1. Reducing hospital costs with Acute Pain Service? Anna Lee Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong annalee@cuhk.edu.hk

2. 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

3. 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

4. How many patients at risk for pain after inpatient surgery? Worldwide  Est. 234.2 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 www.aihw.gov.au/publications/index.cfm/title/11173 Weiser et al. Lancet 2008;372:139-44

5. 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.

6. Is APS cost- effective?

7. J Clin Pain 2007;23: 726-33. 10 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

8. 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: 726-33.

9. 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

10. Lee et al. Anesth Analg 2010;111:1042-50 CE analysis alongside a RCT Major elective surgery (eg. Lap. assist procedures, cardiac surgery)

11. 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;111:1042-50 Cost-effectiveness RCT of APS: patient flow

12. 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;111:1042-50

13. Highly effective pain treatment “How effective do you think the treatment for pain was?” Lee et al. Anesth Analg 2010;111:1042-50 P<0.01 NNT = 9 (95%CI 5-33)

14. Costs (US$) per patient Lee et al. Anesth Analg 2010;111:1042-50 CostsAPSCWPSMean differenceP value Analgesia19118<0.001 Medications to treat opioid side-effects 2110.04 APS staff27126<0.001 Total cost of pain treatment 48345<0.001

15. 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;111:1042-50

16. 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

17. 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

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

19. Efficiency: New perioperative/FT model

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

21. Key elements of fast-track protocols Kranke et al. Expert Opin Pharmacother 2008;9:1541-64

22. 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. 2011 Feb 16;2:CD007635.

23. Fast track (ERAS) programs: LOS ↓ LOS after colorectal surgery associated with ERAS program Spanjersberg et al. Cochrane Database Syst Rev. 2011 Feb 16;2:CD007635.

24. 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;44:245-63.

25. 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;44:245-63.

26. 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

27. 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 (1.7-3.8) increase hospital ED visits  1.6 (1.4-1.8) increase overnight hospital admission Van Den Bos et al. Health Aff 2011;30:596-603 Blyth et al. Pain 2004;111:51-8

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

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

30. 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

31. 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!

32. 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

33. Healthcare costs Weiser et al. Lancet 2008;372:139-44 OECD Health Data 2010

34. 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

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

36. 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

37. 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