The Evolution and Impact of Ambulatory Anesthesia

By Kris Ellis

As ambulatory surgery centers (ASCs) seek to expand on the scope of their procedures and increase the quality of care that they provide, anesthesia practices play a significant role. Additionally, the push for patient-centric care and performance measures will increasingly affect the ways in which ASCs and anesthesiologists approach patient selection, sedation, pain management, and postoperative recovery.

As ASCs identify more and more procedures that can be done on an ambulatory basis, they must evaluate whether principles are applicable to all patients, or only some, according to Lee A. Fleisher, MD, the Robert Dunning Dripps professor and chair of the Department of Anesthesiology and Critical Care at the University of Pennsylvania School of Medicine. “For a surgery center, one of the questions is, to some extent, what rate of admission is or is not acceptable,” he says. Many hospital-based units have continued to push the envelope with an accepted three percent or four percent rate of admission due to the fact that admission from the hospital outpatient department is a relatively simple process, Fleisher notes. For an ASC, however, it may mean having to send the patient to the hospital in an ambulance, a comparatively complicated and expensive proposition.

“One of the issues as we go forward is that many procedures are minimally invasive, and therefore the equipment may be appropriate in the ASC, but the patients themselves may not be appropriate for the ASC,” Fleisher says. “The question becomes, as we get more and more minimally invasive in some procedures, what type of burden are we transferring to the families as opposed to the hospital when we send them home early?”

Another prominent topic is defining measures of quality in the ASC environment, according to Fleisher. The historical tendency of Medicare and other payors has been to allow more and more procedures to be performed in the ambulatory setting as long as they are proven safe. This issue can become more complicated depending on the procedure, however. “For example, take hemorrhoids,” says Fleisher. “There’s a big difference between a small hemorrhoid done in an office vs. something done in an ASC vs. something done in a hospital. Not all surgeries are the same, even if they have the same name.”

The rate of any kind of catastrophic outcomes, i.e., death, in an ASC environment is at a number of about 1 in 50,000, Fleisher says, which does not make this a good quality indicator. “In an ASC that does 10,000 cases per year, that’s once in five years. You’re just not going to have enough mortality to use that as a measure. If two people die in one year, somebody is going to say, ‘what’s going on?’ but that’s very rare.”

This leaves more questions as far as suitable quality measures. “Is it readmission rate? Well, it all depends on your philosophy, or direct admission rate,” Fleisher continues. “I actually think if you send a patient home and he or she comes back, that’s not ideal. But if you decide to directly admit them to the PACU, for example maybe you’ve decided to do laparoscopic gallbladder surgery at your ASC and you accept the two, three, four percent rate because that’s just built into the system. Then, the question becomes, is it readmission to the ER? Is it patient satisfaction? These are all questions to determine how far we should go — how much will someone accept having complications of health, and how do we track them?”

Factors such as obstructive sleep apnea are prominent considerations for ASCs, particularly with regard to anesthesia. “Is it OK to do somebody with sleep apnea, cardiovascular disease, or pulmonary disease, or are there age limits?” Fleisher questions. “We found, for example, that at 65 you’re OK. At 75, you can be a young or an old 75-year-old, but once you hit about 85, physiologically, you’re old.” In evaluating extremes of age, Fleisher notes that it is important to decide whether or not it is appropriate to send a patient home following surgery. For example, does the patient have the support necessary at home to act quickly enough in seeking care for any potential postoperative complications?

A 2004 study explored inpatient hospital admission and death rates following outpatient surgery in elderly patients (older than 65) at different outpatient care locations, including hospital-based outpatient centers, freestanding ASCs, and physicians’ office facilities.1 Rate of death, emergency department risk, and admission to an inpatient hospital within seven days of surgery were evaluated. Of the 564,267 outpatient surgical procedures considered, 28,199 were performed at a physician’s office, 175,288 at an ASC, and 360,780 at an outpatient hospital. No deaths were reported on the day of surgery at a physician’s office, four deaths the day of surgery at an ASC (a rate of 2.3 per 100,000 outpatient procedures), and nine deaths on the day of surgery were found at an outpatient hospital (2.5 per 100,000 outpatient procedures).

The rate of admission to an inpatient hospital within seven days following outpatient surgery was 9.08 per 1,000 outpatient procedures at a physician’s office, 8.41 per 1,000 outpatient procedures at an ASC, and 21 per 1,000 outpatient procedures at an outpatient hospital. More advanced age, prior inpatient hospital admission within six months, surgical performance at a physician’s office or outpatient hospital, and invasiveness of surgery were factors that identified patients who were at increased risk of inpatient hospital admission or death within seven days of surgery.

The presence of co-morbidities is always a vital consideration as well. “I feel strongly that preoperative evaluation is in fact more important in the ambulatory surgery world than it is in the hospital world,” Fleisher notes. “And then how do we keep extending the procedures? Is it good enough to do a series of test patients and determine that they all did well? How do we keep asking the question, ‘is it appropriate?’” Fleisher will explore these types of questions during his presentation at the Society for Ambulatory Anesthesia (SAMBA)’s 21st annual meeting in Washington, D.C.

Pay for Performance

Pay-for-performance, or P4P, is a Medicare initiative that is designed to encourage improved quality of care in all healthcare settings where Medicare beneficiaries receive their services. According to the Centers for Medicare and Medicaid Services (CMS), the foundation of effective pay-for-performance initiatives is “collaboration with providers and other stakeholders to ensure that valid quality measures are used, that providers aren’t being pulled in conflicting directions, and that providers have support for achieving actual improvement.”²

CMS is collaborating with a number of other public agencies and private organizations to develop and implement these initiatives, including the National Quality Forum (NQF), the Joint Commission of the Accreditation of Health Care Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), the Agency for Health Care Research and Quality (AHRQ), and the American Medical Association (AMA), among others.

“The ambulatory area is one that is ripe for all sorts of pay-for-performance measures,” says Karin Bierstein, JD, MPH, associate director of professional affairs for the American Society of Anesthesiologists. Although there are very few that are applicable to anesthesiologists thus far, Bierstein suggests they may be able to use pay-for-performance to their advantage in the future. She will offer ideas about why this idea matters and the directions in which it might go in her presentation at the SAMBA’s annual meeting.

“In primary care, people are reporting on and are being rewarded for things like managing hemoglobin A1c in diabetics,” Bierstein says. “In surgery there is very little, although there are a number of measures in the Medicare physician demonstration project the Physician Voluntary Reporting Program (PVRP), including one for anesthesia, but it’s not likely to be very useful in the ambulatory setting since it’s for cardiac patients, by and large.” Participation in the PVRP, which launched in January 2006, is voluntary; physicians who elect to participate will help capture data about the quality of care provided to Medicare beneficiaries. They will also be provided with feedback on their reporting and performance rates. No financial incentives are being offered to participate in this program; it is described as an interim step in the development of a P4P program that will utilize evidence-based quality measures and will financially reward quality.

“The interesting thing for anesthesiologists is that a lot of what they contribute to improved outcomes and to the whole ambulatory surgical care package is a variety of efficiency and safety measures,” Bierstein continues. “What they do we’re not going to measure on the difference between life and death, because deaths are so exceptional. Otherwise, as we’ve seen from the American Association of Ambulatory Surgery Centers (AAASC) outcome measures, patient satisfaction is high no matter what in ASCs — there’s not a lot of margin there to perfect it. It’s getting out quickly, without nausea and vomiting, and barely having noticed that you had anesthesia, as well as having your concerns about anesthesia dealt with effectively. That’s what matters to patients. Additionally, anesthesiologists are often medical directors in facilities and have responsibilities far beyond those of providing a safe anesthetic.”

Bierstein says she would like to see some performance measures beginning to be built into third party contracts. “I know that they’re built into more and more facility contracts; this is something that’s a benefit to the facility in particular, and other providers also participate in the process, so it’s really going to be, to a considerable extent initially, dividing or allocating the increased revenue or some other measure of the revenue among those who have made it happen for the ASC. So many people are involved with the patient going through the surgical process; there are a lot of things that are not easily or clearly attributable to one individual provider at the front of this.”

Bierstein points out that a looming issue for anesthesiology as well as other specialties is how to report once metrics have been identified. “The Medicare project at the moment is trying to figure out a way to use certain CPT codes to report quality, which is very nice and simple and doesn’t really require any additional time on the part of the physician or billing staff, but the codes aren’t really designed for that,” she says. “The category II CPT codes, which are performance measure codes, are few in number so far. So CMS is still running that project, but there are a number of parties who believe that you’re not going to get anything other than information out of the medical records themselves. Figuring out a way to afford the abstraction of charts is an area where there’s a lot of money to be made.”

The Surgical Care Improvement Project (SCIP) is a Medicare-sponsored partnership of organizations seeking to improve surgical care by reducing surgical complications. Areas of focus include surgical site infections, adverse cardiac events, deep vein thrombosis, and postoperative pneumonia. Process variables such as prophylactic antibiotics, beta blockers, and blood glucose control have been identified by the project. “Right now it’s a report card, but it will turn into a payment system, and that’s clearly coming down the pike,” Fleisher, who is a member of the SCIP committee, explains. “For ambulatory surgery, no one is really sure what those process variables are — how important are antibiotics for surgery done on an outpatient basis? Also, myocardial infarctions (MIs) are very rare. What we’ll need to do as we keep pushing the envelope is figure out what we should measure. Nobody truly knows yet. We need to develop unique measures of ASC quality.”

Postoperative Complications

Nausea, pain, and other symptoms that may arise following surgery are a concern for ASCs, although in a different way than for hospitals. “Given the nature of the patients and the procedures in the hospital setting, people are still worried about having complications after surgery, especially involving the heart, lungs, and kidneys,” Fleisher says. “In ASCs, given the nature and the type of procedures, that’s not really the question, and I think some of the things you may see more of are catheters, preemptive analgesia, different pharmacologic means of preventing nausea, vomiting, and pain, and I think that will be a new frontier.

“One of the things that will be relevant in all this is the patient’s perspective, and I think we’ve tended to not take that into account,” Fleisher continues. “It may be different for each patient, so one of the things that I think will be interesting in the future is the possible trade-off between the various symptoms that you might get after surgery. My hope is that the specialty would actually approach it from the standpoint of tailoring it to patient desires rather than just the general approach.”

One study explored patient-reported symptoms following discharge from the post-anesthesia care unit (PACU) after outpatient surgery.³ This review discovered an overall incidence of post-discharge symptoms at 45 percent for pain, 17 percent for nausea, 8 percent for vomiting, 17 percent for nonspecific headaches, 42 percent for drowsiness, 18 percent for dizziness, and 21 percent for fatigue. The incidence of moderate to severe post-discharge pain was found to be approximately 25 percent to 35 percent. Of the patients who reported post-discharge nausea and vomiting, 36 percent did not experience either before being discharged. The study asserts that the presence of post-discharge symptoms could be incorporated into quality of care measures for outpatient surgery.

References

1. Fleisher LA, et al. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg. 2004 Jan;139(1):67-7

2. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1343

3. Wu CL, Berenholtz SM, Pronovost PJ, Fleisher LA. Systematic review and analysis of post-discharge symptoms after outpatient surgery. Anesthesiology. 2002 Apr;96(4):994-1003. Review.

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