2015Cline.Pdf

E The Open Mind

Residency Board Certification Requirements and Preoperative Surgical Home Activities in the United States: Comparing Anesthesiology, Family Medicine, Internal Medicine, and Surgery

Kayla M. Cline, MS, Rahil Roopani, BA, Bita A. Kash, PhD, MBA, and Thomas R. Vetter, MD, MPH

* † * ‡ THE STATE OF THE PERIOPERATIVE SURGICAL recognized the need for improved surgical care coordina- HOME IN THE UNITED STATES tion and embraced this role and its responsibilities.11–13 Surgical care is not often standardized or coordinated, Surgeons are clearly involved in the pre-/intra-/postop- resulting in duplicated or unnecessary care that costs erative phases of surgery, and their clinical efficiency and an estimated $18 billion annually in the United States.1 productivity are adversely affected by delays, cancellations, The Perioperative Surgical Home (PSH) is a new model and complications when patients are not adequately pre- to address the well-documented high cost, low quality, pared for surgery.14–16 Internal medicine hospitalists can care and suboptimal outcomes of surgical care.2,3 While other for patients pre- and postoperatively.17–19 Anesthesiologists models of perioperative care, such as Enhanced Recovery have expanded their scope of practice to include preopera- After Surgery, have been used in other countries, the PSH tive management and more extensive postoperative care.17 is gaining traction in the United States. The impact of the Thus, any of these specialties could take the lead in provid- PSH on clinical outcomes and cost of care has recently been ing perioperative care. evaluated.4 However, the 2014 Institute of Medicine report on gradu- PSH programs are being developed largely indepen- ate medical education in the United States noted that there dently across the United States and thus vary in their focus is “a gap between new physicians’ knowledge and skills and 20 on preoperative, intraoperative, and/or postoperative the competencies required for current medical practice.” care initiatives.5 However, generally, these PSH programs Activities central to the PSH may be one of these gaps in involve an anesthesiologist-intensivist as primarily over- medical education. The emerging demand to meet this need is seeing care across the perioperative continuum, including unchartered ground for many, if not all, of the specialties. The postdischarge planning.6–10 primary purpose of this study was to identify gaps in edu- Other specialists, including surgeons, internal medi- cation present across 4 specialties to guide future curriculum cine hospitalists, and primary care physicians, have also development to meet the demands of PSH program activities.

RESEARCH APPROACH From the Health Policy and Management, School of Public Health, Texas This study was reviewed and approved by the Texas A&M A&M University Health Science Center, College Station, Texas; University of Texas Medical* School at Houston, Houston, Texas; and Department of University IRB, and written informed consent was obtained Anesthesiology, University of Alabama at Birmingham Medical† Center, from all interview subjects. Birmingham, Alabama. ‡ The first stage in the gap analysis identified PSH pro- Accepted for publication February 23, 2015. gram activities because there is currently no widely Funding: The preparation of this article is based upon work supported by the National Science Foundation (NSF) under Grant No. IIP-0832439. Further, this accepted definition of a PSH. To create a comprehensive list project was cofunded by NSF Center for Health Organization Transformation of activities, we performed a literature review to identify industry members, including the American Society of Anesthesiologists. salient pre/intra/postoperative care elements. These salient Conflict of Interest: See Disclosures at the end of the article. PSH elements from the literature were then validated by Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of interviews within 15 PSH programs in the United States. In this article on the journal’s website (www.anesthesia-analgesia.org). the second stage of the gap analysis, these PSH elements This report was previously presented, in part, at the Spring 2014 Center for were mapped to residency training requirements in anes- Health Transformation Semiannual Meeting, held on April 24–25, 2014, in thesiology, internal medicine, surgery, and family medicine Austin, TX. to ascertain which elements are covered on the 4 selected Reprints will not be available from the authors. Address correspondence to Thomas Vetter, MD, MPH, Department of An- specialty board certification examinations. esthesiology, University of Alabama at Birmingham School of Medicine, 619 19th St. South, Jefferson Tower 862, Birmingham, AL 35249. Address e-mail to [email protected]. Initial Literature Review Copyright © 2015 International Anesthesia Research Society A literature review was conducted in the summer of 2013 DOI: 10.1213/ANE.0000000000000772 and updated in December 2013 and May 2014. Researchers

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Records identified through database Additional records identified searching through other sources (n = 227) (n = 34)

Records after duplicates removed (n = 261)

Full-text articles assessed Full-text articles excluded, for eligibility with reasons (n = 261) (n = 152)

Figure 1. Diagram of literature review approach. Adapted from: Moher D, Liberati A, Tetzlaff J, Studies included in listing Altman DG, The PRISMA Group (2009). Preferred of activities Reporting Items for Systematic Reviews and Meta- (n = 152) Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097.

Table 1. Interview Sites Number of anesthesiologists Number of administrators Interview site Location interviewed interviewed Allentown Anesthesia Services Allentown, PA 1 0 Matrix Anesthesia Bellevue, WA 1 0 University of Alabama at Birmingham Medical Center Birmingham, AL 2 0 Anesthesia of Boise Boise, ID 2 0 Boston Children’s Hospital Boston, MA 1 0 Brigham & Women’s Hospital Boston, MA 1 0 Dartmouth Hitchcock Lebanon, NH 2 0 Aurora Medical Group Milwaukee, WI 2 1 Vanderbilt University Medical Center Nashville, TN 1 0 Anesthesia Services, P.A. Newcastle, DE 1 0 Kaiser Permanente Oakland, CA 1 0 University of California Irvine Medical Center Orange, CA 1 0 Oregon Health & Science University Medical Group Portland, OR 2 1 Mayo Clinic Rochester, MN 2 1 Physicians Anesthesia Service Seattle, WA 1 0

searched PubMed and Google Scholar using keywords by members of the ASA Committee on Future Models of related to the PSH concept: patient engagement, pre- Anesthesia Practice and to obtain broad geographic repre- operative testing, intraoperative efficiency and quality sentation. The final 15 PSH programs ranged in size from improvement, postoperative pain management and early 21 to 120 physicians and were located in 12 states across mobilization, postoperative complications, care coordina- the United States (Table 1). A total of 24 anesthesiologists tion, transition planning, and Enhanced Recovery After and administrators were interviewed by telephone at the 15 Surgery. These searches yielded 118 articles published after sites. Interviews lasted between 60 and 90 minutes and were 1975. Exclusion criteria were lenient to cast the broadest primarily conducted by the first author, with supervision net possible for PSH-relevant activities and concepts. The by a senior author for the first 3 interviews. Interviews were American Society of Anesthesiologists (ASA) recommended audio-recorded and transcribed by a professional transcrip- 34 additional relevant peer-reviewed articles, resulting in tion service. Transcripts were reviewed for accuracy by the 152 articles (Fig. 1). first author.

Selection of Interview Sites Interview Approach and Analysis Selection of PSH programs to be interviewed by the The interview instrument was driven by questions sug- research team was based upon a prior ASA survey of anes- gested by ASA leadership and a comprehensive review of thesiologists that assessed interest of anesthesia practices in the perioperative care and organizational change literature. participating in an ASA PSH-leaning collaborative project. These sources yielded 54 questions subcategorized into 9 This yielded 55 potential interview sites, of which 35 met themes: practice demographics, PSH program profile, PSH the required inclusion criteria of agreeing to participate and patient and payer profile, PSH relationship to the health affiliation with 1 hospital. Our project funding required care organization, quality reporting systems (practice-level), only 15 site interviews, which were selected based on a vote quality reporting systems (hospital-level), barriers and

Table 2. Elements of Preoperative Care Percent of 15 interviewed American Board of American Board of American Board American Board PSH programs reporting Family Medicine Internal Medicine of Anesthesiology of Surgery Key perioperative care activity activitya requirements requirements requirements requirements Preoperative phase Early patient engagement 100% Coordinated preoperative testing 93% Xb X X Lifestyle counseling 73% X X Anemia management 53% X X X X Triaging to identify high-risk X X patients Preoperative protocols (e.g., ERAS) Intraoperative phase OR scheduling initiatives 100% Reduced delay initiatives 100% Quality improvement initiatives 100% Facilities optimization 93% Patient throughput initiatives 93% Surgical error reduction 87% Blood utilization 87% X Integrated pain management Intraoperative protocols (e.g., ERAS) Precise fluid management X X Use of Lean or Six Sigma methodologies Postoperative phase Postoperative pain management 100% X X Reducing length of stay 87% Nausea and vomiting protocols 80% X Coordinated discharge planning 60% Discharge phone calls 60% Early mobility therapy and 40% rehabilitation Postoperative protocols (e.g., ERAS) Postdischarge patient education X PSH = perioperative surgical home; ERAS = enhanced recovery after surgery. aIf no percentage given, this element was identified from a review of the literature rather than key informant interviews. bX: A mark is placed in the table whenever a match between the PSH criteria (a key element or activity of the PSH care model) and the content for the respective residency program examination content was noted.

enablers of PSH success, PSH program performance, and future of PSH programs. The interview script is available as an online supplemental content (Supplemental Digital Content 1, http://links.lww.com/AA/B128). Interview data were used to verify the PSH activities generated by the literature review. Interviewees were asked whether their program participated in each PSH activity identified in the literature review and were asked whether their PSH program performed any additional pre/intra/postoperative activities (Table 2).

Mapping Approach A 2-phase mapping effort followed this verification of perioperative care activities identified in the literature review (Fig. 2). During the summer of 2014, the second author studied the curricular content of the board certification examinations of Figure 2. Stage 2 gap analysis approach: 2 phases of mapping of 4 specialty boards (Supplemental Digital Content 2, http:// key Perioperative Surgical Home activities to residency board certi- links.lww.com/AA/B129; Supplemental Digital Content fication requirements. 3, http://links.lww.com/AA/B130; Supplemental Digital Content 4, http://links.lww.com/AA/B131; Supplemental requirements of these 4 specialties that could potentially Digital Content 5, http://links.lww.com/AA/B132): contribute to a PSH-type program, using keywords such as American Board of Anesthesiology (ABA) (updated 2011), “preoperative testing” or “anemia management,” to evalu- American Board of Family Medicine (ABFM) (updated ate specialties via their board examinations about knowledge 2010), American Board of Internal Medicine (ABIM) (updated of that activity. This mapping process was then edited and 2014), and American Board of Surgery (ABS) (updated 2013). refined by a PhD candidate. The second phase of the map- The salient PSH activities were mapped to board certification ping exercise involved review by the third and fourth author,

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an experienced health services researcher and a senior anes- Lastly, only the ABA examination content contains the topic thesiologist, to further confirm the mapping logic. of “Postdischarge Patient Education” such that its residents are These findings were finally further confirmed by inter- tested on educating patients regarding the basics of postop- views with 2 anesthesiology residency program directors in erative rehabilitation and the expected timeline to recovery as the United States, who are developing perioperative medi- well as what to do for pain control. Notably, however, there cine residency curricula. are several gaps in postoperative care across all 4 specialties, particularly related to early rehabilitation therapies and post- RESULTS discharge planning. This gap is supported by only 60% of the In evaluating which medical specialties are currently best interviewed PSH program directors indicating any involve- prepared to manage the various aspects of a PSH, we stud- ment in postdischarge planning or telephone calls and only ied the curricula content for the board certification examina- 40% involvement in postoperative rehabilitation. tions of the ABA, ABFM, ABIM, and ABS. Table 2 presents the findings. IMPLICATIONS FOR RESIDENCY PROGRAM Across all phases of surgical care, the tallies of “matches” TRAINING IN THE UNITED STATES for the PSH and specialty board certification requirements The results of this exploratory study indicate that residents were: ABA, 7 matches; ABS, 5 matches; ABIM, 3 matches; in all 4 specialties are generally prepared to undertake the and ABFM, 2 matches. preoperative activities involved in a PSH. At least 1 of the 4 The first keyword mapped was “Coordinated Preoperative specialties, and for many care elements, more than 1 specialty, Testing.” Residents in each of the 4 specialties were assessed expects residents to master the coordination of preoperative on their ability to evaluate a surgical patient. This preopera- testing, lifestyle counseling, anemia management, and triag- tive testing includes electrocardiogram or echocardiography, ing of high risk patients. However, early patient engagement chest radiogram or pulmonary function testing, coagulation and development of preoperative protocols are not included in testing, etc. Additionally, the ABA, ABIM, and ABS exami- any specialty training, which suggests that such knowledge is nation contents contain the topic of “Triaging to Identify expected to be learned on the job. Interestingly, 100% of the 15 High Risk Patients” and the ability to recognize patients at PSH program directors interviewed stressed the importance of increased risk of major morbidity and mortality intraopera- early patient engagement, which includes the discussion about tively and postoperatively. preparation for surgery, risks and benefits of the operation, “Lifestyle Counseling,” related to “Prehabilitation” in the other treatment alternatives, and expectations for recovery. PSH model, was only present in the ABFM and ABIM cur- The intraoperative phase is clearly the most sparsely ricula. Family medicine and internal medicine residents are populated section of Table 2; only 2 of the 11 activities (blood tested on their ability to undertake a focused discussion about utilization and fluid management) appeared in any of the 4 patients’ activities of daily living and social routines. These residency training requirements. This may be because many discussions address modifiable behaviors (e.g., diet, alcohol of the key intraoperative PSH activities are less clinical and intake, hours spent exercising) to recommend changes that more organizational in nature: at least 6 of the 11 activi- will benefit the patient. “Anemia Management” was found ties are more administrative than clinical (operating room in all 4 residency curricula, indicating the importance of the scheduling, reduced delays, quality improvement, facilities subject. Residents in all 4 specialties are examined on the optimization, patient throughput, and use of Lean or Six pathophysiology of anemia so that they can presumably cor- Sigma methodologies). Thus, it is not surprising that these rect it preoperatively. However, an intraoperative extension activities are not currently included in residency training of this topic, “Blood Utilization,” was only present in the and board certification requirements. ABA curriculum. This topic includes, but is not only limited The postoperative section of Table 2 was slightly less to, the proper transfusion of blood products in an acutely sparse, with at least 1 specialty requiring education in 3 anemic and thus hypovolemic patient. of the 8 activities (pain management, nausea and vomit- In the curricula of the 4 specialties, only the ABA and ing prevention and treatment, and postdischarge patient ABS examination contents contain topics beyond the pre- education). Several gaps are again largely administrative operative phase of perioperative care coordination. The or organizational, (e.g., reducing length of stay and devel- aforementioned topic of “Blood Utilization” is only present opment of postdischarge protocols). However, other post- in the examination content of the ABA. However, “Fluid operative gaps are more clinical (e.g., early rehabilitation Management” is covered in the curricula of the ABA and and therapy and postdischarge planning). These elements ABS. Residents of these specialties are tested on their ability are also lacking in perioperative practice, so it is possible to accurately monitor fluid input/output and to recognize that a lack of emphasis in residency training is related to the the intraoperative need for fluids in order to maintain car- lack of emphasis in practice. Consequently, it is possible that diac output and thus adequate vital organ perfusion. an increased emphasis during residency on postdischarge “Postoperative Pain Management” is another topic of planning could increase its emphasis in practice. perioperative care that is addressed in the curricula of the Based on specialty board certification requirements, ABA and ABS. Physicians of both these specialties must anesthesiology has the most matches, followed by surgery understand the extent of the procedure and continue proper and then by internal medicine hospitalists. However, anes- care to alleviate pain from the surgery. Furthermore, only thesiology curricula matched on only 7 of the 25 activities the ABA examination curriculum covers postoperative involved in the PSH. Thus, all specialties have room to “Nausea and Vomiting Protocols.” improve training to include key PSH activities.21–23

STUDY LIMITATIONS Name: Bita A. Kash, PhD, MBA. The list of key PSH elements was confirmed by interviews Contribution: This author helped design the study, conduct the with anesthesiologists identified via an informal survey study, and write the manuscript. process by the ASA. Internal medicine hospitalists, family Attestation: Bita A. Kash has seen the original study data, practitioners, and surgeons were not consulted in this con- reviewed the analysis of the data, and approved the final firmation process. This may have contributed to the high manuscript. number of matches between anesthesiology board certi- Conflicts of Interest: Bita A. Kash received research funding fication requirements and PSH elements and may have from American Society of Anesthesiologists as is a member limited the generalizability of these results beyond this of the NSF Center for Health Organization Transformation sample. In addition, requirements for board certification (CHOT) at Texas A&M University. in a given specialty may not be a comprehensive depiction Name: Thomas R. Vetter, MD, MPH. of that specialty’s skill set; there may be unmeasured fac- Contribution: This author helped write the manuscript. tors that contribute to a specialty’s ability to manage the Attestation: Thomas R. Vetter reviewed the analysis of the data perioperative process. Thus, our approach is inherently and approved the final manuscript. simplistic and potentially biased in favor of anesthesiol- Conflicts of Interest: The author has no conflicts of interest to ogy. In addition, all anesthesiologists surveyed practiced declare. This manuscript was handled by: Franklin Dexter, MD, PhD. in the United States and only American residency board certification requirements were studied, limiting gen- REFERENCES eralizability of these results to an international setting. 1. Pasternak LR. 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Kash BA, Cline KM, Timmons S, Roopani R, Miller TR. from American Society of Anesthesiologists. International comparison of preoperative testing and assess- Name: Rahil Roopani, BA. ment protocols and best practices to reduce surgical care costs: Contribution: This author helped analyze the data and write a systematic literature review. In: Buttigieg SC, Rathert C, Von the manuscript. Eiff W, eds. Advances in Health Care Management, Volume 17. Emerald Group Publishing Limited, 2015:161–94 Attestation: Rahil Roopani has seen the original study data, 14. Masursky D, Dexter F, Isaacson SA, Nussmeier NA. Surgeons’ reviewed the analysis of the data, and approved the final and anesthesiologists’ perceptions of turnover times. Anesth manuscript. Analg 2011;112:440–4 Conflicts of Interest: The author has no conflicts of interest to 15. Wright JG, Roche A, Khoury AE. Improving on-time surgical declare. starts in an operating room. Can J Surg 2010;53:167–70

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