Journal-related Activities and Other Special Activities at the 2015 American Society of Anesthesiologists Annual Meeting

Initial Results of Clinical TrialsSunday, October 25, 1:10 pm to 3:10 pm, San Diego Convention Center, Upper 20A Moderators James C. Eisenach, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina. Anesthesiology is sponsoring a Major Trials Session at the 2015 Annual Meeting of the ASA. It will provide a high-profile, large audience forum for initial presentation of major randomized clinical trial results. The session is designed for substantial trials, usually randomized and blinded, with a clinically important primary outcome. Articles selected for the Trials Session will be simultaneously published in the journal as well as have a press release. 24th Annual Journal Symposium: The Anesthesiologist and Healthcare RedesignSunday, October 25, 2015, 9:00 am to 12:00 pm, San Diego Convention Center, Room Upper 4 This year Anesthesiology will sponsor four sessions at the Annual Meeting of the American Society of Anesthesiologists (ASA). The 2015 Journal Symposium addresses the changes in healthcare design and delivery in a session titled, “The Anesthesiologist and Healthcare Redesign.” It will feature the following moderators and speakers. Moderators James P. Rathmell, M.D., Brigham and Women’s Hospital, Boston, Massachusetts; and Warren S. Sandberg, M.D., Ph.D., Vanderbilt University Medical Center, Nashville, Tennessee. Speakers Using Data to Improve Operating Room Throughput Peter F. Dunn, M.D., Massachusetts General Hospital, Boston, Massachusetts; Retsef Levi, Ph.D., Sloan School of Management, MIT, Boston, Massachusetts Redesigning Surgical Patient Care from Decision to Discharge Jonathan P. Wanderer, M.D., Vanderbilt University, Nashville, Tennessee Designing a New Hospital for Surgical Care Brett Simon, M.D., Ph.D., Memorial Sloan Kettering Josie Robertson Surgery Center, New York, New York Description A common axiom in architecture reads: “If you want to change the way people work, change the building they work in.” The 2015 Journal Symposium addresses the changes in healthcare design and delivery head on, with this axiom setting the context. Physician anesthesiologists and others involved in the world of perioperative and procedural medicine are facing intense pressure to alter systems of care to improve the value delivered to patients. Such pressures are not new, but the intensity of the pressure has risen dramatically. The advent of the Affordable Care Act and payer initiatives such as bundling and value-based purchasing provide new impetus for healthcare delivery redesign. Recent descriptive publications have detailed elements of a nascent Perioperative Surgical Home (PSH) model of care. Does this construct represent a true reconsideration of perioperative healthcare delivery? How much redesign is required to truly affect the value a perioperative system brings to patients? Does the value accrue to patients or does the value of redesigning perioperative systems actually benefit healthcare systems and payers? Four experts will introduce these topics for the first 90 min of the symposium, with 20-min presentations and 10-min discussions. The speakers will discuss three different approaches, of increasing scope, for redesigning healthcare delivery systems to meet specific goals. Where available, empirical tests of the redesign efforts’ success at meeting their goals will be presented. These lectures will be followed by oral presentations of 12 abstracts, summarized below, that were selected for their relevance to the Symposium topic. The full text for each abstract can be found at the ASA abstract Web site. JS01 “Effect of Ongoing Process Improvement on an Enhanced Recovery after Surgery Pathway for Colorectal Surgery Patients” by Adam B. King, M.D., Jonathan P. Wanderer, M.D., Timothy Geiger, M.D., Vikram Tiwari, Ph.D., Warren S. Sandberg, M.D., Ph.D., Matthew D. McEvoy, M.D., Vanderbilt University Medical Center, Nashville, Tennessee. The authors conducted a quality improvement exercise, with the goal of reducing hospital resource length of stay (rLOS) through systematic application of enhanced recovery after surgery (ERAS) principles in colorectal surgery patients. They created a formal perioperative consult service to oversee the application of pertinent and appropriate ERAS elements for each patient after project initiation. Preimplementation baseline data for 181 consecutive elective colorectal surgery patients (with no exclusions) revealed a median rLOS of 4.2 days (which is in the best-performing quintile of the National Surgical Quality Improvement Project consortium). After implementation, rLOS for the subsequent 284 patients, without exclusions, was 3.3 days. In addition, costs declined by 17.5% after implementation. Both reductions were statistically significant using nonparametric tests. Emergency department visits and 7- and 30-day readmission rates were not measurably affected. The authors demonstrated that already excellent rLOS performance can be improved, that the improvement can be sustained for at least 1 yr, and that substantial LOS reductions can be achieved. Considering only colorectal surgery patients, access (and throughput) could be increased by one third, more than offsetting the cost of the intervention. JS02 “Impact on Cost and Cost Variation of a Surgical Home for Nephrectomy Cases” by Shermeen B. Vakharia, M.D., M.B.A., John Patton, Jr., Ross Moskowitz, M.D., Kwang Pak, B.S., Zeev N. Kain, M.D., M.B.A., Joseph B. Rinehart, M.D., University of California, Irvine, Orange, California. The authors extended an already-developed PSH model to a new service line (urology) and a new case type (nephrectomy). Using a before–after design, the authors studied the impact of a complete perioperative process redesign on length of stay (LOS) and cost of care. Process redesign included comprehensive nutritional, respiratory, and medical optimization, patient education, and risk identification for renal and pulmonary complications and delirium, and complete standardization of case carts across surgeons. There were 148 cases in the control group and 22 cases studied after process change implementation. Mean LOS declined from 3.2 ± 2.7 days to 2.3 ± 0.8 days, mostly attributed by the authors to reduction in complications. Costs declined by approximately 50%. Both comparisons were statistically significant. Although the postintervention sample was small, the variation in costs appeared to be reduced, suggesting that the postintervention process was in better control. Reliability is a key goal of the PSH. JS03 “Preoperative Evaluation Clinic Visit Decreases Risk of In-hospital Postoperative Mortality” by Jeanna D. Blitz, M.D., Samir N. Kendale, M.D., Germain Cuff, D.Phil., Andrew D. Rosenberg, M.D., New York University School of Medicine, New York, New York. In a retrospective exploratory study of 75,763 surgical encounters, the authors compared in-hospital postoperative mortality between patients who had visited the anesthesiology preoperative clinic for risk stratification, optimization, and care coordination, versus those who had not. Propensity scoring (matching) and logistic regression methods were used to compare the in-hospital mortality rate between surgical patients exposed (n = 39,840) and not exposed (n = 35,923) to the preoperative clinic. After matching, patients who had been seen in preoperative clinic were less likely to die during their surgical admission (odds ratio [OR], 0.55; 95% CI, 0.34 to 0.88). Similar results were obtained after logistic regression analysis (OR, 0.54; 95% CI, 0.36 to 0.82). JS04 “Effect of Implementing an Enhanced Recovery after Surgery Pathway via Perioperative Consult Service for Bariatric Surgical Patients” by Matthew D. McEvoy, M.D., Adam B. King, M.D., Matthew D. Spann, M.D., Vikram Tiwari, Ph.D., Warren S. Sandberg, M.D., Ph.D., Jonathan P. Wanderer, M.D., Vanderbilt University Medical Center, Nashville, Tennessee. Application of ERAS interventions via an anesthesia perioperative consult service was undertaken for bariatric surgical patients. This was a formal process improvement exercise including the surgeons and was conducted as a before–after design with 393 control cases, 68 postintervention cases, and no exclusions. After intervention, rLOS declined from 1.6 to 1.4 days, the proportion of patients ready for discharge in less than 2 days increased from 81 to 94% and total hospital costs declined by 37% (all comparisons were statistically significant). Readmission to emergency room or hospital was not measurably increased. Changing the distribution of rLOS so that more patients are discharged in under 48 h means that a patient admitted to preoperative holding in the morning will vacate their postoperative bed the morning of postoperative day 2 at the latest, in time to turn the bed for a new first-case patient leaving the postanesthesia care unit. JS05 “Medical Follow-up in the Year after Surgery and Subsequent Survival among a National Cohort of Surgical Patients” by Robert B. Schonberger, M.D., Feng Dai, Ph.D., Cynthia A. Brandt, M.D., M.P.H., Matthew M. Burg, Ph.D., Yale University School of Medicine, New Haven, Connecticut. The authors investigated healthcare redesign by attempting to integrate surgical care episodes with efforts to improve longitudinal postoperative preventive medical care. In this retrospective analysis, the association between nonsurgical medical follow-up during the first postoperative year and subsequent all-cause mortality during postoperative year 2 was examined. The postoperative course of U.S. Veterans presenting for surgery from 2006 to 2011 was examined to measure the association between exposure to medical follow-up in the year after surgery and subsequent survival in postoperative year 2. Of 385,790 patients, 113 (0.03%) were removed due to an invalid date of death. Of the remaining 385,677 patients, 342,563 (88.8%) survived the 365-day postsurgical exposure period and were included. In unadjusted analysis, 5.9% of patients with medical follow-up died during postsurgical year 2. This compares with 9.5% mortality among those lacking medical follow-up. Medical follow-up during the first postoperative year was associated with a reduction in all-cause mortality in postoperative year 2. Care coordination to improve medical follow-up is unlikely to impede long-term postoperative survival. JS06 “Total Joint Replacement Perioperative Surgical Home Program: Impact of Patient Characteristics and Comorbidities on Postoperative Length of Stay” by Kyle S. Ahn, M.D., Ran Schwarzkopf, M.D., Joseph B. Rinehart, M.D., Maxime Cannesson, M.D., Ph.D., Zeev N. Kain, M.D., M.B.A., University of California, Irvine, Orange, California. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two of the most common surgical procedures in the United States. The authors implemented a total joint PSH program, hypothesizing that patients enrolled in the PSH program undergoing primary TKA and THA would have similar postoperative outcomes regardless of patient characteristics, comorbidities, and ASA score. This was a retrospective review of elective primary total hip and knee arthroplasty patients under the total joint replacement PSH. Primary outcome was LOS, and secondary outcomes included readmission rate, postoperative complications, discharge disposition, and postanesthesia care unit stay duration. Age, gender, body mass index, and THA versus TKA were not significant predictors of LOS. ASA score remained strongly predictive (P = 0.0011). predictors of postoperative complications are not predictive in joint arthroplasty patients in a PSH care This be due to preoperative of patients in a PSH The PSH model has been to postoperative outcomes among total joint arthroplasty patients regardless of their and medical in a PSH care ASA score and body mass a significant in postoperative outcomes in joint arthroplasty patients. “The Impact of Perioperative on Patient by M. M.D., M.P.H., Jonathan P. Wanderer, M.D., S. M.D., Warren S. Sandberg, M.D., Ph.D., Vanderbilt University Medical Center, Nashville, Tennessee. The authors conducted a perioperative system redesign to the proportion of patients who This an system to patients the the medical for and to anesthesia to of impact was a (n = versus after (n = design with score The outcome was the surgical The rate of increased from to (P = and on postanesthesia care unit to = on postanesthesia care unit was The unadjusted surgical rate from (n = to (n = = after matching, the and after surgical rates were versus A using systems to a process performance and with Surgical Care Improvement Project for with Clinical by Andrew B.S., M.D., B.S., M.D., M.D., M. M.D., Medicine, The authors used the Surgical Care Improvement Project to measure is associated with outcomes by the that is associated with a of and a of medical data from was to with was associated with a of and The primary outcomes were and outcomes were mortality and hospital LOS. admission to the postoperative care unit was in the group ± = compared with the group ± = (P was associated with outcomes in and was associated with a of 95% CI, to 95% CI, to and mortality 95% CI, to was associated with a risk for and as well as a LOS. in the Postoperative of with by A. B.S., B.S., M.D., University of The authors a retrospective analysis, using data from the They studied patients with hypothesizing that of pressure in these patients during would be associated with long-term LOS, and Data were on and to were found between in postoperative median total or median LOS. of was associated with reduction in long-term and in-hospital mortality statistically comparisons that the were between and and A Data by M.D., M.D., M.D., D. M.D., M.D., D. M.D., C. M.D., Andrew M.D., Robert N. M.D., Brigham and Women’s Hospital, Boston, The authors compared performance procedural on and and time for between cases and room anesthesia of anesthesia was for versus in the The rate due to was versus for The cost of time was than including the cost of and in the studied is an process and through perioperative systems design could improve and Program: and by M.D., M.P.H., B.S., M.D., M.D., Medical Center, San California. substantial in patient is a substantial to This is the first program by the U.S. is an program, of days a for and and exercise and are as of a process improvement service in from to of There were significant after the of the were in and total are of increased the to a of among were seen in and after to their Initial from this program to the service to to full “The of by Anesthesiologists in Perioperative Medical and Surgical by P. M.D., M.D., University of Medical Center, The of perioperative by anesthesiologists has in The authors the impact of via a Perioperative Consult Service The was to the of preoperative by anesthesiologists on perioperative medical and surgical data from the Quality on patients the of who had a during their Clinic was included. Evaluation for change in preoperative medical and surgical was and the impact on clinical perioperative was patients were as a preoperative via through data of the first patients that patients had changes of care on their of these changes were on in perioperative anesthesia included case for medical optimization, or or consult surgery for preoperative by anesthesiologists can change surgical and medical in from to of The most common for preoperative was or Clinical and Anesthesiology will sponsor two this one in and in clinical These were by a of who examined the scoring from the ASA those with important and clinical application and a of these and from the ASA will one abstract in each to the for and clinical at the meeting in San are of the that will be presented. Clinical October 1:10 pm to 3:10 pm, San Diego Convention Center, Upper 4 Moderators P. Hospital for University of and M. M.D., University of California, San San California. with following by N. Ph.D., Ph.D., John M.D., M.D., Ph.D., D. M.P.H., F. M.D., Joseph P. M.D., of and University, North Carolina. Postoperative in a of patients after anesthesia and but the between in the is not patients undergoing surgery and control nonsurgical patients were to a of tests and at baseline and significant were found between of postoperative change in and outcomes in the and in the patients who The data that and are important of the that of postoperative through an by M.D., M.D., M.P.H., M.D., Healthcare and University of California, Irvine, California. has been to provide and sustained of the that the of with was in patients with was 1 and 1 after under was in three of patients. The was more in the in with included and improvement in with that on the and in the The data that be a of to that likely of are to Improve Postoperative Quality of Recovery after A by S. Jr., M.D., University, have a quality of recovery from This randomized study the of an to improve the quality of recovery after The of and h after surgery was associated with quality of recovery and improve the quality of recovery after surgery in patients. a Visit to the Evaluation Clinic In-hospital Length of Stay” by C. M.D., Jeanna D. Blitz, M.D., Samir M. Kendale, M.D., Cuff, Ph.D., Andrew D. Rosenberg, M.D., New York University School of Medicine, New York, New York. The of a Evaluation Clinic on 30-day readmission rate has been but the with postoperative in-hospital LOS, is with cost of has not been Propensity scoring methods and were used to compare LOS ratio between patients exposed (n = and not exposed (n = to after for The ratio was in patients the This a for Recovery after Surgery Clinical Pathway for Surgery Decreases Hospital Length of Stay” by P. M.D., Timothy P. M.D., Robert S. M.P.H., M.D., M. M.D., University of North at North Carolina. ERAS clinical postoperative This study the of an ERAS on LOS after and postoperative were included in the ERAS of the ERAS was associated with and day reductions in LOS for and patients, of ERAS recovery and the of healthcare in to and This at by Andrew B.S., Ph.D., B.S., B.S., M.D., M.D., M. M.D., M. M.D., School of Medicine, the of a in of the of to in were and the and after on postoperative days and as well as from and from The (and in was approximately of the in or in preoperative patient (and was after surgery in patients who no by patients who had of (and approximately of preoperative and this had not by the postoperative of the of impact on to and the and to Surgery Using versus by M.D., Ph.D., M.D., M.D., M.D., M.D., Ph.D., M.D., Ph.D., M.D., Ph.D., M.D., Ph.D., M.D., Ph.D., Simon, M.D., Ph.D., Hospital have to of on and In surgery the for is and the of such are A total of patients undergoing anesthesia were randomized to as the primary or each to a common index, and with common patients demonstrated in in the after such were after versus Postoperative of were after versus Although was associated with a of postoperative pulmonary complications, this was not in LOS in the care unit or in the The study was to an impact on of impact the perioperative is required to and this impact patient outcome. of by M.D., Ph.D., James S. M.D., James M.D., Perioperative Medicine, Brigham and Women’s Hospital, Boston, is used to of in the patient is by of and of A new was to this The and of was compared with in There was a of between the two with a of ± These in patients with significant that is a for of rate that to a New of by M.D., Ph.D., B.S., M.D., Ph.D., James Ph.D., M. Ph.D., University and California. have at the the of a new of that as for in 12 those with were in in and their were in The most a of in with an of approximately demonstrated enhanced and of the of a new of that will as for Postoperative in with by and the by M.D., Ph.D., Ph.D., University of California, San San California. and surgery in the and in the postoperative period and this is and in of can The of exercise in and on and the was In the and were these were by preoperative exercise the in the exercise postoperative and provide an to improve surgical outcomes in patients. October 25, 1 pm to pm, San Diego Convention Center, Upper 4 Moderators M.D., Ph.D., University, M. M.D., University of California, San San California. of the A in to by M.D., M.D., Ph.D., James M. Ph.D., M.D., University, New York, New York. among the in only and this the for without system impact mostly by and and with and have been by In that were to one of the or the and of or were and in from versus and of each increased the of of in and demonstrated less in to with or with system a in by M.D., Ph.D., B.S., B.S., B.S., P. Ph.D., Ph.D., Medical Center, California. is four as common in than but in of pulmonary are The model the of to the and and In addition, the identification of the of the or the of were exposed to for and in these the of a of pulmonary of In addition, the of a was more important than the of the is and of that are in the provide of by of by M.D., A. Ph.D., M.D., Ph.D., M.D., Massachusetts General Hospital, Hospital for Boston, is an important of are in during and can impact on is not were to with in increased of and two to with a specific the of and the to total body of in among versus in by Andrew M.D., Ph.D., of Anesthesiology and Perioperative Medicine, California. The in with increasing of anesthesia has been to be due to increasing of of the the of is not A was to that and was in a of and was in 2 to increasing of of was in than in The data are with the that increasing of the is in due to of of from in versus in by M.D., Ph.D., Ph.D., Ph.D., N. M.D., Ph.D., N. M.D., Care and Medicine, Massachusetts General Hospital, Boston, better is in the and after from and and in to and were obtained from in were under to were Recovery of and was complete recovery of in the was These results that is recovery of during from anesthesia and that of is in in the in with in the of after by M.D., Ph.D., P. M.D., Ph.D., and University, Although is to to in of their to to be were to in and of the the in the after was with These data are with the that an important in death. the in and in A In by Ph.D., M.D., Ph.D., F. M.D., S. M.D., M.D., University School of Medicine, The of of and in is not from were and were with a The changes in in were in to of the not affect but the in of the The distribution of the the was not affected. The data that but does not to in the of with by M.D., Matthew M.D., M.D., Ph.D., M. M.D., M.D., University of California, San San California. exposure during the period to a substantial in that The is not but and to this The of on and were in and in and in the of exposed to increased and in and in In in the of the 4 after The data that is in by and that the of of Using and from These by M.D., Ph.D., M.D., Ph.D., M.D., Ph.D., M.D., Ph.D., M.D., Ph.D., M.D., Ph.D., University School of Medicine, in the 1 to is via were from and from patients with to and the were more exposure to than control The were that and and from these can as a model for the study of the of of in in by M.D., M.D., Ph.D., University Hospital, The of and in is a but a one for In these of and were in a for in each of these was These results will was from The authors no

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