Value-based Healthcare: Preoperative Assessment and Global Optimization (PASS-GO): Improving Value in Total Joint Replacement Care

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In 2012, the Institute of Medicine convened a panel of chief executive officers from US healthcare organizations to discuss healthcare delivery transformation initiatives with the stated goal of providing better outcomes at lower costs [2]. The panel identified key strategies to achieve high-value healthcare including: (1) Evidence protocols to reduce variation and inefficiencies in care, (2) integrated care (finding the right team to provide the right care in the right setting), (3) shared decision-making to enable the patient and physician to make care decisions collaboratively, (4) targeted services (tailoring interventions for resource intensive patients), and (5) internal transparency on quality and cost performance measures [2].
Currently, there is wide variation across all phases of care for patients who undergo hip or knee arthroplasty, including preoperative use of imaging and medical interventions, intraoperative implant choice and anesthetic technique, postoperative inpatient physical therapy and analgesic regimen, and postdischarge disposition and rehabilitation [1]. By decreasing this variation, hospitals and their clinicians can potentially improve quality and reduce costs for total joint arthroplasty episodes.
A central component of our perioperative management system at the Dell Medical School at the University of Texas at Austin is what we call the Preoperative Assessment and Global Optimization (PASS-GO) program, which realigns the conventional preoperative steps and decision points (Fig. 1). This perioperative management program encompasses the entire episode of care and is designed to guide patients and their family members through the complexities across the perioperative continuum. The program emphasizes patient-centered care, shared decision-making, rigorous process standardization, the use of evidence-based clinical care pathways to achieve current “best practices,” and robust coordination and integration of care. The overall goal is to improve not only surgical outcomes, but also to reduce costs, thereby improving the value (outcomes/cost) of care [5].
Once a patient and the surgeon decide to pursue hip or knee replacement surgery, the PASS-GO process is initiated. A designated registered nurse in our integrated Perioperative Command Center conducts a telephone interview with all patients, collects information, and enters it into the patient's electronic health record through an individualized “preoperative dashboard.” This information is made available to the surgeon, anesthesiologists, hospitalists, and other patient-care providers. All patients then undergo a brief preadmission testing visit for routine vital signs, standardized, evidence-based laboratory testing, electrocardiogram, a nasal swab culture, and a joint replacement education class.
Based on the data collected, the patient is risk-stratified by an advanced-practice registered nurse or physician assistant in the Perioperative Command Center, and designated into one of three associated care “swim lanes”—EXPRESS, PASS, or GO. This stratification is generated from a combination of preoperative comorbidities based on the results of a Preoperative Clearance and Consult Questionnaire [4], a set of risk screening tools, and the level of surgical intensity [3]. The level of intensity is based on invasiveness, physiologic stress, estimated blood loss, and planned postoperative intensive care unit admission (Fig. 2). Hip and knee replacement, for example, are considered moderate-intensity procedures [3]. The Perioperative Command Center team also assists in determining the patient's immediate postdischarge disposition, including, when indicated, a site visit to the patient's current residence for successful rehabilitation.
Individuals with minimal or no comorbid risk factors are designated as EXPRESS patients. EXPRESS patients can be scheduled for surgery immediately, have an additional brief telephone interview with an anesthesia nurse, and are evaluated by an anesthesiologist on the day of surgery (Fig. 3).
Patients with moderate comorbid risk factors are categorized as needing Preoperative Assessment (PASS). Patients in the PASS “swim lane” have a face-to-face, preoperative evaluation and management encounter with an advanced-practice provider, collaborating closely with an anesthesiologist or internist.
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