Redesign of Perioperative Care Pathways


Patients follow a journey through time when they progress from the first symptoms or screening tests, through investigations and receiving a new diagnosis of cancer, to the initiation of treatment and beyond. The notions of “survivorship” and “living with and beyond cancer” encapsulate the changing face of this journey and emphasize the chronicity of experience that people with cancer now have. Increasingly effective cancer treatments are facilitating prolonged survival living with, or cure from, cancer. With these changes come ever more complex clinical pathways, as each patient navigates their unique journey through the intricate landscape of treatments, tumor response, and personal resilience.

Surgery is the most common first intervention for solid tumors, but many patients will receive systematic anticancer treatments (e.g., chemotherapy targeted therapies or hormonal treatment) and/or radiotherapy during their treatment. As survival following cancer continues to increase, so the likelihood of having multiple sequential different treatments rises. While these journeys may not feel like simple linear paths to the person with cancer, health care providers often focus on the idea of such a linear pathway in order to conceptualize the patient journey and to contrast this thinking with a “silo” focused approach, which has historically been associated with limited attention on how different components of each pathway interact together.

Pathway-based thinking has been driven by a number of factors, including policy, economics (funding mechanisms), and patient engagement in health care. Integrated care, meaning seamless integration of care between primary and secondary care settings, is increasingly seen as more efficient and effective than alternatives for both practical and financial reasons. Modifying underpinning funding mechanisms, which incentivize the way that care is delivered, may be the most economical approach to the challenge of managing relentlessly escalating health costs. The transition from fee-for-service through bundled payments to, in some cases, capitation payment mechanisms exemplifies this and contributes to the drive toward improved integration of care. Finally, better informed patients have less patience with constraints on care delivery that are driven by provider, rather than patient, convenience. Each of these factors serves as a driver toward a focus on pathways rather than silos of care.

This chapter will explore these drivers for pathway-based care, the processes through which pathway reorganization may be achieved, and the consequences for perioperative care in general and in relation to specific elements of that care.

Drivers for Pathway-Based Care

Patient Versus Provider Perspectives

Care providers often contextualize themselves according to their setting. Their thinking and actions are typically based on their immediate physical and organizational interactions. For example, surgeons and anesthetists/anesthesiologists typically focus primarily on the operating room environment and adjacent areas (preoperative ward and recovery). Moreover, operational budgets within hospitals are characteristically held at a department level, with surgery separate from anesthesiology or medicine. In fee-for-service settings, this division is magnified by the consequences of which particular individuals or departments receive fees. Such an environment has been described as “silo-based care,” in which the boundaries between specialty silos are identified as obstacles to the efficient and effective delivery of care. These boundaries may be physical, for example the setting of care, or organizational, for example the way departments or budgets are arranged. These issues are of particular relevance to elective/scheduled secondary care pathways where the efficient integrated function of many components of the hospital, working in concert with primary/community care, is essential to facilitate the best preparation for and recovery from significant intervention such as major surgery.

Currently, it can be argued that the “timing, location and manner of interactions between patients and health care providers are frequently dictated by provider priorities rather than patient wishes.” “Control of the pathway resides almost exclusively with the providers, not those being provided for.” Services are often arranged for the convenience of providers. Patients typically come to doctors, during normal working hours, and at a place of convenience for the doctor, not the patient. To date, limited effort has been invested in remote consultation for most patients, and those developments that have taken place in this area have often been driven by financial efficiency considerations, rather than patient convenience.

A variety of approaches are available that can readily facilitate the delivery of more patient-focused care and overcome some of the challenges presented by health care delivery “silos.” Technologic developments, including remote consultations and diagnostics, facilitated via telemedicine, the use of wearable technologies for screening diagnosis and monitoring of physiologic signals, and the use of mobile devices for collecting health data and disseminating health information (so-called m-health). The requirement for the patient to attend a face-to-face interaction with a health care worker may diminish as these innovations are adopted more widely among secondary care providers. Such changes enable patients to interact with health care professionals at a time and in a setting of their choice, rather than at the convenience of others. Furthermore, it may allow them to have important communications, such as the diagnosis of cancer, to be delivered in a timelier manner than is possible with traditional face-to-face interactions. While not all patients may be attracted to such methods of communication, some may cherish the face-to-face clinical interaction; these approaches offer the potential for better and more efficient interactions for many.

Patients are increasingly involved in contributing to the development of health care services. Experienced-based co-design (EBCD) is becoming more common and incorporates the “lived experience” of non-health care professionals (patients and public) in contributing to service design across primary and secondary care. Examples have included cancer care, palliative, and end-of-life care pathways.

Early evidence supports the notion that patients may engage better with such pathways.

Health Policy Developments

The “Triple Aim” proposed by the US Institute for Health care Improvement encapsulates improving individual patient experience of care (including quality and experience), health of the population, and value. , Two current areas of policy that are linked to this are personalized care and integrated care.

The concept of personalized care links two distinct concepts. First, the ever growing availability of data with which to make decisions about health care, for example, in relation to the various “omics” techniques (genomics, metabolomics, etc.) has the potential to provide information to guide care at an individual patient level. Second, patients increasingly expect to take more control over their own health as the paternalistic model of health care becomes less common. One example of improving patient control is the idea of “personal health budgets” in which patients within a publicly funded health care system have control over some of the resources available to fund their care and allocate them according to best information and advice. This is linked with initiatives around shared decision-making (SDM), such as the international “Choosing Wisely” movement, as well as the provision of better and clearer data to inform choices, for example through the UK NHS Choices website in the UK. Such developments are symptomatic of the evolution from traditional paternalistic approaches to health care, in which the physician made decisions about the patient care, to so-called “patient-centered care” in which decisions are made in partnership between health care provider and patient. In some situations, patients may behave as independent consumers with little reference to health care providers, particularly in relation to diagnostic services such as “screening scans” and over-the-counter genetic information.

Integrated Care Organizations (ICOs) deliver care across a defined geography by an alliance of relevant health care providers in primary, secondary, and social care. The development of ICOs has, in part, been a response to the economic challenges outlined in the following section and the quest for value in modern health care. There is a perception that fundamental changes in methods of service provision (e.g., pathway redesign) are required to meet current funding challenges; incremental cost-saving and gradual refinement of services are unlikely to offer a solution. ICOs stand in contrast to the concept of market-driven local health economies and certainly in the UK, represent a response to the perceived failure of a local health care market embodying arrangements such as the “purchaser-provider” split. An important aspect of ICOs is that funding is allocated at the level of geographically defined populations resulting in a so-called “capitation” mechanism (see later). Such capitation mechanisms may be a more efficient means of achieving value, defined as outcome per unit cost, than traditional fee-for-service or more recent “bundled payment” mechanisms, which tend to incentivize activity, rather than improved outcome.

Health Economics

The fundamental challenge in relation to health economics in high-income countries is the relentlessly rising cost of health care as a consequence of apparently limitless demand. Achieving health care cost containment has become a political imperative as the proportion of gross domestic product that is allocated to health care approaches one-fifth in the United States and exceeds 10% in many high-income countries.

The key drivers of cost escalation are health care innovation and demographic change. Health care innovation is probably the primary driver: interventions from knee replacements through complex cancer surgery and novel biological anticancer agents are new to our therapeutic repertoire and each innovation becomes a new drain on the limited available pool of health care resource. However, each of these innovations also contributes to improvements in the quantity and/or quality of life for patients for whom they provide benefit. This benefit is, in turn, at least partially responsible for the demographic change that is taking place in high-income countries, where life expectancy is rising in parallel with the duration of life living with comorbidities. As the population ages, life expectancy in good health rises more slowly, and consequently time lived with ill health is progressively increasing with the associated attendant health care costs.

One way in which health care controls may be brought under control may be through modification of funding mechanisms within health care systems. Incentivization resulting from different funding mechanisms is recognized to be a key driver of behavior within health systems. For example, “fee for service” models incentivize physician activity through encouraging the conduct of tests and procedures that can be billed for and thereby increase the income of health care providers. With this funding model, it may be argued that physician and patient interests are not aligned and perverse incentives may arise: physicians get more remuneration the longer and more complicated a patient’s hospital stay. In such a setting, there is little financial incentive to make a decision against surgery as both the procedure and any adverse consequences will provide revenue to the provider. By contrast, so-called capitation involves the provision of funding to particular geographically or functionally defined groups of patients to provide for their entire health care needs. In such a system, the incentives for health care providers are to maximize positive health outcomes and minimize burden on the health care system to provide the greatest benefit to the largest number of patients. So called “bundled payment” systems reside in the middle ground between these two approaches. Bundled payments involve the provision of funding for all the care of a particular category of patients with a specific problem. For example, elective hip surgery may attract a certain monetary tariff that is fixed for all patients. Hospitals that deliver good efficient care with few adverse outcomes will be rewarded through the generation of an operating surplus within such a system. Less efficient and effective systems with worse outcomes will lose money and may therefore exit the market, invest in improving their processes, or focus more attention on decision-making with respect to which patients they operate on.

Each system favors a particular type of thinking in relation to organization of activity. Fee-for-service models will tend to drive organizations into provider silos with types of practitioners who receive payments (e.g., surgeons) being protective of this situation and tending to make choices that contribute to increasing activity, and therefore income. Bundled payments tend to drive behavior at an institutional level, which may for example encourage institutions to avoid higher-risk patients because of the institutional level-financial risk. Capitation systems tend to drive thinking across the whole health care system, in order to maximize positive outcomes while minimizing cost. Both bundled payments and capitation systems tend to encourage attention to pathways in contrast to silos. Saving money in one silo is of little benefit to an institution or health care system if the consequence is to drive up costs in another part of the system. Movement toward capitation funding mechanisms is an important element of the ICOs discussed above.

Pathway Reengineering

One approach to addressing the challenge of silo-based care and moving toward a pathway focus is encapsulated in the methods of business process reengineering (BPRE). BPRE is an approach borrowed from the corporate management literature that is based on the analysis of workflows and process in order to facilitate fundamental redesign of a more efficient and effective health care system. The aims of BPRE are to improve “customer experience” and efficiency and thereby lower costs. In the context of health care, “customer experience” can be reframed as “patient outcomes and experience,” and the effectiveness of the pathway in delivering patient outcomes becomes an important driver of value along with attention to cost containment. Self-evidently, these ambitions are consistent with the recognized aims of health care systems, including the IHI Triple Aim discussed earlier. ,

In the health care setting, execution of BPRE requires careful mapping of the relevant clinical pathway(s), with attention to the timing and scale of flow of patients at different decision points followed by deconstruction/reconstruction according to the aims of patient focus, efficiency, and value. Experience with pathway remodeling in relation to the introduction of enhanced recovery pathways has taught us that achieving such reengineering is only likely to be successful in the context of a multi-disciplinary approach.

In the perioperative context a critical element of such reengineering is moving the encounter between perioperative specialist and patient earlier in the pathway. As an example, preoperative assessment clinics typically take place a few days before surgery. The consequence of this timing is that opportunities for preoperative intervention and decision-making are substantially limited. The alternative approach involves restructuring the pathway to ensure that the encounter between specialist and patient occurs as soon as possible after the “moment of contemplation of surgery”—the first time that surgery becomes a significant likelihood. Such a change enables improved decision-making in relation to future treatments as well as providing the opportunity to improve patient resilience in the face of an imminent physiologically challenging treatment (e.g., surgery, chemotherapy). Examples of traditional and “reengineered” pathways are shown in Fig. 16.1 . However, such changes require close inter-disciplinary working with a focus on best patient outcomes, rather than on provider convenience.

Jun 26, 2022 | Posted by in ANESTHESIA | Comments Off on Redesign of Perioperative Care Pathways
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