Vertical and Horizontal Pathways: Intersection and Integration of Enhanced Recovery After Surgery and the Perioperative Surgical Home

As health care transitions toward value-based care in the United States,1,2 it is vital for anesthesiologists to participate in clinical programs that enhance delivery of perioperative care.3,4 However, successful implementation of coordinated and collaborative models of health care remains a challenge at most institutions.5 When taking into account the design of the perioperative environment and how anesthesiology departments interact with the rest of the perioperative ecosystem, a few observations come to mind. First, while surgical lines are often “siloed” and fragmented (each surgical line—vascular surgery, neurosurgery, cardiac surgery, urology, etc—operates quasi-independently from the other ones), anesthesia departments are usually consolidated and operate across all surgical lines. Second, anesthesia departments and anesthesiologists are uniquely positioned to work across the whole continuum of care from the preoperative, intraoperative, to the postoperative period, and everywhere in the hospital. Third, due to our comprehensive understanding of both the medical and surgical risks of individual patients, anesthesiologists can improve perioperative health care delivery by risk stratifying and coordinating patients and procedures using appropriate management approaches.6 And, finally, anesthesiologists have developed expertise in the use of electronic medical records specifically for the perioperative period, which allows us to leverage this technology for data mining, information management, and decision support to monitor and improve the effectiveness and impact of our interventions.7–11 Based on these observations, we would like to propose a simple construct that can enable implementation of multiple quality improvement processes and care pathway redesign in the perioperative period. We believe that this approach should follow vertical and horizontal pathways similar to the vertical and horizontal integration approaches used in business. In business, vertical integration is used to control the whole supply chain for production of a given product while horizontal integration is used by companies to acquire similar business lines or at the same level of value chain to increase market shares and eliminate competition. One of the best examples of vertical integration in business is Apple, controlling the whole production and distribution chain of its product. An example of horizontal integration is Disney’s acquisition of Pixar, Marvel Entertainment, and Lucasfilms. While this approach has been shown to improve coordination and cooperation, and achieve economies of scale, in most cases, it also presents some limitations and disadvantages. The main disadvantages of vertical integration in business are the expenses and the capital needed to control the production and distribution chains, the decreased flexibility, the loss of focus, and the different set of skills needed to run different parts of the business. The main disadvantages of horizontal integration are the unexpected consequences of wrong synergy when the expected benefits never materialize despite the cost of the merger, the decreased flexibility, and the legal risks associated with potential monopoly. In the perioperative period, vertical pathways are comprehensive approaches that encompass all perioperative aspects of a single surgery from the preoperative and intraoperative to the postoperative periods, while horizontal pathways are comprehensive approaches toward dealing with a single issue (eg, diabetes management) across several surgeries. The development of vertical pathways is based on surgical line pathways such as Enhanced Recovery After Surgery for colorectal surgery and/or the Perioperative Surgical Home for orthopedic surgery, to name a few.12–17 On the other side, horizontal pathways are pathways that are not dedicated to a single surgical line but rather implemented across all surgical lines (disease- or symptom-based pathways). Some of these horizontal pathways will be implemented over the entire continuum of perioperative care such as anemia management pathways or prevention of postoperative respiratory complications that both require interventions in the preoperative, intraoperative, and postoperative phases, while some would be limited to a single phase of care, such as postoperative nausea and vomiting prophylaxis in the operating room. While we believe these vertical and horizontal pathways should be developed and implemented concomitantly in a stepwise manner, they present some fundamental differences and are associated with their own challenges and opportunities. The main attributes that define these pathways should be intimately understood to facilitate their effective implementation. These attributes are based on (1) the drivers that lead to the development, (2) their design, (3) their implementation and the way adherence to the pathway is ensured, and (4) their expected impact and the way it is assessed. In the end, both vertical and horizontal pathways should synergistically interact with each other to effectively cover the whole perioperative ecosystem. VERTICAL PATHWAYS In our construct, vertical pathways are associated with individual surgical lines. Today, the most popular vertical pathways in the United States are Enhanced Recovery After Surgery programs and the Perioperative Surgical Home model of care.15–17 Despite their different names, these 2 concepts clearly aim for the same goals: improved patient outcome, improved patient satisfaction, and decreased cost, and share the same challenges and opportunities.16,18 Designing a vertical pathway requires a multidisciplinary approach. The design of these pathways takes time and effort, as they require engaging all stakeholders involved in the care of these patients. The drivers for these vertical pathways are usually linked to payment and reimbursement models and to major financial goals. For example, for the Orthopedic Surgical Home, the main driver is the recently proposed bundle payment model (Comprehensive Care for Joint Replacement)19 for joint replacement surgery, which makes the acute care organization delivering the joint replacement surgery financially accountable for patient outcome up to 90 days after surgery.12 In this bundle, length of stay in the hospital, discharge disposition, such as home versus skilled nursing facility or rehabilitation, and 90-day readmission are the main drivers of cost that need to be controlled. This bundle payment approach is expected to align all stakeholders and help with the care redesign to achieve better outcomes and patient satisfaction, at a lower cost. The main challenge of this approach is that it requires very significant effort, resources, and team building in an environment where some of the key players may not initially see the outcome. However, because the team that develops and designs the pathway is the same as the team that actually implements the pathway, compliance with the process is expected to be high as long as the buy-in and engagement in the design of the pathway from the team members has been achieved during the design process. Assessing the impact of these pathways requires measurement of process and outcome metrics with the focus being on big-picture outcomes such as length of stay, 90-day readmission, patients’ satisfaction, discharge disposition, and overall cost of the episode of care. HORIZONTAL PATHWAYS In our construct, horizontal pathways are implemented across all surgical lines within an institution. The aim of these pathways is to improve the care of all patients undergoing surgery within an organization while focusing on a specific clinical problem to solve or a process to improve. Classical examples are postoperative nausea and vomiting prophylaxis, pain management, anemia and blood management, or prevention of postoperative respiratory complications or postoperative delirium, to name a few. The drivers for these horizontal pathways are usually based on the need to improve local processes that are underperforming on accepted national benchmarks on which payments and reimbursements are usually subjected or based on purely local initiatives. These pathways are usually easier to design when compared to the vertical pathways as they only require a small number of stakeholders and rely heavily on evidence-based best practices. However, implementation and the adherence to these pathways may prove to be challenging, as these pathways are required to be applied by each anesthesiology department member rotating across several surgical lines and occasionally by other groups (such as anemia management, postoperative infection prevention, or postoperative delirium prevention). Because it is unlikely that most of the department members were initially involved in the design and may not be completely bought in, appropriate dissemination and engagement need to occur for proper implementation. Typically, these horizontal pathways are processes that are amenable to implementation tools such as clinical decision support using the electronic medical records and automated providers’ feedback.8–10 In contrast to the vertical pathways, assessing the impact of these pathways is based on the primary outcome targeted by the pathway, such as postoperative nausea and vomiting, perioperative blood transfusion, postoperative pain, patient satisfaction with pain management, etc. These 2 approaches, vertical and horizontal pathways, are not competing but complimentary and synergistic. Both allow the development of a multidisciplinary approach to value-based care. They (1) are focused on a specific surgical line or on a specific disease or process of care, (2) are based on measurable metrics, and (3) trigger a change in culture that has potential to engage all providers in the perioperative care redesign. As they intersect and interact with each other, the horizontal pathways become tightly woven with the vertical pathways, and vertical pathways provide a way to anchor horizontal pathways and ensure compliance to the elements that comprise them. When taking into account the design of the perioperative environment described in the introduction and how we interact with the rest of the perioperative ecosystem, we believe this approach presents a significant opportunity for our specialty to help with the implementation of care pathways for the surgical patients to achieve better outcomes and patient satisfaction, at a lower cost. DISCLOSURES Name: Maxime Cannesson, MD, PhD. Contribution: This author helped write and edit the manuscript and contributed to the final approval. Name: Aman Mahajan, MD, PhD. Contribution: This author helped write and edit the manuscript and contributed to the final approval. This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.