Reducing hospital costs with Acute Pain Service? Anna Lee Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong

Outline Need to reduce hospital costs Is APS itself cost-effective? How can APS improve hospital efficiency?  APS involvement in fast-track programs  Education to improve quality of acute pain management  Risk reduction of chronic pain after surgery

Soaring hospital expenses Hospital costs represents one-third of all healthcare spending in US Contributing factors Ageing population Demand for new drugs & technology Increase compensation for healthcare personnel Centers for Medicare and Medicaid Services

How many patients at risk for pain after inpatient surgery? Worldwide  Est million major surgical procedures done each year Australia  1.8 million elective surgery in 08/09  ~ 22% of all inpatient visits  AUD$4471/casemix adjusted separation Weiser et al. Lancet 2008;372:139-44

Types of Acute Pain Service Nurse-based, anaesthesiologist supervised  Most patients with conventional postoperative analgesia (oral/IM analgesia), some with patient- controlled analgesia and postoperative regional analgesia. Care in the postoperative period only. Anaesthesiologist-based ± nurse support  All patients with patient-controlled analgesia or postoperative regional analgesia. Care before and after surgery.

Is APS cost- effective?

J Clin Pain 2007;23: studies (14,774 patients)  Lack of high quality economic studies Only one study (Stadler et al. 2004) used a formal cost- effectiveness analysis. Nurse-based anaesthetist supervised APS was cost-effective  Insufficient data to identify which APS model is more cost-effective

APS shortens LOS and hospital costs AuthorsModel baseLOSCost savings/ patient/day (US$) Tsui (1997)Anaesthetist↓26%*11.40 (↓LOS) Tighe (1998)Nurse?2.62 (↓nursing time) Brodner (2000)†Anaesthetist↓78% ICU*9.90 (↓ICU LOS) Stadler (2004)NursesameNIL *P<0.05 † subgroup analysis (16%) J Clin Pain 2007;23:

Surgeons’ view about APS Half (54%) thought APS had a significant impact on patient outcome Few (10%) agreed that APS would ↓LOS Chan et al. HKMJ 2008;14:342-7

Lee et al. Anesth Analg 2010;111: CE analysis alongside a RCT Major elective surgery (eg. Lap. assist procedures, cardiac surgery)

Assessed for eligibility (n = 470) Excluded (n = 48) Anesthesiologist refusal (n = 33) Patient refusal (n = 10) Recruited to other trials (n =4) Surgeon refusal (n = 1) Randomized (n = 422) Allocated to APS (n = 209)Allocated to CWPS (n = 213) Lost to follow up (n = 10) Unstable after surgery (n = 6) Anesthesiologist refusal (n =1) Patient consent withdrawn (n = 2) Data lost (n =1) Lost to follow up (n = 10) Unstable after surgery (n = 2) Anesthesiologist refusal (n =7) Patient consent withdrawn (n = 1) 199 Included in Analysis203 Included in Analysis Lee et al. Anesth Analg 2010;111: Cost-effectiveness RCT of APS: patient flow

Benefits of APS Pain intensity similar over 3 days Pain at rest less on D1  (-0.9, 95%CI -1.4 to -0.3 using a 0-10 NRS) Pain interfering with daily activities less on D1  (-0.9, -1.6 to -0.2 using a 0-10 NRS) Milder opioid related side-effects but similar incidence Quality of Recovery score similar over 3 days LOS similar (APS=12 ±11 vs CWPS=10±12, P=0.13) Lee et al. Anesth Analg 2010;111:

Highly effective pain treatment “How effective do you think the treatment for pain was?” Lee et al. Anesth Analg 2010;111: P<0.01 NNT = 9 (95%CI 5-33)

Costs (US$) per patient Lee et al. Anesth Analg 2010;111: CostsAPSCWPSMean differenceP value Analgesia19118<0.001 Medications to treat opioid side-effects APS staff27126<0.001 Total cost of pain treatment 48345<0.001

APS cost-effectiveness APS not cost-effective if WTP<US$87/patient APS cost-effective if WTP>US$546/patient APS marginally cost- effective in this extended surgical population using PCA Lee et al. Anesth Analg 2010;111:

APS cost is small In comparison to the overall hospital cost APS with IV morphine PCA (1%) APS with ropivacaine ± sufentanil via PCEA (5%) Lee et al. unpublished Schuster et al. Anesth Analg 2004;98:708-13

Χ APS to reduce hospital costs: poor published evidence to date Acute Pain Service ↓ LOS ↓ Cost $$$ APS time in 2 cost-effectiveness studies made up 25%~33% overall LOS

Improve efficiency to reduce hospital costs Improve hospital efficiency Acute Pain Service ↓ LOS ↓ Cost $$$

Efficiency: New perioperative/FT model

Can we be more efficient by planning the need for APS at preoperative anaesthetic clinic?

Key elements of fast-track protocols Kranke et al. Expert Opin Pharmacother 2008;9:

Fast track (ERAS) programs: postoperative complications ↓ complications after colorectal surgery associated with ERAS program (NNB = 4, 95% CI: 3 to 7) Spanjersberg et al. Cochrane Database Syst Rev Feb 16;2:CD

Fast track (ERAS) programs: LOS ↓ LOS after colorectal surgery associated with ERAS program Spanjersberg et al. Cochrane Database Syst Rev Feb 16;2:CD

Translating research into practice Multicentre RCT educational intervention of EBM guidelines on Acute Pain Management in the Elderly Nurse change champions, physician opinion leaders, web-based course, educational resource texts, videos, manuals, outreach visits every 3 weeks by advanced practice nurse -> organizational and unit changes Brooks et al. Health Serv Res 2009;44:

Translating research into practice: results Intervention Group associated with ↑11% compliance with EBM good pain management practices ↓19% total cost (P<0.001) ↓ 0.5 day in LOS (↓9%, P=0.06) ↓10% total cost/day (P<0.01) Brooks et al. Health Serv Res 2009;44:

De Kock. Anesthesiology 2009;111:461-3 Dedicated service rather than “Chronic Pain Clinic” Help to determine true incidence of CPSP Identify populations at risk to provide early treatment  APS aggressive pain therapy for severe postop pain -> ↓CPSP and ↓downstream healthcare costs Ideal to establish link between perioperative analgesia management to CPSP development

Cost of chronic postsurgical pain Postlaminectomy syndrome  ~US$8739/patient  ~6% of annual cost of measureable medical errors Chronic pain patients were associated with  2.5 ( ) increase hospital ED visits  1.6 ( ) increase overnight hospital admission Van Den Bos et al. Health Aff 2011;30: Blyth et al. Pain 2004;111:51-8

If we could predict who is likely get chronic postsurgical pain…

Gene polymorphism for predicting CPSP Meng Z. MPhil (CUHK) 2010 In open abdominal surgery, 40% CPSP at 6 mths.

Summary APS is cost-effective in itself but does not reduce overall hospital cost Hospital costs can be reduce by increasing efficiency of perioperative system if APS:  Integration into Fast Track Programs  Engagement of ward staff by education on EBM good pain management practices  Identifying at risk chronic postsurgical pain patients

Take home message Acknowledgements Part of this presentation describes the work funded by a grant from the Central Policy Unit of the Government of HKSAR and the Research Grants Council of the HKSAR, China (Project reference: CUHK4004-PPR20051). Funding for this presentation from Shaw College (CUHK) Conference Grant Proactive APS physicians and nurses can make a difference to patient outcome and healthcare system!

Outline Need to reduce hospital costs Is APS itself cost-effective? How can APS improve hospital efficiency?  APS involvement in fast-track programs  Education to improve quality of acute pain management  Risk reduction of serious postoperative events  Risk reduction of chronic pain after surgery

Healthcare costs Weiser et al. Lancet 2008;372: OECD Health Data 2010

Pay for Performance within HK public hospitals 2003/04 funding to 7 clusters based on age- adjusted population based model Hospital services outdated Little incentive to promote productivity and quality Long waiting times 2009/10 P4P casemix model introduced Hospitals paid extra for treating more patients New service innovations to improve patient care Target extra resources to service priorities Lee & Gillett. BMC Health Services Research 2010:10 (suppl 2):A17

Story et al. Anaesthesia 2006;61:24-8.

Implementing APS/MET team: ↓Serious adverse events (23 events/100 patients to 16 events/100 patients) ↓30 day mortality (9% to 3%) BUT unsustainable workload

Summary APS is cost-effective in itself but does not reduce overall hospital cost Hospital costs can be reduce by increasing efficiency of perioperative system if APS:  Integration into Fast Track Programs  Engagement of ward staff by education on EBM good pain management practices  Postop surveillance of events as APS/MET service  Identifying at risk chronic postsurgical pain patients