Introduction: Rising Demand and Resource Constraint
One of the few constants throughout health-care is an inexorable rise in demand. This rise has been ongoing for many years and is driven by several factors. Across the decades, as health-care has advanced, demand has been generated by new life-saving and life-enhancing treatments, which reach patients and conditions previously untreated. For example, the total knee replacement (TKR) was first developed in the 1970s, yet more than 700,000 are now performed each year in the United States. The positive effect of such technical health-care advances, combined with changes in society and public health, significantly increases life expectancy in many developed countries (see Fig. 46.1 ). However, this increased life expectancy is now, in turn, providing a demographic driver of demand. The sharpest rise in demand is now occurring as the post-war “baby boom” generation reach old age, with a longer life expectancy than their forebears. The ultimate outcome of this is a progressively aging population. The global population aged over 60 years doubled between 1980 and 2017 and over the next 25 years the proportion of the population aged over 85 years will double in the UK. An aging population, with higher levels of morbidity and disability, drives increased health-care demand. How this rising demand will be met poses a significant challenge for all areas of health-care.
Historically, rising demand has been met through increased spending. Over the last 50 years, health-care spending has been on a steady upward trajectory both in raw currency terms and as a percentage of GDP (see Fig. 46.2 ). Such an inexorable rise cannot be a sustainable long-term solution. A 2007 report by the Congressional Budget Office of the United States suggested that if spending patterns increased at historical rates, health-care spending would approach 100% of GDP after 75 years, and even when some limits to excess spending are introduced, health-care could still account for almost half (49%) of GDP by 2082. It seems likely that figures of this magnitude will be deemed unacceptable by wider society. If demand continues to increase, yet spending cannot keep pace, there must be some constraint in health-care resources. In order to achieve the best health-care outcomes in a resource constrained environment value must be sought wherever possible. Perioperative medicine offers a means to deliver surgical care in a more cost-efficient manner. Interventions, pathways, and systems that aim to reduce complications and improve patient outcomes have a byproduct of reduced resource utilization and this chapter will explore how this may be delivered and its importance in what are set to be increasingly resource-constrained times.
The Cost and Value of Surgery
Surgery is, by its very nature, a resource-intensive undertaking. In the UK’s National Health Service (NHS) an operating theater is estimated to cost £1200/hour (approximately $1500/hour) or £20/minute. Even the most straightforward procedures, therefore, have significant cost attached. However, as the complexity escalates, so too do the costs of the procedure. A surgical implant, an inpatient hospital stay, a planned critical care admission all add to the total cost. What is important to recognize, however, is that the total cost is not dictated by the procedure alone. The same procedure performed on two different patients, or even the same patient under different circumstances, may yield an entirely different final sum. For example, the cost of an emergency procedure is higher than the equivalent procedure performed electively.
These cost variations arise in a number of ways. The duration of inpatient stay is a major influencer of final cost. NHS reference costs suggest an average figure of £431 (approx. $475) per excess bed day for elective care. Of course, extended inpatient stay is often dictated by clinical need, but reductions in length of stay (LoS) over the years suggest altered practice plays a role. Widespread variation in LoS, unexplained by clinical differences, continues to exist, suggesting scope for improvement remains.
The single biggest driver of increased costs, however, may be complications or morbidity. These can lead to prolonged length of hospital stay, additional investigations, reinterventions and additional critical care stays, each with associated costs. A study in the Netherlands suggested that although only 20.8% of colectomy patients develop major complications, these patients account for 53% of all costs. Studies in Europe and the United States replicate this marked cost increase in cases where postoperative morbidity occurs. Just as for prolonged LoS, complications will never be entirely preventable. Variation is found both within and between health-care systems. This suggests scope for improvement exists and a number of national projects, such as the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) in the United States and the Perioperative Quality Improvement Programme (PQIP) in the UK, seek to measure this and to promote quality improvement through reduction in unwarranted variation.
In summary, in settings where inpatient hospital stay and complications can be minimized significant monetary savings may be made, while performing the same procedure. Enhanced recovery after surgery (ERAS) offers some evidence of this occurring in practice. However, when considering cost reduction and factors that influence it, it is also key to consider another concept closely related to cost but importantly different, value.
Value is a complex concept that economists have debated for centuries. The most important part of this concept for our purposes, which most modern economists would agree with, is that value is related to the benefit, or utility, that the consumer gains, as well as the costs associated with it for the provider. In traditional free market economics, the consumer makes their own judgement on the benefit they will gain and decides upon a value. If this value is acceptable to the provider or seller, for example if it exceeds the cost, then a transaction or sale will take place. In reality there is more complexity but at its heart this is how trade works in most economic sectors.
In health-care, several factors distort this seemingly simple calculation. Government intervention is a feature in most health-care markets, although the level of involvement varies greatly and will modify or entirely remove the cost aspect of an individual consumers calculation. Even private insurance-based models distort choice on an individual procedure basis as the full cost of a single intervention may not be realized. Regardless of this economic distortion, the decision-making process for an individual is profoundly different where health-care is concerned. There is a high level of complexity in understanding the options available, and a significant knowledge imbalance between the provider and consumer. Even where symmetry of knowledge exists uncertainty remains: we are not yet able to predict with certainty the outcome of health-care interventions on an individual basis. The decisions can also be very high stakes, with life and death discussions not uncommon. There may often be limited time to make such decisions. All these factors combine to mean that patients cannot be expected to behave as the perfect, rational decision-maker of economic theory. Therefore, patients will, typically, and to differing extents, rely upon advice from health-care professionals. To protect patients and to ensure the impartiality of this advice, professional standards exist to govern the behavior of providers; further divorcing health-care from a typical free market scenario. Fortunately, health-care professionals continue to enjoy, comparatively, high levels of trust and play a vital role in guiding their patients through health-care decisions.
Returning to value, if we accept it is related to the benefit to the consumer (or in this case the patient) and combine this with the role of the health-care practitioner in guiding the patient, then the concept of value to the health-care provider should be inherently patient centered. A surgical intervention, which delivers no benefit or utility to a patient, no matter how low its cost, will offer extremely poor value, while conversely an expensive intervention that offers great benefit may offer good value. In essence minimizing the cost, both financial and personal, while maximizing benefit offers increased value. The challenge for health-care does not arise from understanding this concept or appreciating the importance of value, but instead from quantifying it.
Perhaps the simplest and most intuitive expression of this is :
An alternative expression, which has been advocated specifically for health-care is :
However, for both of these there is a fundamental limitation. Both require accurate and consistent measurement of both benefit and cost. Cost initially appears to be the simpler of the two. As discussed previously, while those issues are highly relevant, it is important to note when considering value we should assess not only the cost of the surgical intervention but also examine the full cycle of care for a patient. For example, it has been suggested that bariatric surgery may significantly reduce health-care costs in the long-term by reducing the severity and costs of managing chronic conditions such as sleep apnea, diabetes, and asthma, while other surgeries such as transplants may require additional lifelong medical costs.
The measurement of benefit is more complex still. The challenge here is twofold. First, how to predict and subsequently measure the benefit of any intervention and second, how this measured benefit can then be quantified in a uniform fashion to allow a meaningful cost benefit analysis. Considering the latter: one option is to place a monetary value on health-care outcomes, however, this approach is fraught with challenges and no perfect solution exists. A number of approaches have been advocated including: cost-effectiveness analysis, cost-utility analysis, and incremental cost-effectiveness ratios (ICERs). None of these is without controversy. ICERs, for example, are widely used in the UK by the National Institute for Health and Care Excellence (NICE) to define thresholds for providing a treatment. In the United States, however, the Patient Protection and Affordable Care Act (2010) prohibited the use of cost-effectiveness thresholds by Medicare, although their ongoing use in research was not affected.
Each approach discussed previously has potential advantages and pitfalls. Yet conceptually they all encourage a drive toward the same endpoint. Value in health-care should be about delivering the maximal patient benefit for the minimal unit cost. This should be measured with the patient at the center, examining the entire health journey, not siloed to individual elements. This will be increasingly important as resource constraints becomes a more pervasive feature of global health-care. The remainder of this chapter will focus on the role of perioperative medicine in delivering this.
Shared Decision Making
Having discussed value and the traditional economic model of relating it to consumer/patient benefit it would seem logical to seek to replicate this as closely as possible within health-care. A number of the challenges discussed (relating to complexity, knowledge imbalance, uncertainty of outcome and benefit, and time to make decisions) are all factors that can be potentially ameliorated.
Shared (or collaborative) decision making (SDM) is an approach to surgical decision making, which focuses on the patient, their individual circumstances, health and views and helps them to decide between treatment options, including no treatment at all. The model allows clinicians, ideally working in a multidisciplinary team, the time and resources to meet with patients and families and overcome many of the barriers to patients making their own value judgment as has been discussed earlier. Complex decisions can be broken down, additional information provided, time given and, although uncertainty of outcome and benefit are unavoidable, we are able to provide individualized risk estimates.
The consequence of SDM on value is likely to be positive. Although there are resource implications for operating a SDM service these may be outweighed by patients making alternative health-care choices. During SDM, patients who are at high risk of complications and poor outcomes will have this explained to them. A proportion of these patients are likely to weigh this against the potential benefits of surgery and opt for either no surgery or alternative less high-risk interventions. This is in line with the earlier discussion about consumer value judgments. The choice for alternative, or no, treatment is most likely to be made by those at highest risk and as we have discussed postoperative complications dramatically increase health-care costs, while these high-risk patients may also receive less benefit as perioperative morbidity is associated with poorer long-term health outcomes. As such, through SDM we are able to empower patients to make the appropriate decisions for themselves, while simultaneously reducing some of the highest risk procedures, all whilst avoiding paternalistic rationing of care. Indeed, a recent study explored the association between SDM, resource utilization and patient-reported outcome measures (PROMs) and suggested that poor SDM was associated with increased resource utilization and worse PROMs.
The value challenge for SDM is likely to be related to how it is delivered. Although the principles of SDM should be applied in all cases, a dedicated multidisciplinary discussion or clinic may only deliver value for higher risk groups. For example, the cost of delivering this to generally healthy individuals undergoing minor procedures is unlikely to yield significant reductions in resource utilization as few will opt for alternative, less resource intensive, options. At present insufficient data exist to provide a clear level of risk or complexity at which a formalized SDM process will improve value, although there is an argument for a clinical and ethical imperative of SDM for all. Further study will hopefully yield more information on cost effectiveness at different levels of risk; but at present clinicians should focus on applying the principles at all patient consultations and ensuring those at highest risk are prioritized for formal SDM.
The majority of patients, particularly in the context of an aging population, are likely to have some kind of modifiable factors, which contribute to their risk and subsequent outcome (physical fitness, anemia, smoking, etc.). As the name suggests, these are modifiable and with suitable interventions risk may be reduced and outcomes improved. However, many of these interventions require, or benefit from, time. At present, surgical pathways tend to focus on evaluation of the primary pathology and deciding upon the optimal treatment. There is often no, or extremely limited, evaluation of overall physiology and modifiable risk factors, while surgery is being contemplated (see Fig. 46.3 ). It is only after the final decision to operate is taken that these are considered, by which point time is often limited. An alternative pathway has been proposed (see Fig. 46.4 ), which emphasizes that this “patient staging” at the point of contemplation greatly increases the time available for addressing modifiable risk factors, as well as informing the multidisciplinary team about overall patient physical status for any proposed interventions. This pathway also offers variable levels of assessment and intervention based on risk, addressing some of the issues discussed previously regarding SDM, which also apply to other preoperative measures.