Do we need regional in ERAS?

1. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anesthesiology
University of Ottawa
Head of Anesthesiology
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Enhanced Recovery and Regional
Anesthesia:
Do we need regional?

2. Conflicts of Interest
 Consultant for Teleflex Medical
 I will not be discussing off-label or
investigative uses of commercial
devices

3. Objectives
 Describe the place of enhanced recovery
in perioperative care
 Learn the place of regional anesthesia in
enhanced recovery
 Examine the current evidence to support
regional anesthesia within the enhanced
recovery process
 Look at the future of regional anesthesia
in ERAS

4. Summary
 ERAS pathways have become common for colorectal and
orthopedic surgical pathways
 Regional anesthesia techniques are used in many
pathways but use has suffered due to educational and
other barriers
 Regional anesthesia has demonstrated several benefits
for patients in ERAS pathways
 As healthcare spending becomes further constrained we
need to align our outcome measures with those being
used to justify funding for our interventions

6. Enhanced Recovery after Surgery
 Largely influenced by work of Professor
Henrik Kehlet (Denmark)1
 Integrated coordinated bundles of care
with a focus on multimodal techniques
and interdisciplinary care
 Major focus on colorectal and orthopedic
surgery
 Regional anesthesia often included
1Kehlet H BJA 1997; 78: 606-17

7. Enhanced Recovery after Surgery
 Less use of ERAS pathways outside
colorectal and orthopedic surgery
 Barriers to implementation in many
centres
 Regional anesthesia use often limited
 Specific focus on evidence-base for
regional within ERAS not available
1Kehlet H BJA 1997; 78: 606-17

8. Concepts within ERAS
 Standardization of care
 Evidence-based care
 Multimodal care pathways based on best
evidence
 Multidisciplinary (focus on the team)

9.  Many reviews of efficacy of enhanced
recovery protocols
 Little written about specific place of RA
with ERAS protocols
 Scoping review to examine area
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

10.  Scoping review: a rapid
gathering of evidence in
a given clinical area with
an aim to accumulate as
much evidence as
possible and map the
results
 Focus on triple aim
outcomes
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

11. Institute for Healthcare Improvement
Triple Aim in Healthcare

12.  Searched for all articles that examined
regional anesthesia within an enhanced
recovery pathway (ERP)
 EMBASE, MEDLINE, CENTRAL, CDSR,
PROSPERO and the NHS Evaluation
Database
 Inception to May 2015
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA 2015

13.  695 unique citations; 446 excluded after
title review, 249 full text review with 191
excluded
 58 unique studies for data extraction
 67% RCTs and one non-randomized trial
 14 controlled before-and-after studies, 5
retrospective cohort studies and one
prospective cohort
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

14.  >50% of studies examined colorectal
surgery
 Orthopedic (21%) and other types of non-
colorectal general surgery (29%)
 Regional techniques: Epidural, SAB, TAP
block and lower limb PNB techniques
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

15. Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

16.  Good news! Strong evidence that RA
provides:
– Improved pain control
– Improved organ function and mobility
– Reduced PONV, length of stay and adverse
events
 Bad news: little focus on triple aim
outcomes
Dan McIsaac MD MPH, Evan Cole MD and Colin McCartney MB PhD BJA: in press

17.  Elective colon resection
 64 patients randomized to epidural or PCA
 Primary outcome: 6 MWT
 Secondary outcome: HRQoL: SF-36

18.  Both groups had decrease in 6MWT and
SF-36 3 and 6 weeks following surgery
 Significantly greater decrease in the PCA
group (p<0.01)

19.  Clinical pathway including multimodal
analgesia and continuous PNBs
 Reduced length of stay, hospital costs and
improved pain control

20. Bad News
 Poor translation of current evidence into
practice
 Little focus on Triple Aim

21. Wong PA, McCartney CJ et al Pain Medicine: In press

22.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

23.  120 patients randomized to spinal vs TIVA
for TKA
 Primary outcome: LOS
 No opioid (intrathecal or other) in spinal
group
 Both groups received LIA

25. The KT Gap and RA?
Patient factors
System factors
Education factors

26. Barriers to RA
 Patient education
 Surgeon education
 Anesthesiology
education
 Administrative barriers

27. Patient education
 Patients don’t like
needles
 Patients don’t like
being awake in
the OR
 Patients don’t like
postoperative pain

28. Importance of good acute pain
control to patients
Apfelbaum JL A&A 2003

29. Surgical education
Masursky D et al A&A 2008

30. Anesthesiology education
 Anesthesiologists remain poorly trained in
regional anesthesia
 Anesthesiologists fear risk of failure and
complications
 Leadership and support must come from
the top of every department

31. Administrative Barriers
 Anesthesiology leadership and leadership
in perioperative medicine
 Hospital funding silos
 Overfocus on RCT evidence and lack of
larger population-based evidence

32. Anesthesiology Leadership
 We need to leading perioperative teams in
our hospitals
 Invest in our ability to care for patients
from admission to discharge
 Realize that anesthesiologists are the key
perioperative physicians
 Understand the threat to our patients if
we do not step up

33. Funding Silos
 Inability to leverage total hospital savings
against possible increase in OR costs
 No incentive to save costs in our current
system
 Funding of innovative but unproven
therapy at expense of “less sexy” proven
methods

34. Overfocus on RCT evidence
 RCTs constitute <25% of all patients
 Strict inclusion/exclusion criteria
 ? Reflect real practice
 Pragmatic trials possibly the answer
 Good quality case control or cohort studies
 Definition of standardized outcomes
across studies
 More focus on longer term outcomes

37.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

39. Bad News
 Poor translation of current evidence into
practice
 Little focus on Triple Aim

40. Importance of Triple Aim
 Used increasingly by government agencies
to allocate funding:
– US: Centre for Medicaid and Medicare
Services
– Canada: Provincial Funding Model and
Quality-Based Procedures
– UK: CQUINS: Commissioning for Quality and
Innovation Payments

41. What outcomes do we need to
study?

42. What is patient experience?

43.  “a national study revealed that patients who
reported being most satisfied with their doctors
actually had higher healthcare and prescription
costs and were more likely to be hospitalized
than patients who were not as satisfied. Worse,
the most satisfied patients were significantly
more likely to die in the next four years”
http://www.theatlantic.com

44. Patient Experience vs Satisfaction
 Patient experience goes beyond patient
satisfaction and making patients happy
 You may have a negative outcome but a positive
experience
 You may have a positive outcome but a negative
experience
 Patient experience is linked to staff engagement
 Patients judge healthcare providers not only on
outcome but on compassionate and excellent
patient care

45. What measures should we use?
Phase of
recovery
Definition Time
Frame
Threshold Outcomes Example of
measures
Early OR to PACU
discharge
Hours Safety (to go
to ward)
Physiological Aldrete
Score
Intermediate PACU to
hospital
discharge
Days Self-care Symptoms
and
impairment
of IADL
Quality of
Recovery
score
Late Discharge
to return to
normal
function
Weeks to
months
Return to
normal
Function and
HRQoL
6MWT
CHAMPS
SF-6D
Lee L et al Surgery 2014

46. What can we focus on?
Process vs Outcome Measures
 Timing of antibiotic administration and SSI
 Patient warming and CVS events
 Use of neuraxial anesthesia
 Use of multimodal analgesia and effective
early pain control and rehabilitation

47. What can we focus on?
Process vs Outcome Measures
 Focus on quality of care for individual
patients. Smaller RCTs and QA processes
 Focus on standards of care for populations
of patients. Larger pragmatic and
population based studies to determine
broad guidelines for care e.g. AAOS, HQO

48. Summary
 ERAS pathways are common for colorectal and
orthopedic surgical pathways
 Regional anesthesia techniques are used in
many pathways but use has suffered due to
educational and other barriers
 Regional anesthesia has demonstrated several
benefits for patients
 Align outcome measures with Triple Aim to
ensure funding of valuable interventions

49. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anesthesiology
University of Ottawa
Head of Anesthesiology
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Enhanced Recovery and Regional
Anesthesia:
Do we need regional? Yes

50. What do we need?
 Studies of RA that focus on outcomes relevant
to patients and the system
 Studies examining non-colorectal and orthopedic
populations
 A system that facilitates use of best treatments
 Invest in our own clinical, education and
research leaders looking outside our own
institutions
 Don’t forget about the importance of pain
control, care after discharge and care of each
individual

51. Winterlude Anesthesia 2016
January 30-31, Ottawa
http://www.med.uottawa.ca/anesthesia/eng/06_winterlude.html