A Patient/Primary Care Perspective Kurt Lindberg, MD 5/18/2018

Patient Perspectives Conflicting advice A 58 year old line-worker has been tolerating severe hip osteoarthritis for many years. He finally schedules a THA on a date which aligns with a plant shut-down along with “banked” vacation days. His PCP tells him to go off Xarelto, which he takes for atrial fibrillation, five days before surgery. However, he follows his cardiologist’s advice to stop this med 48 hours before surgery. When he arrives on the morning of surgery, the anesthesiologist notes he must be off this medicine for at least 72 hours and cancels the procedure.

We need a better system

Management of Anti-coagulants around surgery

Management of Anti-coagulants around surgery

Patient Perspectives Last minute issues A 43 year-old woman presented to her PCP with severe lumbar radiculopathy. The PCP refused to give her narcotic pain medicines, sending her instead through 6 weeks of physical therapy, followed by two months of spinal injections at a pain clinic. She then met with a physiatrist who recommended she seek a surgical consult. Sixteen weeks into the course of her debilitating pain, the surgeon calls her insurance company to pre-authorize surgery. Six days later the authorization is denied since she must demonstrate smoking cessation.

Holland Hospital’s Preoperative Glucose Pathway

Holland PHO’s new Pre-Joint Pathway

Why you might get pushback from PCPs Our patients are like friends and family We often feel a bit protective of them No one knows these people’s conditions and histories better Stress about the success of our low profit-margin practice Some see losing pre-operative assessment as a financial threat A further reduction in scope of care Other examples: inpatient care, neonatal resuscitation, low-risk obstetrics, endoscopy, surgical assist, nursing home care Change fatigue Other examples: EMR, pre-authorizations, quality metrics, daily fights with patients over antibiotics and opiate pain meds

Why PCPs may be your best allies for change We are often frustrated by what happens to “our patients” New systems and protocols may help coordinate between silos We are already very familiar with population health. Delaying elective surgery is a powerful motivator for changing chronic unhealthy habits Poorly controlled diabetics Smokers

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