Perioperative Quality Improvement: Opportunities and Challenges for Pragmatic Trial Designs

See Article, page 517 In this issue of Anesthesia (2) the waiver will not adversely affect the rights and welfare of the subjects; (3) the research could not practicably be performed without the waiver; and (4) the subjects will be provided with additional pertinent information after participation, if appropriate. 9 When approached from a cost-effectiveness perspective, perioperative care can be delivered in a high-value, low-value, or no-value format. High-value care means reducing costs while improving outcomes, increasing costs modestly for improved outcomes, or decreasing costs with acceptable declines in clinical outcome. Low-value care means higher costs with only small improvement in outcomes, or lower costs with substantial deterioration of outcomes. Finally, no-value care harms patients. 10 Accordingly, quality improvement projects should be designed and then proven to increase high-value care. The integration of local perioperative quality improvement into multi-institutional collaboratives may further provide an opportunity for cost savings. In a recent retrospective observational study comparing eight hospitals participating in the Anesthesiology Performance Improvement and Reporting Exchange Collaborative Quality Initiative with eight matched, nonparticipating hospitals, researchers observed a significant 719 reduction in total episode payments for major high-volume surgical procedures in the participating hospitals. 11 Determined value from these projects is not just cost, although that is certainly the easiest to measure. A health care system looks at the opportunity for standardization with increased quality, decreased cost, reduced adverse events, and improved workflow and work stress of their care teams. Each of these measures has both a cost and a reputational benefit. 12, 13 In addition to leveraging a multicenter approach to assist in benchmarking and learning from other clinicians and health care systems, applying pragmatic design approaches, advanced analytic solutions to existing data, and assessments of costs can be key to increase the positive impact of perioperative quality improvement efforts in the future. DISCLOSURES Name: Karsten Bartels, MD, PhD, MBA. Contribution: This author helped write and revise the article. Name: Joanne M. Conroy, MD. Contribution: This author helped write and revise the article. Name: Tong J. Gan, MD, MBA, MHS. Contribution: This author helped write and revise the article. This manuscript was handled by: Thomas R. Vetter, MD, MPH, MFA.