Population Health Management and Perioperative Medicine: The Expanding Role of the Anesthesiologist

The principles of population health have recently been introduced to anesthesiologists,1 but the concept remains relatively foreign to most practicing physicians. However, population health is a current area of major interest and increasing emphasis in health care in the United States and other developed Western countries. An online search for “population health management” identifies a large numbers of vendors and information technology platforms advertising their analytic and management systems. The escalating and disproportionate costs of health care in the United States are well recognized, with influential stakeholders arguing that 1 reason for significant international cost differences is the application of population health management in other countries.2 Boudreaux and Vetter1 have previously described the key principles of population health and its perioperative application in a Special Article in Anesthesia & Analgesia in 2016. Population health is defined as “the health outcomes of a group of individuals including the distribution of outcomes within that group.”3 In practice, a defined population is risk-stratified and segmented according to need and utilization, and high risk or rising risk patients are identified. Strategies are then put in place to reduce preventable and costly adverse outcomes from occurring wherever possible. Themes common to most population health management programs include the use of data analytics to segment or stratify a target patient population and to optimize case management of its complex members. Population health is a fundamental component of the Triple Aim4 central to current health policy and redesign, with its pursuit of 3 dimensions of improvement, namely, population outcomes, patient experience, and the per capita cost of care. For anesthesiologists, the population to be managed is patients undergoing or contemplating surgery.1 In this issue of Anesthesia & Analgesia, Aronson et al5,6 discuss why and how they have successfully applied the concepts of population health management and the Triple Aim to their diverse perioperative practice. The concept of value is central to the new health care delivery paradigm. Value improves with increased quality and decreased costs—ideal solutions deliver both parameters, with the value focus clearly on the patient.7,8 The multidisciplinary integrated programs delivering perioperative medicine services, which are described here by Aronson et al,5,6 offer an opportunity to structure and define perioperative management that detects conditions that can be improved, given the time needed to optimize them before surgery. Patient complications can be avoided, and the health care system minimizes length of stay and costs. If patients are first seen when contemplating surgery, they are not given a definitive surgical date until fully prepared. Compromised care resulting from anesthetizing and operating on a patient whose health status could be improved, as well as disruptive, last-minute cancellations, are avoided. The value for the patient increases with improved outcomes and a better experience of care. The focus by the Duke team on the economics of their perioperative enhancement team (POET) and preoperative risk evaluation and optimization (PREOp) program6 is important; for such models to be widely implemented, they must prove their worth in financial terms, and payment models must be appropriate to fund them. The potential is great. In general discussions of population health models, figures quoted are that for the US civilian population: 1% of the population accounts for 22.8% of health care costs, with an annual mean expenditure of approximately $110,000; 5% of the population accounts for about 50% of costs and 10% two-thirds of cost, whereas the healthier 50% of the population accounts for only 2.8% of costs.9 For surgical patients, the actual numbers may vary, but the principle applies: a relatively small and definable cohort of patients consume the vast majority of resources, and indeed we know that for outcomes, a relatively small percentage of surgical patients account for the majority of complications and deaths.10 While not all factors are modifiable for elective surgical patients, identification of the high-risk group has already shown that value improvement can be great, as measured by better outcomes (including mortality),11 efficiency, patient satisfaction, shared decision-making, and team collaboration.12 Use of data analytics, predictive modeling, algorithms, and feedback loops with outcome data will help to ensure the right patients are targeted with the right interventions depending on surgical type. Population health tools can therefore be applied to the high-risk surgical patient, as an individual who falls into the segment of the surgical population requiring active management. To succeed this must be a multidisciplinary approach13; surgeons thus must be fully included and engaged for perioperative population health management to be effective. The opportunity to redesign the way we mange perioperative care has never been greater. The concept of bundled care and alternate payment models8 shifts the onus of cost onto providers to deliver optimal outcomes within a defined, fixed payment. Payors are beginning to better understand the impact of comorbidities on surgical costs and the waste present in the unstructured use and overuse of tests and procedures.14 Employers are beginning to take on risk for their insured populations, and the new models of value-based care payments such as the merit-based incentive payment system and the Medicare access and Children's Health Insurance Program Reauthorization Act bring renewed physician attention to the measurement and management of quality. Models of care which can meet many of these needs, to deliver value for surgical patients, have already been described in detail and go by several names, including the Perioperative Surgical Home,15 Perioperative Medicine,16 and Enhanced Recovery After Surgery.17 The central principle behind these approaches is recognition that care of the patient before, during, and after surgery requires a systematically engineered approach, focused on the patient and involving teamwork, coordination, and collaboration among all disciplines involved in care.18 To demonstrate success and to manage continuous quality improvement, we must become better at defining and measuring the key process and outcome metrics of surgical pathways.12 To make this a reality, these metrics should be embedded in the electronic health record and be easily extractable. Process and outcome metrics should be regularly reviewed to identify areas for improvement, and implementation science tools used to ensure optimal system performance.19 The approach described by the Duke team begins to describe what such a system might look like in practice.5,6 The resources the Duke team has applied to develop its PREOp/POET approach are impressive. Such investment speaks volumes about the recognition by a major academic medical system of the need to improve value by investing in perioperative medicine. However, the costs and complexity of resources required to set up the multiple clinics described Aronson et al5,6 may deter smaller hospitals and group practices. Yet this does not need to be the case. The initial costs to launch POET were absorbed by the Duke Department of Anesthesiology, and even a small department or group practice can use many of the techniques required for actuating perioperative medicine pathways, such as standardization of assessment based on patient and surgical complexity, use of preoperative clinics for high-risk patients, and use of enhanced recovery pathways.10,11,15,17,18 What is most important is the will to change the culture around perioperative care, from siloed specialty and individual practitioner approaches, to a multidisciplinary, patient-focused model that includes primary and community providers. We all have a duty to ensure the patient is as well prepared as possible, physically and mentally, for the impact of the surgical episode. Some simple concepts used and described here in the Duke approach and by others could easily be adopted elsewhere with little cost, including the clear definition of “hard-stop” criteria applied to elective joint replacement patients. The “hard-stop” criteria are modifiable comorbidities and behaviors, such as smoking and not actively engaged in a smoking cessation program and stroke or transient ischemic attack within the last 9 months. These criteria clearly signal to the surgeon, and indeed the primary care practitioner, that the patient should be referred to a PREOp clinic for further management before deemed “ready for surgery.” Clearly establishing these nonnegotiable triggers, and promoting the concept that the contemplation, rather than the declaration of surgery, triggers the evaluation process, will start to change the conversation among all providers about the way patients are managed and prepared for surgery. The POET/PREOp model described by Aronson et al5,6 uses a hub-and-spoke design with a central preoperative service surrounded by other more condition-specific clinics. These clinics provide the opportunity to manage specific patient issues in greater depth. One example is the perioperative optimization for senior health or “POSH” model for seniors. The recognition that older patients are a high-volume, high-risk segment of the surgical population and deserve holistic management of issues such as frailty, nutrition, cognitive impairment, and multiple comorbidity is not a new concept but a very important one. The oldest old (>85 years) are the fastest growing segment of the population in Western societies. Currently, one-third of inpatient surgical procedures in the United States are performed on older patients, and this will only grow with the changing population demographics. As a discipline, we provide specialist pediatric services, it is intuitive that we should provide specialist perioperative geriatric services. If we take just 1 issue such as delirium, predominantly affecting older patients, data suggest that this is one of the commonest postoperative complications, occurring in up to 70% of patients over the age of 65 years. Some 40% of this delirium may be preventable with simple strategies20 that need to begin preoperatively. The costs incurred in managing patients with delirium are very high, and the subsequent impact on patient health and family distress are extremely significant. This is a major opportunity for realized value. The need for postoperative support in the community can also be discussed in advance with the patient and family and preparations made, potentially reducing acute length of stay and the need for discharge to a skilled nursing facility or inpatient rehabilitation facility. The provision of a clinic under the Duke POET/PREOp structure for preoperative pain optimization and chronic opioid use is another example of addressing a population health need and social issue, as part of global preoperative preparation and optimization. Conditions that subsequently present for surgery (eg, back pain or joint arthritis) may have been the trigger to start opioid use. Currently, patients with chronic opioid use have longer lengths of stay, more readmissions, and poorer outcomes than opioid-naïve patients. Throughout the description of the spoke or satellite clinics surrounding the central hub in the Duke model is a greater emphasis on patient-centered care and the practicalities of managing a surgical condition within pragmatic time constraints. Slots are held open for PREOp patients in specialist clinics, waiting times are minimized, and care is coordinated. Previously unidentified health care needs such as management of elevated blood sugar can thus be addressed more efficiently. What is not so obvious from the Duke model5,6 is how the management of the complex patient continues postoperatively and into the community. The emphasis on case management outside of the hospital is a major component of nonsurgical, chronic medical population health management. CONCLUSIONS The model described by Aronson et al5,6 illustrates how a systematic approach to perioperative care aligns with population health management concepts. The surgical population at risk is identified, health assessments are performed, and patients are stratified into levels of risk. Patient-centered interventions then occur to mitigate risk whenever possible and to ensure the patient is in the best possible condition, mentally and physically, for surgery. The system works within a clear structure supported by electronic health record–derived metrics. The parallels and overlap with community-based population health management programs (eg, opioid use reduction and diabetes management) are apparent. Presentation for surgery and preoperative assessment provides a thus far under-recognized touch-point at which to engage with patients in education and comanagement of their health. While none of the interventions at Duke are novel, the application of a structured, systematic, well-funded model, which is recognized for the greater value it provides to the organization and its patients, is to be commended. DISCLOSURES Name: Carol J. Peden, BSc, MBChB, MD, MPH. Contribution: This author helped write and revise the manuscript. Name: Michael G. Mythen, MBBS, MD. Contribution: This author helped write and revise the manuscript. Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Jean-Francois Pittet, MD.