A UPMC program that helps patients "prehabilitate" in preparation for elective surgery is helping reduce postoperative mortality, complications, readmissions, and longer ICU stays.
A new tool deployed at the VA and the academic medical centers of the University of Pittsburgh Medical Center is helping to evaluate patients prior to surgery and has the potential to dramatically improve outcomes.
The algorithmic tool encourages physicians to speak with surgery patients who the tool flags as being at risk for complications, to ensure the patients will survive and thrive following an elective surgery, says Daniel Hall, MD, an associate professor of surgery at the University of Pittsburgh and a staff surgeon at the VA Pittsburgh Healthcare System.
Hall helped develop the tool after it was first proposed by Jason Johanning, MD. Johanning, chief of surgery at the Omaha VA Medical Center, recognized that mortality post-surgery was higher than it should have been based on variability, suggesting that some patients were dying due to high-risk for postoperative complications because of their "frailty" prior to surgery.
"I got involved in late 2014 and 2015 after [Johanning] had been doing this for two or three years, but he didn’t have resources to validate the tool in any meaningful way," says Hall. "The two of us teamed up and developed a risk analysis in a cohort of between 6,000 and 7,000 patients."
Hall brought the data to clinical leaders at UPMC and says it "caught their imagination."
Even before the final data was published in the Journal of the American Medical Association in 2017, Hall says UPMC implemented the frailty index tool to evaluate all new patients presenting to surgical clinics across the system.
UPMC built the tool into its EMR infrastructure by July 2016 to measure the 14 variables that make up the risk analysis, and incentivized physicians to evaluate their patients using it.
UPMC allocates a portion of physician compensation to each department to encourage quality improvement projects.
That chunk of money is contingent on clinicians meeting benchmarks of desired behavior, Hall says. To qualify for the frailty index portion, physicians were required to conduct the risk assessment on 80% of new patients, a threshold which Hall says physicians met quickly.
But evaluating risky patients is only one part of the equation. Physicians then must intervene to suggest patients improve their health before surgery.
For this reason, UPMC established its Center for Presurgical Care, one of the referral destinations for such patients (they could also be referred back to their primary care physician or to the musculoskeletal clinic for joint problems, for example).
At the CPC, patients can go through a prehabilitation protocol, to better prepare them for the rigors of surgery and hopefully, improve their post-surgical prospects, says Mary Kay Wisniewski, a senior improvement specialist at the Wolff Center of UPMC, the system's quality improvement arm.
Prior to working with Hall, Wisniewski says the Wolff Center had been collecting data on surgery and outcomes.
One interesting group of data showed that one of the system's AMCs had done more than 60,000 elective surgeries, and 13% of those patients were high risk. Post-surgery, those patients accounted for 30% of ICU admissions and a large portion of postop deaths, she says.
Hall's frailty index tool was much better than other tools available that were focused on certain conditions or body systems, Wisniewski says.
"We needed to really understand where we can help patients improve before surgery," she says. "Undergoing two hours of anesthesia is as stressful as running a 5k race. Would you run that race without being prepared?"
That analogy got traction and interest from surgeons, she says.
The CPC focuses on patients the surgeon thinks can benefit from prehabilitation. It employs surgery coaches, generally advanced practice providers, who help patients with nutrition, weight management, exercise, pain management, mental health, smoking cessation, and goals of care, pre-surgery.
"We have algorithms that help surgery coaches follow a pattern and care plan," says Wisniewski.
As a scientist, Hall says while strong evidence clearly shows outcomes, including mortality readmission, length of stay, and complication rates, are all related to the frailty score—the evidence base for intervening is not yet fully developed.
The hope is, however, that as the evidence base increases and as surgeons and other clinicians become familiar, frailty will factor in how patients and doctors will interact over a surgical decision.
Prehab is difficult
While such interventions are proven effective, they are challenging to actually accomplish, Hall says. Controlling diabetes and weight, for example, are important even for patients who are not candidates for surgery, yet are tasks often difficult to accomplish.
"There is a motivating force in telling patients we know they are at higher risk with surgery. Let’s use the event of surgery as occasion to adopt health practices that are not rocket science," he says.
And though the frailty score is associated with markers of cost, readmission, and length of stay, it's still too new to show a bending of the cost curve across an entire system, though there have been smaller pilot studies on that, Hall says.
Right now, the tool is for patients who are vulnerable, says Wisniewski, but there's huge potential in a large system such as UPMC to improve outcomes over a much larger population.
"This is just the beginning. Eventually, we should have all patients coming to the center," she says. "So far, we’ve helped over 400 patients at three hospitals, but outlying community hospitals are also interested, and there's potential in doing this through telemedicine."
Philip Betbeze is the senior leadership editor at HealthLeaders.