The Agency for Healthcare Research and Quality (AHRQ) was first established in 1989 in the hopes of improving the quality and efficiency of healthcare in the United States using evidence-based approaches [1]. The AHRQ contributes to improving health systems in the United States primarily by investing in research and evidence generation efforts, creating training materials and resources, and by sponsoring performance and evaluation initiatives[2]. It is important to understand the role and impact of the AHRQ when considering ways to improve one’s own clinical practice, and in making decisions about initiatives through the agency one may like to support and advocate for moving forward.

The AHRQ funds basic research in an effort to improve the safety and quality of hospital care. Some have attributed the decrease in hospital acquired infections (HACs) to the Affordable Care Act’s expanded quality and safety provisions, that are supported by the tools, resources, and data generated by the AHRQ. For instance, basic research on central line infections that was supported by the AHRQ motivated and informed the Partnership for Patients (PfP) initiatives for national education and outreach programming [2, 3]. Additionally, as part of their research initiatives, the AHRQ designed the Evidence-based Practice Center (EPC) program. The EPC program initially included 12 centers across the U.S. recruited to conduct systematic reviews of the evidence available on important questions in healthcare. These questions were nominated by leaders in the medical field who would later be tasked with utilizing the results of these studies to improve clinical practices. There are now 13 centers, the majority of which are generalist EPCs that review a wide range of topics decided by outside partners [1].

The AHRQ plays an important role in nurturing system-wide change by reshaping, restructuring, supporting and supplementing provider training. TeamSTEPPS, for instance, is an evidence-based set of teamwork tools that is available on the AHRQ website aimed at improving communication and collaboration skills between health care professionals, making study evidence applicable and usable in direct patient practice [4]. One of the essential resources they have made available is the AHRQ Guideline Clearing House, which lost it’s funding and has since shut down in 2018 [5]. The Guideline Clearing House was a comprehensive national clinical guideline resource created in 1998, which summarized over 10,000 clinical practice guidelines over its lifetime. The Clearing House was born from a clinical guidelines program established by AHRQ between 1990 and 1996, which received pushback from specialists who interpreted the guidelines as an attempt to limit expensive procedures as well as a large contingency of professionals who wanted to limit government involvement in clinical policy [1].

Data resources, reports, and national surveys provided by AHRQ are essential information pools for researchers, providers, and policy makers. Important data projects on patient experience and quality improvement have been spearheaded by AHRQ. This includes the largest family of databases on hospital care in the United States under The Healthcare Cost and Utilization Project as well as The Medical Expenditure Panel Survey, which is the most complete dataset on healthcare costs and insurance in the U.S [2].

Incredible work has been done by the AHRQ to create evidence-based standards and guidelines across the United States for improving the quality of healthcare while also investing efforts into creating training resources and access to national data and important population-level information. As with any agency with high hopes of changing and improving systems to safely and effectively treat all patients with the same quality standard of care, the AHRQ still has much to strive for. Early criticism of AHRQ guidelines highlighted the slow and expensive process of developing such guidelines, as well as the need for further adaptation of guidelines for local practices due to the challenge of creating standardized guidelines that consider and include all possible scenarios. The agency continues to investigate new ways to improve practices outside of the hospital, wherever patients need and receive care through grants that support opioid use reduction in rural areas, as well as community health physician training programs in New Mexico [2, 6, 7]. Moving forward, it is the hope that AHRQ will continue to improve their processes to make information more accessible to patients, policy makers, physicians, and researchers in a timely manner, and to find innovative ways to make better healthcare decisions using evidence-based approaches. 

References

1.         David Atkins, K.F., Jean Slutsky, Better Information for Better Health Care: The Evidence-based Practice Center Program and the Agency for Healthcare Research and Quality Annals of Internal Medicine, 2005. 142(12): p. 1035-1041.

2.         Kronick, R., AHRQ’s Role in Improving Quality, Safety, and Health System Performance. Public Health Reports, 2016. 131(2): p. 229-232.

3.         Department of Health and Human Services (US), Office of the Assistant Secretary for

Planning and Evaluation, Saving lives and saving money: hospital-acquired conditions

update. 2015.

4.         Department of Health and Human Services (US), Office of the Assistant Secretary for

Planning and Evaluation, TeamSTEPPS®: Strategies and Tools to Enhance Performance

and Patient Safety.

5.         Physicians, A.A.o.F., AHRQ: National Guideline Clearinghouse to Shut Down July 16. 2018.

6.         Department of Health and Human Services (US), Office of the Assistant Secretary for

Planning and Evaluation, AHRQ announces grant opportunities to address opioid abuse

disorder in rural areas.

7.         Department of Health and Human Services (US), Office of the Assistant Secretary for

Planning and Evaluation. Project ECHO: Extension for Community Healthcare Outcomes

(New Mexico) Available from: https://healthit.ahrq.gov/ahrq-funded-projects/project-echo-extension-community-healthcare-outcomes.

The Quality Payment Program, also referred to as the QPP, is a program implemented by the Department of Health and Human Services through the Centers for Medicare and Medicaid Services (CMS). In brief, the QPP is a reimbursement mechanism that is designed to place a high value, and hence reimbursement, on physicians that are delivering high-quality care, while separating these from physicians who are not meeting national or specific standards of quality of care. The QPP is a program in multiple parts, including data collection, summarization, feedback generation, and finally, calculation of payment^[1]. Not only is the QPP a means of ascertaining the financial reimbursement for physicians serving Medicare-insured populations, but also, it is a mechanism by which physicians can be included in the decision-making process. Launched in 2017, the QPP is currently now in its second year of program participation across the United States, with preliminary results promising.

Before a discussion of the current state of the QPP, it is important to understand how exactly the program functions. To participate in the program, physician practices must agree to meet extensive data collection objectives. In line with this, the QPP urges practices to demonstrate how technology, specifically advanced technology, has aided with the collection and generation of data. The next step requires practices to send in summarization reports of collected metrics to the program, under deadlines. Following this stage, CMS will conduct an analysis of your data, matching your outcomes on specific objectives to nationally recognized benchmarks in the field. CMS will then share these results with you, along with the determination of your projected reimbursement. This number may include any incentives given for above-average delivery of care. In addition, if you participate in one of the other CMS programs, for example an advanced APM, then you may be eligible for further incentives.

This is the theoretical framework of the program. However, in the last two years, how has the program functioned in practice? CMS recently released results that provide an illustration of the QPP in its second participation year^[2]. Of note, the number of eligible physicians who are electing to participate in the QPP has increased from its initial year, from 95% to 98%. The proportion of participating physicians who hail from small practices has also increased significantly, currently up to 90% of the total workforce nationwide. In addition, increasing program membership has not been linked to any decrease in reimbursement. Quite the opposite. In this program year, it is reported that 97% of participating physicians will earn a positive payment adjustment, or incentive, in 2020 as a result of meeting metrics in the program year 2018. Such results reflect CMS’ decision to align quality of care with payment and reimbursement, in a thoughtful, engaged manner.

Moving forward, the QPP continues to be a work-in-progress, shaped by the successes of years prior with attention to the areas of improvement in the past. Physicians are encouraged to be involved in the program’s development by dispersing feedback to CMS and the QPP, thus ensuring that high-quality, compassionate care is at the center of the U.S. healthcare system.

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^[1] “Quality Payment Program Overview.” QPP, Centers for Medicare and Medicaid Services, 2017, qpp.cms.gov/about/qpp-overview.

^[2] Ellison, Ayla. “CMS Releases Quality Payment Program Results: 5 Takeaways. CMS Released Preliminary Second-Year Participation Data for the Quality Payment Program on July 11.” Becker’s Hospital Review, 15 July 2019, www.beckershospitalreview.com/finance/cms-releases-quality-payment-program-results-5-takeaways.html.

The gradual shift from inpatient to outpatient care has given patients increased flexibility in their medical care. By seeking treatment at ambulatory surgery centers (ASCs), outpatients will not only avoid overnight hospital stays, but also benefit from more cost-effective and transparent pricing models, as well as a more intimate treatment setting compared to that in hospital departments. Due to their increased efficiency, potential cost savings, and operational effectiveness, ASCs represent a pragmatic and evolutionary shift for patients, taxpayers, and physicians alike.

An ASC is defined as a healthcare facility where surgical care is delivered to patients without a hospital admission. On the other hand, hospital outpatient departments (HOPDs) are OR suites within hospitals that are designed to serve non-overnight patients [6]. Both care settings comprise the growing sector of outpatient surgical care. The last decade has seen a 6.6% decrease in inpatient stays, despite the population boom from 2005 to 2015; on the other hand, visits to outpatient facilities have increased by 14% [1,8]. Although both forms of delivery currently benefit from the shift to outpatient care, ASCs have several attractive distinctions compared to traditional hospital outpatient surgery departments.

The first example of the ASC advantage lies in efficiency. According to the Ambulatory Surgery Association, Medicare spends roughly 82% more for the same procedures performed in hospital outpatient departments as compared to those performed in ASC’s [2]. Moreover, after adjusting for procedure type, patients spend on average 31.8 minutes less under surgery in ASCs than in HOPDs [9]. With such noteworthy differences in pricing and surgical efficiency, ASCs improve the ability of patients to afford treatment; allows doctors to effectively utilize their time; and saves taxpayers money.

The second key distinction of ASCs lies in their unmatched history of personalized care. As early as 2006, 70 percent of ASC’s had no more than twenty employees on staff [4]. Although typically smaller in scale than HOPDs, ASCs are better able to specialize [4,10]. Because of this specialization, ASC physicians can tailor their services to patient needs. Therefore, ASC physicians can give a level of individualized care logistically unmatchable in hospital settings. This phenomenon has helped lead to a 22% higher satisfaction rate among patients treated in ASCs versus hospital outpatient surgical departments [10].

 ASCs’ third merit is that compared to HOPDs, they are more willing to disclosure service prices [2]. In a study by Ge Bai et al., ASCs’ throughout several states quoted a single bundled price for procedures prior to operation [5]. The demand for this transparency is reflected by new White House policy measures forcing healthcare providers to be more up front about costs for routine procedures [7]. In a digital age where transparency is highly valued in professional, academic, and digital settings, the desire for the same level of consciousness from the medical industry makes many ASCs policy front runners. In conjunction with government policy, such practices will likely encourage transparency throughout the medical industry and decrease the frequency of patients being blind-sided by excessive hospital rates.

It is no secret that patients and taxpayers would prefer to not foot the bill of bloated healthcare expenditures. In addition, many physicians desire the freedom to better specialize and optimize their time management in the process. Luckily, the growing prominence of ASCs allows these preferences to be conveniently met. ASC growth has been a positive trend and will set the stage for the continued evolution of quality and cost-effective patient care.

References

1. AHA Annual Survey Database, ahadata.com. Accessed July 4, 2019.

2. Ambulatory Surgery Center Association. Ascassociation.org. Accessed July 4, 2019. https://www.ascassociation.org/advancingsurgicalcare/aboutascs/industryoverview/apositivetrendinhealthcare.

3. University of South Florida. “Ambulatory and Primary Care.” USF.edu. Accessed July 4, 2019. http://eta.health.usf.edu/publichealth/HSC4933US/wk6/AmbulatoryPrimaryCare.pdf.

4. Ambulatory Surgery Center Association. “Ambulatory Surgery Centers Brochure.” Inova.org. Accessed July 4, 2019. https://www.inova.org/upload/docs/Healthcare Services/Surgery/ambulatory-surgery-centers-brochure.pdf,.

5. Bai, Ge, Pavan Patel, Martin A. Makary, and David A. Hyman. “Providing Useful Hospital Pricing Information To Patients: Lessons From Voluntary Price Disclosure.” Healthaffairs.org. April 19, 2019. Accessed July 4, 2019. https://www.healthaffairs.org/do/10.1377/hblog20190416.853636/full/.

6. The Free Dictionary. 2012. Accessed July 4, 2019. http://medical-dictionary.thefreedictionary.com/Outpatient department.

7. The White House. “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.” The White House. June 24, 2019. Accessed July 4, 2019. https://www.whitehouse.gov/presidential-actions/executive-order-improving-price-quality-transparency-american-healthcare-put-patients-first/.

8. Deloitte Insights. “Growth in Outpatient Care, The Role of Quality and Value Incentives.” Www2.deloitte.com. 2018. Accessed July 4, 2019. https://www2.deloitte.com/content/dam/insights/us/articles/4170_Outpatient-growth-patterns/DI_Patterns-of-outpatient-growth.pdf.

9. Munnich, Elizabeth L., and Stephen T. Parente. “Procedures Take Less Time At Ambulatory Surgery Centers, Keeping Costs Down And Ability To Meet Demand Up.” Healthaffairs.org. May 2014. Accessed July 4, 2019. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.1281.

10. West Plains Surgery Center. “Why Choose West Plains Surgery Center over a Hospital?” Www.wpsurgerycenter.com. 2019. Accessed July 4, 2019. http://www.wpsurgerycenter.com/why-choose-west-plains-surgery-center-over-a-hospital.

Along with becoming an excellent clinician, many anesthesiologists also have the objective of becoming involved in physician leadership. This could take the form of a leadership position at the departmental level, such as Chief or Vice-Chief of Anesthesiology, leadership at the hospital level, working on policies that affect all departments, or leadership in the multiple professional society groups, such as the American Society of Anesthesiologists and various local organizations. While the field of anesthesiology is swiftly diversifying to include those traditionally under-represented in medicine, leadership positions lack the same level of representativeness. Although the past twenty years has seen great progress towards diversifying leadership, continued improvement is still needed.

To commence, it is important to underscore that physician involvement in leadership is essential for driving change. Practicing anesthesiologists understand the very nature of delivering medicine in the perioperative and surgical setting, including stressors, roadblocks, challenges and opportunities. Anesthesiologists’ insight is salient at the departmental and hospital level for initiating policy changes. In line with this, it is also prudent to have a diversity of experiences and opinions at the decision-making table, to ensure that the highest proportion of needs are being heard. Female anesthesiologists thus provide a particularly important voice to be heard.

In a broad sense, the number of female clinicians pursuing surgical fields has trailed below the number of males. Anesthesiology as a field has similarly aligned with this trend. In 2007, approximately 25% of anesthesiologists under 36 years of age were female, although this number has increased to about 40% as of 2013^[1]. This gender disparity exists despite concerted efforts by academic medical centers to encourage female medical school graduates to pursue fields such as anesthesiology.

Moreover, the proliferation of female anesthesiologists into high-profile leadership positions has drifted behind, even with the relative increase of women in anesthesiology. In a recent issue of Anesthesia and Analgesia, Toledo et al explored diversity in the anesthesiology workplace with respect to female clinicians^[2]. Based on a large-scale survey, it was concluded that the percentage of female anesthesiologists who were involved in leadership in a professional organization was about 10% lower than the national average of such clinicians in the workforce. Moreover, the proportion of female physicians who achieve leadership in the hospital or academic medicine setting was found to be strikingly low, currently sitting at about 6%-17%. The data supports that female anesthesiologists are not currently represented equally in leadership roles.

Therefore, it is important to consider what measures can facilitate equality in anesthesiology, and especially in anesthesiology leadership roles. One program that has been implemented in the field is the establishment of formal mentorship programs specific to female leadership in medicine. By starting at the medical school and residency program level, female anesthesiologists-in-training who are interested in exploring leadership can be matched with current leaders in the field, developing skills and learning the undercurrents of the landscape as they train. In addition to formal mentorship opportunities, it may be useful to gain objective, non-biased metrics on the current state of leadership on a micro-level, such as surveys of individual hospitals. In this way, hospitals and clinics can assess their own progress in diversifying the leadership field, whilst developing solutions that account for their specific ecosystem. Lastly, increased visibility and published research on this issue will serve as an impetus for change.

Anesthesiologists have always served as leaders in the OR, hospital, and professional societies alike. Moving forward, it is important to continue the discussion, and therefore spur change, towards a more representative leadership establishment in the field of anesthesiology.

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^[1] Baird, Matthew D, et al. “Regional and Gender Differences and Trends in the Anesthesiologist Workforce.” RAND Corporation, American Society of Anesthesiologists, 2015, www.rand.org/news/press/2015/09/17.html.

^[2] Leslie, Kate, et al. “Women, Minorities, and Leadership in Anesthesiology.” Anesthesia & Analgesia, vol. 124, no. 5, 2017, pp. 1394–1396., doi:10.1213/ane.0000000000001967.

Throughout the history of the medical profession, physicians and students have relied on various forms of patient simulation, utilizing animals and cadavers to supplement their training [1]. Changing attitudes toward patient safety and recognition of the limitations of apprenticeship and spontaneous exposure-based training have motivated the development of more advanced simulation training. Academic anesthesiologists were pioneers in utilizing simulation-based training, adopting the use of full-body mannequins, training models such as crisis resource management (CRM), and assessment of non-technical skills (NTS) early on [2]. Today, patient simulation can take many forms, each with its own strengths and limitations: “standardized patients” (SPs) realistically portray specific conditions and are sometimes trained to evaluate and provide feedback to medical students [3], patient-specific 3D silicon models allow surgeons to find the best procedural options by trialing different surgical techniques and approaches [4], and computational models allow for real-time predictions and experimental repetition.

Simulation-based training has been associated with significant effects on educational outcomes in the broader healthcare literature and researchers have quantitatively determined that key instructional design features of simulation-based training can have small to moderate benefits. However, the positive impact of patient simulation on anesthesiology training in particular is less definitive. A 2014 systematic review and meta-analysis of 77 studies of anesthesiology simulation-based training from 2007-2011 found that when compared to no intervention, simulation-based training was associated with  statistically significant effects for satisfaction and skills, large effects for behaviors, and small effects for time, knowledge, and patient effects (patient outcomes)[2].

Despite the benefits associated with simulation-training in anesthesiology, some specific approaches may prove to be less effective in practice. For instance, the same meta-analysis found that anatomically correct simulators did not always add value to education, and learners were still satisfied working with other realistic tissue models. Additionally, the study concluded that even though trainees preferred them, simulation scenarios that included NTS training did not have significant impact on knowledge or skills [2]. These findings highlight the importance of evidence-based training design moving forward. But how seriously should we take these findings? As others have pointed out, there are limitations to our ability to evaluate the effectiveness of such tools. For one, only four studies out of 77 were identified as NTS intervention studies. As others have noted, this may be an issue with standard definitions, since NTS actually comprise all CRM skills, according to Gaba et al who define Anesthesia Crisis Resource Management (ACRM) as the “articulation of principles of individual and crew behaviour that focuses on skills of dynamic decision-making, interpersonal behaviour, and team management”. When we look at articles focusing on CRM training in anesthesia, 32 of 77 articles become relevant to the evaluation of NTS interventions [5].

ACRM training originated from the aviation industry’s Cockpit/Crew Resource Management Training (CRM), which are high-fidelity simulation trainings for flight crews. An important component of CRM is an extensive debriefing process of NTS after simulated scenarios. Researchers have found some modest improvement in performance between groups that receive simulation debriefing with an experienced facilitator, and groups with self-reflection at home, and no intervention, based on blind performance ratings from experts and trained scorers. There is still no evidence to determine the significance of simulation training debriefings in clinical practice or to draw conclusions about their effect on patient outcomes [6].

As patient simulations continue to supplement and enrich medical training programs today, it is important that educators and leaders in anesthesiology participate in understanding their efficacy. There is a continuing need, not only for the development of new ways to simulate patient scenarios, but also for the development of gold standards for evaluating these methods. Patient safety and improved outcomes remain priorities of the medical field, making patient simulation an important consideration in the training of new anesthesiologists and the continuing education of seasoned practitioners and instructors.

References:

1.         Wood, G.K. and L. Kenny, Patient-specific simulation: a new avenue to be explored. Gen Thorac Cardiovasc Surg, 2017. 65(8): p. 484.

2.         Lorello, G.R., et al., Simulation-based training in anaesthesiology: a systematic review and meta-analysis. Br J Anaesth, 2014. 112(2): p. 231-45.

3.         Cleland, J.A., K. Abe, and J.J. Rethans, The use of simulated patients in medical education: AMEE Guide No 42. Med Teach, 2009. 31(6): p. 477-86.

4.         Takashi Murakami, D.Y., Mitsuharu Hosono, Masanori Sakaguchi, Yosuke Takahashi, Toshihiko Shibata, Preoperative simulation of minimally invasive aortic valve replacement using patient-specific replica. General Thoracic and Cardiovascular Surgery, 2017. 65(5): p. 302-303.

5.         Corvetto, M.A. and F.R. Altermatt, Simulation-based training in anaesthesia: have we been training non-technical skills? Br J Anaesth, 2015. 114(3): p. 528-9.

6.         Morgan, P.J., et al., Efficacy of high-fidelity simulation debriefing on the performance of practicing anaesthetists in simulated scenarios. Br J Anaesth, 2009. 103(4): p. 531-7.