THE CLINICAL PRACTICE OF REGIONAL ANESTHESIA has evolved into modern-day regional anesthesiology and acute pain medicine (RAAPM). This medical subspecialty continues to change based on new health-care initiatives, technological advances, and scientific breakthroughs in understanding pain mechanisms and the human body’s responses to pain and pain relief. The use of regional analgesia techniques for pain management is typically combined with systemic nonopioid analgesics in a multimodal approach (1). When setting up a RAAPM system, one must first understand the context in which a new system will be developed, the practical aspects of initiating a new service line, and trends that may direct the system’s future goals.

I. Value, not volume. Health-care systems stress value and not volume—every new program or service will be evaluated based on its value contribution. According to the Triple Aim for health, the three primary goals of any health-care program should be to improve the patient experience, reduce costs of care, and advance population health (2). Anesthesiology practice itself is evolving with the emergence of large anesthesia groups and multispecialty national health-care companies. Competition for contracts creates demand for innovation and value. “Value-based purchasing” (3) is a program designed by the Centers for Medicare and Medicaid Services (CMS) to encourage “better outcomes, patient outcomes, and innovations (4).” Value, according to CMS, is composed of three domains—clinical processes, patient experience, and outcomes (mortality rates)—which align well with the Triple Aim (4). Data related to these domains are publicly available and comparable across health-care institutions consistent with the Institute of Medicine’s recommendation to make health-care performance data more transparent for consumers (5).

II. The Perioperative Surgical Home. From the perspective of a patient or family member, the process of undergoing surgery, from the decision to schedule until full recovery, can be an incredibly disjointed and intimidating one. The American Society of Anesthesiologists (ASA) has proposed a physician anesthesiologist-led, patient-centered model, known as the Perioperative Surgical Home (PSH) that coordinates this process (6). To date, there are few practical models of PSH to follow but most depend on the existence of a RAAPM program (7,8). For a PSH model to be accepted within a health-care system, the example set by a functioning RAAPM program is essential. The patient’s experience of pain is woven throughout the perioperative period (9). RAAPM encompasses preoperative preparation of the anticipated difficult pain patient (e.g., high-dose opioids or chronic pain at baseline), the coordination of intraoperative anesthesia care and postoperative pain management through clinical pathways (10), and the transition of analgesic regimens from inpatient to outpatient.

III. Rationale for a RAAPM system. Using value as a starting point and considering the societal issues affecting health-care priorities, there are two compelling reasons for starting a RAAPM system: curbing perioperative opioid use and improving the patient experience.

A. Opioid crisis. The crisis of prescription opioid overuse and abuse has affected countries around the world; anesthesiologists are ideally positioned to make positive changes toward reversing this trend (11). Even minor outpatient surgical procedures, and their associated anesthesia and analgesia techniques, can lead to long-term opioid use (12). It is impossible to predict which opioid-naïve patients are predisposed to developing chronic opioid use postoperatively. Patients who present for surgery with an active opioid prescription are very likely to still be on opioids after a year (13). A RAAPM program that coordinates inpatient and outpatient pain management can make a difference in patient outcomes. Regional analgesia, especially continuous peripheral nerve block techniques, has been shown to reduce the need for opioid analgesia in the acute postoperative period (14).

B. Patient experience. Effective expectation management is a primary determinant of patient satisfaction. Patients wish to avoid nausea, vomiting, and most importantly pain (15), which has a particularly strong influence on overall patient experience. Indeed, seven of the CMS survey questions relate to pain (3), and this theme of effective pain management is expected to persist into the future. Opioid-sparing regional analgesic techniques that provide targeted pain control with minimal side effects will play a crucial role in creating a more positive patient experience. The optimal duration of regional analgesia continues to be studied, but current evidence demonstrates advantages of continuous over single-injection techniques in terms of overall pain control, opioid requirements, and patient-reported satisfaction (16).

IV. Hospital cost considerations. Nearly half the costs of providing care for the hospitalized surgical patient are fixed (17); the remaining variable costs may be influenced by care models. Despite associated start-up costs, RAAPM may be the catalyst that promotes cost-saving processes within a hospital.

A. Clinical pathways. Clinical pathways, such as those for joint replacement surgery, decrease hospitalization costs. Coordinated perioperative pain management that includes regional analgesic techniques is a key component of these protocols (18). Also called enhanced recovery protocols, clinical pathways can be nested within the PSH model and decrease costs by streamlining the surgical process and minimizing variability (19). The advantage of a PSH is that it provides stable oversight and leadership for clinical pathway development and continuous improvement (10).

B. Postoperative complications. Postoperative complications also influence hospitalization costs. Certain postoperative “hospital-acquired conditions” (HACs) are ineligible for payment by CMS. Examples of HACs include catheter-associated urinary tract infection, surgical-site infection after orthopedic surgery, inpatient falls and trauma, hospital-acquired pressure ulcers, and deep venous thrombosis or pulmonary embolism (20). The incidence of HACs after joint replacement is estimated to be 1.3% and may cost hospitals a collective 70 million dollars annually (20). HACs are also considered within the clinical processes domain of value-based purchasing (4). Although use of regional anesthesia and analgesia may not directly prevent HACs, evidence suggests that certain techniques such as neuraxial anesthesia may be associated with a lower rate of inpatient falls (21) and postoperative infection (22), and the use of peripheral nerve blocks has not been shown conclusively to increase fall risk (21). Moreover, a comprehensive RAAPM program should incorporate fall prevention for patients undergoing lower extremity peripheral nerve blocks, especially the joint replacement population (23). Regional analgesia-facilitated early mobility after surgery may indirectly decrease the incidence of pressure ulcers, blood clots, and the need for continuous urinary bladder catheterization. Joint replacement surgery represents an important target for health-care cost reduction programs given the increasing number of new joint replacements per year (24).