Rewarding Best Practice: Tracking the Impact of Incentives in Anesthesiology

See Article, p 32 This issue of Anesthesia & Analgesia includes a study by Lam et al1 noting an increase in the use of peripheral nerve blocks for analgesia after mastectomy, as reported in the National Anesthesia Clinical Outcomes Registry (NACOR) from 2010 to 2018. This article is noteworthy for several reasons. This is the most recent of several studies based on data from NACOR, a registry which I helped to found; hopefully it will not be the last. In the decade since NACOR was founded, the name of the registry has proven to be disappointingly optimistic, because the ability to harvest valid and meaningful clinical outcomes has proven elusive. This has been even more true in recent years, as the need to manage federal regulatory reporting for independent anesthesia groups has consumed the time and effort of the Anesthesia Quality Institute; the tail that wags the dog. Longer term projects, with less obvious return on investment, have been relegated to the back burner. This article by Lam et al,1 reporting on a significant trend in national anesthesia practice, represents a pivot back to the original spirit of NACOR as a tool to better understand the practice of anesthesiology in the United States, and to demonstrate the value that anesthesiologists bring.2 Short-term outcomes of anesthesia—those which can be directly observed by anesthesiologists and reported to the Centers for Medicare and Medicaid Services (CMS) as quality measures—are almost uniformly good, and thus of little use to change current practice. High performance scores serve us well with the public: they make it clear that anesthesia is safe and predictable. However, lack of variability provides little fodder for ongoing improvement. The relevant outcomes occur outside our direct vision: ranging from postrecovery-room strokes or myocardial infarctions, to prolonged mechanical ventilation or hospital length of stay, to mortality at 30 days, 90 days, or a year following anesthesia. Referrable to outcomes from mastectomy, we would love to know which patients with and without regional analgesia experience a recurrence of cancer in the subsequent year; think of how this knowledge could influence future prospective observational research! But without spending millions of dollars on focused and individual chart review this data is lost to us in the Tower of Babel of contemporary medical records. Is there an efficient way to link up the necessary data on a national level? Another anesthesia registry has tried. In the same decade that NACOR has been harvesting administrative data, the Multicenter Perioperative Outcomes Group (MPOG) has been working to unite granular electronic medical record (EMR) data from disparate systems. While MPOG has had notable success in capturing some outcomes following surgery,3 the registry is limited to data which can be captured in the EMR before the patient’s discharge, and it comes at a cost in time and effort that makes participation prohibitive for most nonacademic medical centers. While MPOG has been remarkably successful in linking objective data from 50 large hospitals—with 6 published papers in 2020 alone—the cost barrier makes MPOG less representative of the evolving pivot toward outpatient surgical care than NACOR, and thus potentially less suitable for a study of broad trends in practice. With acknowledgement to MPOG Research Director Sachin Kheterpal for the turn of phrase, MPOG is narrow and deep; NACOR is broad and shallow. What can be done with NACOR data? This article by Lam et al1 illustrates 1 worthy use: providing a description of community-based US anesthesia practice and showing how it evolves over time. This is especially useful for identifying trends that are reliably captured by administrative data. In the present case, the fact that a regional anesthetic block provided for the purpose of postoperative analgesia is separately compensable from the anesthetic itself makes it easy to identify these cases in the data routinely reported to NACOR. There is a financial incentive for clinicians to report the block, and for complete and accurate coding of the case. There is a disincentive to report data selectively to NACOR because it would cost more time and effort to filter data than to send it all; the overall description of the practice is thus valid and complete; we can be reasonably confident that we are “seeing” all the practice’s mastectomy cases and all the blocks performed during those anesthetics. The authors note that some cases may have been performed using the block as the primary anesthetic, and therefore not captured under a separate code. This seems unlikely based on common experience with these cases, and the authors noted no difference in results for older patients or those with a higher American Society of Anesthesiologists (ASA) physical status, cases in which this might have occurred. We don’t know if the hundreds of groups reporting cases to NACOR are truly representative of US anesthesia practice, but the numbers reported are large enough to be interesting in any case: more than 45 million nonobstetric adult anesthetics in the 9 years studied. This represents 5%–10% of all the anesthetics performed in the United States in that period, and covers a wide range of practice types, surgical locations, and care models. While hard to validate, it is likely that NACOR comes closer to capturing the reality of community anesthesia practice—and developing trends—than could be accomplished in MPOG or in an age-biased public source such as Medicare data. A similar study to Lam et al’s1 study, using MPOG data, would be of great interest to further explore this question. In any case, this kind of broad study of anesthesia practice demographics is the right niche for NACOR-based research today, much like prior work by Nagrebetsky et al4 demonstrating the growing volume of nonoperating room cases in community practice. The increase in regional blocks likely has 2 causes. First is the widespread deployment of high-resolution ultrasonography. This enables anesthesiologists to perform rapid, safe, and precise regional blocks after a relatively short learning curve. Second is the same incentive which makes the data in NACOR reliable: supplemental payment for the procedure. Fee-for-service payment is widely decried as a driver of high health care costs, and in this example increased income is a motivator for many anesthesiologists to invest in ultrasound equipment and training, and to perform regional analgesia procedures whenever indicated. The inflection in the data in 2014 is interesting, and not entirely explained. It likely represents greater availability of ultrasound equipment intersecting with increased awareness of both the clinical and financial utility of regional analgesia. The trend since 2014 is indisputable, however; billing for a supplemental regional block has become common in mastectomy cases. But has the increased cost of care led to a benefit for our patients? In this case, the answer appears to be “Yes!” Regional analgesia (specifically pectoral nerve block) is a key component of enhanced recovery after mastectomy, enabling a substantial reduction in the use of opiate pain medications.5 Combined with early ambulation and sustained oral intake through the perioperative period, regional-based multimodal analgesia enables early discharge from the hospital—usually on postoperative day 1 after a mastectomy—with a low rate of complications and readmissions. How much of this impact is specific to the regional nerve block, versus all other elements of enhanced recovery, is unknown of course, as are the correlation of long-term outcomes (eg, 5-year survival) with short-term benefits. Whether opiate analgesia increases the risk of metastasis in cancer surgery remains an open and controversial question, but 1 short-term benefit of regional blockade (again, specifically pectoral nerve block) that is not in doubt is improved patient satisfaction.6 Overall, it seems likely that use of adjuvant regional analgesia is beneficial, at least based on what we know right now. One of the centers making the greatest use of these advantages—to the benefit of their patients—is the authors’ own Josey Robertson Center, a “surgical hospital” designed from the ground up to facilitate the rapid and effective delivery of oncologic surgical procedures.7 Authors from this center have described a highly reliable process for routine surgery and rapid recovery that is serving as a model for others wishing to innovate toward the “focused factory” vision of more efficient health care. Reduction in hospital length of stay outweighs increased cost of anesthesia by a substantial sum. This makes investment in an incentive for regional analgesia a wise decision by the payer community, including CMS. And the present study demonstrates the incentive has worked to drive a change in community practice, potentially benefitting thousands of patients each year. Lam et al1 are to be commended for documenting this global improvement in the value of anesthesia. DISCLOSURES Name: Richard P. Dutton, MD, MBA, FASA. Contribution: This author conceived this editorial and wrote it himself. This manuscript was handled by: Honorio T. Benzon, MD.