assessment? Are the results of stratification related to outcomes? Does preop cognitive screening matter?? How can we implement high value geriatric preoptimization targeting resources to those at highest risk to impact quality outcomes? How does cognitive stratification impact preoperative SDM?

33 Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients Anesthesiology. 2017;127(5): doi: /aln A substantial (one fourth to nearly half) portion of elective surgical patients 65 yr or older without dementia have cognitive impairment at baseline before surgery It is unknown whether routine preoperative cognitive screening can identify patients at risk for an adverse postoperative outcome after common and elective surgical procedures Date of download: 11/29/2017 Copyright 2017 American Society of Anesthesiologists. All rights reserved.

34 From: Preoperative Cognitive Dysfunction: It s More Common Than You Think Anesthes. 2017;127(5):A19. doi: /aln Date of download: 11/29/2017 Copyright 2017 American Society of Anesthesiologists. All rights reserved.

35 Vulnerable Group: Geriatric Patients Can we implement routine cognitive testing during preoperative assessment? Are the results of stratification related to outcomes? Does preop cognitive screening matter?? How can we implement high value geriatric preoptimization targeting resources to those at highest risk to impact quality outcomes? Can we incorporate high quality shared decision making into these pathways?

36 Development of Geriatric Pathway Multidisciplinary input (surgery, nursing, anesthesia, geriatrics) Throughout perioperative care period Financial modeling Clinical, operational, and financial metrics

37 Integrating Geriatric Consults into Routine Care of Older Trauma Patients: One-Year Experience of a Level I Trauma Center Presented at the 96th Annual Meeting of the New England Surgical Society, Newport, RI, September A.OlufajoMD, MPH ab SamirTulebaevMD c HoumanJavedanMD c J onathangatesmd, MBA, FACS a JustinWangBA d MariaDuarteBA a EdwardK ellymd, FACS a ElizabethLilleyMD, MPH b AliSalimMD, FACS ab ZaraCooperMD, MSc, FACS ab

38 BWH PERIOPERATIVE ORTHOPEDIC GERIATRIC PATHWAY Surgeon s Office Visit IDENTIFY PATIENTS >age 80 having ortho procedure >age 70 on >4 meds Known cognitive issues Schedule geriatric consult at time of preop visit Preoperative Clinic Visit PREOP VISIT WITH NP SUPERVISED BY ANESTHESIA ATTENDING Additional patients identified: Concerns during preop or low minicog Visit with geriatrician Perioperative Geriatric Comanagement Goals of care discussion; health care proxy, advanced care directives Identifying frailty, assessing physiologic changes of aging, providing more accurate risk assessment Medicine adjustment periop med recommendations Delerium prevention Comanagement during hospitalization Long Range Planning

39 Integrating Geriatric Consults into Routine Care of Older Trauma Patients: One-Year Experience of a Level I Trauma Center Olubode A Olufajo, MD, MPH, et al J Am Coll Surg 2016 Looking at geriatric trauma patients, integrating geriatric assessment shown to improve advanced care planning and increased multidisciplinary care. 30 day mortality decreased from 11.63% to 6.81%; in hospital mortality decreased from decreased from 9.30% to 5.24%, ACP/HCP also increased- impact on SDM.

40 Potential Measured Outcomes Initial Data Length of Stay- decreased significantly Delirium Rates- decreased significantly 30 day readmission In hospital vs. 30 day mortality Discharge to post-acute care facility vs home- significant increase in patients going home instead of to a facility 1 year mortality ADL at 1 month and 6 months after surgery MOCA/MiniCog serially Financial analysis

41 Duke s POSH Initiative Is Rapidly Expanding (Perioperative Senior Health) -A geriatric perioperative screening initiative called the Perioperative Optimization of Senior Health (POSH) developed by Duke is reducing hospital stays and readmissions while increasing discharges to self-care at home following surgery. -Brought together surgical, anesthesia, and hospital care teams -Incorporates thorough assessment (including cognitive and frailty) and high quality SDM METRICS: 1.95-day reduction in length of hospital stay, a 7.08% decrease in hospital readmissions at 7 days, and a 10.53% decrease in hospital readmission decrease at 30 days. The percentage of patients returning to self-care at home was 11.25% higher,

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43 JEPM, Under review

44 Figure 1 Study Flow Diagram Baseline Survey self reported comfort with CSD/GOCD past CSD/GOCD experience Pre Intervention CSD/GOCD OSCE for all participants CSD/GOCD Checklist scored by two trained evaluators Communication proficiency scored by standardized patient Randomization to CONTROL or STUDY group Group A CONTROL (n=25) Anesthesiology CA1 residents Group B STUDY (n=25) Anesthesiology CA1 residents Finalize CSD/GOCD training program Educational Intervention: Online Modules Only Educational Intervention: Online Modules + Self Assessment + Small Group Exercises Post intervention CSD/GOCD OSCE for all participants CSD/GOCD Checklist scored by two trained evaluators Communication proficiency scored by standardized patient CSD/GOCD Skills Feedback Feedback from standardized patients, Individual feedback sessions with faculty members for global review of CSD/GOCD skills Follow up Survey (3 and 6 months) self reported comfort with CSD/GOCD, interim CSD/GOCD experiences, satisfaction with program

45 Improving Completion of ACD/HCP in Patients with ICU Stays after surgery Team Members: Nicholas Sadovnikoff, MD Angela Bader, MD, MPH Caroline Gross, MD Richard Urman, MD, MBA

46 Improving Completion of ACD/HCP in Patients with ICU Stays after surgery Problem: Fewer than 40% of patients at BWH scheduled for highrisk surgery/postoperative ICU care have identified a Health Care Agent (HCA) by the day of surgery Patients may develop complications requiring use of unplanned, often burdensome life-sustaining interventions but had not previously expressed whether these would be consistent with their wishes! Leads to patient/family dissatisfaction, moral distress for providers, substantial expense/resource utilization

47 Solution Patients who are scheduled for postoperative ICU admission watch a short video on a tablet in the waiting area of the preoperative evaluation center. It explains the importance of the documents they will be receiving during their visit (Advance Care Directives Form) Short questionnaire before and after the video Measure the effect of the intervention on rate of: having identified a HCA by day of surgery having had a conversation with that person

48 Study objectives Urman RD, Lilley EJ, Changala M, Lindvall C, Hepner DL, Bader, AM*. High concentration of preoperative DNR orders VGT placement for MBO Retrospective chart review of VGT procedures at 2 academic institutions in Code status: admission, subsequent changes Code status discussions: screen provider notes *Under review

49 Measuring Decisional Quality - Designing SDM metrics- NIH RFP

50 The Challenge We need to be willing to: 1. Engage in research defining appropriateness and shared decision making in surgery, evolve our training in residency and beyond to meet these needs and redefine leadership roles to incorporate these issues top down approach 2. Use this research to validate clinical innovation with qualitative and quantitative research 3. Take on new clinical roles as coordinators and managers of these overall perioperative systems, working to generate high value, integrated, multidisciplinary pathways that incorporate the results of cognitive and shared decision making research 4. Use this research, training and new roles to Focus on VALUE, defined as outcomes that matter to patients over cost