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October 17, 2012
8:00:00 AM - 9:30:00 AM
Room 101
Surgical Home: Anesthesiologist-Directed Preoperative Triage Reduces Unnecessary Testing and Associated Economic Burden
Sharon Carrillo, M.D., M.S., Melody J. Ritter, M.D., James R. Douglas, M.D.,Ph.D., Andre's Rubiano, B.A., Armin Schubert, MD, MBA
Ochsner Medical Center, New Orleans, Louisiana, United States
Background: Anesthesiologist-directed preoperative clinics are a component of the “Surgical Home,” a concept identified to create substantive savings in surgical health care. Our premise is that dedicated anesthesiologists likely have more insight into surgical stresses and test requirements than primary care physicians (PCP) who, with surgeons, still predominantly “clear” most patients in U.S. clinical practice. Goals of the Surgical Home include increased efficiency and coordination of care and decreased healthcare costs without sacrificing outcomes.

Methods: We developed a comprehensive preoperative triage process where anesthesiologists review available electronic medical records (EMR), order tests, and request appropriate consults for total knee arthroplasty (TKA) and total hip arthroplasty (THA) for certain orthopedists. After review of the clinic medical record, preoperative testing was based on algorithms devised using evidence-based practice and collaborative decision-making for given surgical and medical risk profiles. For example, APTT was not obtained without history of unusual bleeding or coagulapathy. Screening PT/INR was ordered if patients would receive warfarin postoperatively. A basic metabolic profile (BMP) replaced the more costly comprehensive metabolic profile (CMP) except in current or suspected liver disease or heavy alcohol use. With no previous EKG, a screening EKG was obtained for healthy patients >65 years old. Key medical conditions factored into EKG screening at any age. Symptoms or exam findings triggered CXR’s. With this approach, duplicate tests were avoided.

IRB exempt status was obtained for manual and electronic surgical database query. Analysis was restricted to ASA II and III patients due to the infrequency of ASA I and IV TKA/THA cases. The Triage Group was comprised of 101 ASA II and 118 ASA III patients occurring from 1/1/10 to 4/15/11. The Non-Triage Group included 543 ASA II and 589 ASA III patients in the database between 1/1/08 and 4/15/11, who received standard practice evaluation. Using a 30 day look-back from surgery start, blood test counts were determined by an automated search of our EMR using a Structured Query Language (SQL) approach. Review of EKG and CXR testing was manually conducted for both triage and control groups. About 15% of Triage cases were excluded from group comparisons for EKG and CXR frequency because PCPs added these outside of our Triage plan.

Results: Table 1 shows the comparison of common tests per 100 patients for the both groups. Based on each test frequency and established fees, the net estimated reduction of charges in the Triage Group was $18,187 for ASA IIs and $20,664 for ASA IIIs as compared to the Non-Triage Groups. Although some test rates appear lower in the Triage Group, automated data collection did not allow calculation of standard deviations, therefore precluding statistical analysis. EKG and CXR rates were lower in the Triage Group (chi square analysis; P<0.01) for both ASA II and III categories. It is of interest that these findings were observed during a period in which an external auditor, HealthGrades, determined that major complications in TKA/THA cases for our institution were decreasing.

Conclusions: If the observed favorable trends can be extended to other surgical groups and tests, an even greater impact can be expected. We plan to study preoperative triage in other surgical cohorts, assessing clinical outcomes and quantifying the value stream of anesthesiologist-directed perioperative efficiency and resource stewardship in the context of the Surgical Home.

Figure 1

Copyright © 2012 American Society of Anesthesiologists