Presentation
Evaluating Perioperative Surgical Home Model in a Rural Community Hospital Compared to a Traditional Surgical System
Event Type
Oral Presentations
TimeThursday, June 9th4:00pm - 4:30pm EDT
Location
DescriptionBackground
Perioperative Surgical Home (PSH) was designed by the American Society of Anesthesiologists (ASA) to improve perioperative care through more coordinated and communicative decision-making. Compared to traditional surgical systems, the PSH system is a coordinated interdisciplinary team encompassing all the surgical care provided to patients from preoperative (30 days before surgery) to recovery phase (90 days after surgery). PSH was developed as a solution to achieve the healthcare triple aim of improving patient experience, improving health of the patient population, and being compatible with the new payment to reduce healthcare costs. PSH has proven its successes in large urban health centers by reducing surgery cancellation, operating room time, and readmission rates. Only limited studies have been done on assessing surgical outcomes and quality in rural areas through PSH. The study compares surgical outcomes – Length of Stay (LOS), discharge disposition, and 90-day readmission of the Total Joint Replacement (TJR) procedures – from cohorts before and after implementation of PSH at a rural community hospital.
Methods
An initial PSH outpatient clinic was created at a rural community hospital. The PSH clinic affiliated with the hospital began seeing TJR patients in November 2018. The hospital was an 83 bed, licensed level-III trauma center primarily serving three counties, but often saw patients from more than 10 surrounding counties in the region. The research team, composed of system engineers and clinicians, retrospectively collected and analyzed TJR surgery data from the hospital.
The data from the period November 2017 to April 2018 (before implementation of PSH, n = 324) was compared with data from the period November 2018 to April 2019 (after implementation of PSH, n = 326) to account for seasonal and surgical volume fluctuation. Other variables like type of procedure (total hip, knee, shoulder, or unilateral knee replacements), insurance (private or public payer), and home of record county (patient’s residence) were also considered in the analysis.
Statistical analysis including the chi-square test or fisher’s exact test were used to compare the categorical data between two cohorts. The continuous data between the cohorts were analyzed using Mann-Whitney test or Student’s t-test, as appropriate. The Poisson regression was used to fit an adjusted model for LOS. Similarly, the binomial logistic regression was used to fit an adjusted model for discharge disposition and 90-days readmission after surgery. All data handling, visualization, and statistical analysis were performed using R (V 4.0.3, Vienna, Austria).
Results
There was a significant difference observed in LOS between PSH and non-PSH cohorts using Mann-Whitney test (median = 33 vs 40 hours, P-value = 0.021). The chi-square test was found significant for discharge disposition between PSH (17 discharged to a nursing facility out of 326) and non-PSH (36 discharged to a nursing facility out of 323) cohorts, P-value < 0.01. The fisher test had moderate evidence for a difference in the readmission rates between PSH (11 readmitted after surgery) and non-PSH cohorts (22 readmitted after surgery), P-value = 0.051.
In adjusted general linear models, implementing PSH had a significant effect on LOS (P-value < 0.01), discharge disposition (P-value < 0.01), and readmission (P-value = 0.03). Other variables like procedure type (P-value < 0.01) and insurance type (P-value < 0.01) affected the patient’s LOS. Similarly, procedure type (P-value = 0.04), insurance type (P-value = 0.01), and patient’s LOS (P-value < 0.01) had a significant effect on discharge. For readmission, the insurance type (P-value = 0.02) was found significant against patient’s 90-day readmission rate.
The results delineated how PSH system’s functionality in the rural surgical system improved TJR surgical outcomes: LOS, discharge disposition, and readmissions. The PSH preoperative process, approximately 30 days before surgery, helped clinicians identify patients with high risks. The preoperative phase, usually led by a PSH-registered nurse and physician assistant, enabled a thorough patient assessment and quantified risks in a standardized way.
Conclusion
Rural areas require more attention in terms of quality healthcare and good surgical outcomes. Almost more than fifty percent of patient seen in total joint surgery have some medical complication or high-risk patients leading to adverse effect if not taken care of it properly. Poor surgical outcome has been an important problem faced in community hospitals which leads to suboptimal surgical care for patients. Through this study, the authors identified how PSH system in rural community hospitals works to optimize and standardize the surgical process which helps in reducing LOS, readmissions, and fewer discharges to nursing facilities.
PSH system was designed by ASA to improve perioperative care through more coordinated and communicative between surgical clinicians. The PSH system incorporates anesthesiologist, surgeon, hospitalist working together as a team for a pathway for improving safety, quality of services, and patient satisfaction. Future research should include more variables associated with risk for poor surgical outcomes such as age, gender, Body Mass Index (BMI), and ASA score for a better understanding of PSH influence in the rural surgical system.
Perioperative Surgical Home (PSH) was designed by the American Society of Anesthesiologists (ASA) to improve perioperative care through more coordinated and communicative decision-making. Compared to traditional surgical systems, the PSH system is a coordinated interdisciplinary team encompassing all the surgical care provided to patients from preoperative (30 days before surgery) to recovery phase (90 days after surgery). PSH was developed as a solution to achieve the healthcare triple aim of improving patient experience, improving health of the patient population, and being compatible with the new payment to reduce healthcare costs. PSH has proven its successes in large urban health centers by reducing surgery cancellation, operating room time, and readmission rates. Only limited studies have been done on assessing surgical outcomes and quality in rural areas through PSH. The study compares surgical outcomes – Length of Stay (LOS), discharge disposition, and 90-day readmission of the Total Joint Replacement (TJR) procedures – from cohorts before and after implementation of PSH at a rural community hospital.
Methods
An initial PSH outpatient clinic was created at a rural community hospital. The PSH clinic affiliated with the hospital began seeing TJR patients in November 2018. The hospital was an 83 bed, licensed level-III trauma center primarily serving three counties, but often saw patients from more than 10 surrounding counties in the region. The research team, composed of system engineers and clinicians, retrospectively collected and analyzed TJR surgery data from the hospital.
The data from the period November 2017 to April 2018 (before implementation of PSH, n = 324) was compared with data from the period November 2018 to April 2019 (after implementation of PSH, n = 326) to account for seasonal and surgical volume fluctuation. Other variables like type of procedure (total hip, knee, shoulder, or unilateral knee replacements), insurance (private or public payer), and home of record county (patient’s residence) were also considered in the analysis.
Statistical analysis including the chi-square test or fisher’s exact test were used to compare the categorical data between two cohorts. The continuous data between the cohorts were analyzed using Mann-Whitney test or Student’s t-test, as appropriate. The Poisson regression was used to fit an adjusted model for LOS. Similarly, the binomial logistic regression was used to fit an adjusted model for discharge disposition and 90-days readmission after surgery. All data handling, visualization, and statistical analysis were performed using R (V 4.0.3, Vienna, Austria).
Results
There was a significant difference observed in LOS between PSH and non-PSH cohorts using Mann-Whitney test (median = 33 vs 40 hours, P-value = 0.021). The chi-square test was found significant for discharge disposition between PSH (17 discharged to a nursing facility out of 326) and non-PSH (36 discharged to a nursing facility out of 323) cohorts, P-value < 0.01. The fisher test had moderate evidence for a difference in the readmission rates between PSH (11 readmitted after surgery) and non-PSH cohorts (22 readmitted after surgery), P-value = 0.051.
In adjusted general linear models, implementing PSH had a significant effect on LOS (P-value < 0.01), discharge disposition (P-value < 0.01), and readmission (P-value = 0.03). Other variables like procedure type (P-value < 0.01) and insurance type (P-value < 0.01) affected the patient’s LOS. Similarly, procedure type (P-value = 0.04), insurance type (P-value = 0.01), and patient’s LOS (P-value < 0.01) had a significant effect on discharge. For readmission, the insurance type (P-value = 0.02) was found significant against patient’s 90-day readmission rate.
The results delineated how PSH system’s functionality in the rural surgical system improved TJR surgical outcomes: LOS, discharge disposition, and readmissions. The PSH preoperative process, approximately 30 days before surgery, helped clinicians identify patients with high risks. The preoperative phase, usually led by a PSH-registered nurse and physician assistant, enabled a thorough patient assessment and quantified risks in a standardized way.
Conclusion
Rural areas require more attention in terms of quality healthcare and good surgical outcomes. Almost more than fifty percent of patient seen in total joint surgery have some medical complication or high-risk patients leading to adverse effect if not taken care of it properly. Poor surgical outcome has been an important problem faced in community hospitals which leads to suboptimal surgical care for patients. Through this study, the authors identified how PSH system in rural community hospitals works to optimize and standardize the surgical process which helps in reducing LOS, readmissions, and fewer discharges to nursing facilities.
PSH system was designed by ASA to improve perioperative care through more coordinated and communicative between surgical clinicians. The PSH system incorporates anesthesiologist, surgeon, hospitalist working together as a team for a pathway for improving safety, quality of services, and patient satisfaction. Future research should include more variables associated with risk for poor surgical outcomes such as age, gender, Body Mass Index (BMI), and ASA score for a better understanding of PSH influence in the rural surgical system.
Authors
Doctoral Candidate
Anesthesiologist