Transcript Slide 1

Reducing hospital costs with
Acute Pain Service?
Anna Lee
Department of Anaesthesia and Intensive Care
The Chinese University of Hong Kong
[email protected]
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
Average annual increase
in spending (%)
10
8
Contributing factors
• Ageing population
6
4
• Demand for new drugs &
technology
2
• Increase compensation for
healthcare personnel
0
2000
2002
2004
2006
2008
2010
Year
Centers for Medicare and Medicaid Services
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$4471/casemix adjusted separation
www.aihw.gov.au/publications/index.cfm/title/11173
Weiser et al. Lancet 2008;372:139-44
Types of Acute Pain Service

Nurse-based, anaesthesiologist supervised
 Most
patients with conventional postoperative
analgesia (oral/IM analgesia), some with patientcontrolled analgesia and postoperative regional
analgesia. Care in the postoperative period only.

Anaesthesiologist-based ± nurse support
 All
patients with patient-controlled analgesia or
postoperative regional analgesia. Care before and
after surgery.
Is APS costeffective?

10 studies (14,774 patients)
 Lack

of high quality economic studies
Only one study (Stadler et al. 2004) used a formal costeffectiveness analysis. Nurse-based anaesthetist supervised
APS was cost-effective
 Insufficient
data to identify which APS model is more
cost-effective
J Clin Pain 2007;23: 726-33.
APS shortens LOS and hospital costs
Authors
Model base
LOS
Cost savings/
patient/day (US$)
Tsui (1997)
Anaesthetist
↓26%*
11.40 (↓LOS)
Nurse
?
2.62 (↓nursing time)
Anaesthetist
↓78% ICU*
9.90 (↓ICU LOS)
Nurse
same
NIL
Tighe (1998)
Brodner (2000)†
Stadler (2004)
*P<0.05
† subgroup analysis (16%)
J Clin Pain 2007;23: 726-33.
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;111:1042-50
• CE analysis alongside a RCT
• Major elective surgery (eg. Lap. assist procedures, cardiac surgery)
Cost-effectiveness RCT of APS: patient flow
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)
Lost to follow up (n = 10)
Unstable after surgery (n = 6)
Anesthesiologist refusal (n =1)
Patient consent withdrawn (n = 2)
Data lost (n =1)
Unstable after surgery (n = 2)
Anesthesiologist refusal (n =7)
Patient consent withdrawn (n = 1)
199 Included in Analysis
203 Included in Analysis
Lee et al. Anesth Analg 2010;111:1042-50
Benefits of APS


Pain intensity similar over 3 days
Pain at rest less on D1
 (-0.9,

Pain interfering with daily activities less on D1
 (-0.9,



95%CI -1.4 to -0.3 using a 0-10 NRS)
-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
Highly effective pain treatment
“How effective do you think the treatment for pain was?”
80
Acute Pain Service
Conventional Ward Pain Service
No. of Patients
60
P<0.01
40
NNT = 9 (95%CI 5-33)
20
0
0
1
2
3
No. of days with highly effective pain treatment
Lee et al. Anesth Analg
2010;111:1042-50
Costs (US$) per patient
Costs
APS
CWPS
Mean difference
P value
Analgesia
19
1
18
<0.001
Medications to treat
opioid side-effects
2
1
1
0.04
APS staff
27
1
26
<0.001
Total cost of pain
treatment
48
3
45
<0.001
Lee et al. Anesth Analg 2010;111:1042-50
Probability of APS is cost-effective (%)
APS cost-effectiveness
100
80

60

40

20
0
0
500
1000
1500
2000
2500
APS not cost-effective if
WTP<US$87/patient
APS cost-effective if
WTP>US$546/patient
APS marginally costeffective in this extended
surgical population using
PCA
3000
Willingness-to-pay (Maximum acceptable cost per
one day with highly effective pain treatment gained)
Lee et al. Anesth Analg 2010;111:1042-50
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
APS to reduce hospital costs:
poor published evidence to date
Acute Pain Service
Χ
↓ LOS
↓ Cost $$$
APS time in 2 cost-effectiveness
studies made up 25%~33%
overall LOS
Improve efficiency to reduce hospital costs
Acute Pain Service
Improve hospital efficiency
↓ LOS
↓ Cost $$$
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;9:1541-64
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.
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.
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.
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.



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
De Kock. Anesthesiology 2009;111:461-3
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
If we could predict who is likely get chronic postsurgical pain…
Gene polymorphism for predicting CPSP
Incidence of chronic
postsurgical pain (%)
70
60
OR 0.54
(95%CI 0.31-0.94)
OR 0.55
(95%CI 0.32-0.97)
50
40
In open abdominal
surgery, 40% CPSP at
6 mths.
30
20
10
0
COMT1
rs4680 [G/A]
B-arrestin2
rs1045280 [T/C]
common allele
variant allele
Meng Z. MPhil (CUHK) 2010
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
Proactive APS physicians and nurses can make
a difference to patient outcome and healthcare
system!
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