Becker's Hospital Review

9 Executive Briefing At TeamHealth, our purpose is to perfect our physicians' ability to practice medicine, every day, in everything we do. TeamHealth offers outsourced emergency medicine, hospital medicine, anesthesia, orthopedic hospitalist, acute care surgery, obstetrics and gynecology hospitalist, urgent care, post-acute care and medical call center solutions to approximately 3,200 civilian and military hospitals, clinics, physician groups and post-acute care facilities nationwide. Because patients who aren't treated with fentanyl have fewer and less severe post-surgical symptoms, they typically utilize fewer healthcare services and are associated with decreased spending. For instance, researchers associated preoperative opioid use among elective surgical patients with an increased likelihood of being discharged to a rehabilitation facility or readmitted into the hospital within 30 days, thereby driving healthcare spending and utilization, according to study published April 2017 in the Annals of Surgery. Besides improving pain management, limiting opioid-related side effects carries added fiscal benefits amid a healthcare reimbursement landscape that is increasingly shifting to value- based payment models. Reduce opioids, reduce costs Eliminating or reducing opioid-related adverse events in hospital settings has the potential to generate significant cost savings, studies show. Adverse events related to opioid use that occur in the hospital setting include respiratory depression, nausea, vomiting, urinary retention and constipation. A 2015 study published in the journal American Health & Drug Benefits examined the relationship between healthcare costs and opioid-induced constipation among patients with non-cancer pain. Researchers identified significant increases in inpatient, outpatient and emergency department costs among nonelderly patients with opioid-induced constipation and non-cancer pain. Among elderly patients with non-cancer pain, opioid-induced constipation was associated with higher inpatient and ED costs. In 2014, the Advisory Board published an analysis estimating the fiscal impact of implementing multimodal pain management approaches and reducing high-dose opioid use. Researchers determined a 250-bed facility could potentially cut unreimbursed charges by more than $1 million dollars every year by reducing the use of opioids in major small and large bowel surgical procedures. "By removing the bulk of opioids, the hospital can avoid costs [related to opioid side effects]," says Sonya Pease, MD, CMO of the anesthesiology division at TeamHealth. Dr. Pease says multimodal pain management programs, which involve two or more non-opioid analgesics, offer significant opportunities for cost avoidance and cost savings. "You can avoid costs by avoiding complications and you're also using cheaper adjuvant narcotics to treat pain. Less time in the recovery area leads to cost savings. Also, less incidence of nausea leads to savings in medication costs." Educate the clinician, educate the patient When outlining the building blocks of opioid-free anesthesia and multimodal pain management programs, Enrico Camporesi, MD, professor emeritus at the University of South Florida in Tampa and director of research for TeamHealth Anesthesia Research Institute, described patient education as crucial to success. However, before patient education can take place, providers must receive education on the substantial benefits of multimodal and opioid-free pain management techniques. Organizations should empower their care teams to gain knowledge on the subject and educate patients on opioid risks and alternative pain management techniques. "Nurses, surgeons — these are people who for the last 10 to 12 years have been operating in a different culture," Dr. Camporesi says. "Then there is a patient education process. Providers have to convince patients that nothing is being taken away from them, and patients have to buy into the process." To educate its providers, TeamHealth offers Continuing Medical Education credits through an online platform. TeamHealth clinicians are required to complete about 10 online opioid- reduction training modules as part of the organization's risk management training requirements. Moving anesthesiologists and nurse anesthetists away from opioids represents a major cultural change. Such a shift requires concerted education efforts targeting the entire perioperative staff, according to Dr. Pease. She says these efforts at TeamHealth have spurred "clinician to clinician pollination" of knowledge with regards to opioid use and multimodal pain management. "Once they see the results [of opioid reduction], the strategy sells itself since patients wake up from surgery with less of the typical side effects we are used to seeing," Dr. Pease says. Dr. Pease describes the movement away from opioids as a massive but necessary paradigm shift. "I think most of us that work with narcotics think it's horrifying that we could be adding to the problem," says Dr. Pease. A call to action As the number of opioid-related deaths in the United States soared in recent years, the problem stretched far beyond the issue of prescription drug diversion. Increased availability of heroin and illicitly obtained fentanyl from sources overseas has led some healthcare stakeholders to question how healthcare will help end the crisis it helped create. In the face of cynicism, it's important for healthcare leaders to keep in mind the advice of leaders like Dr. Cosgrove and do their part to bring this national crisis to a close. Few frontline caregivers underestimate the brutal nature of this epidemic — they are the ones treating overdose victims regularly. This too is important to keep in mind: Much of the dying related to the opioid epidemic happens inside hospital walls. According to a Health Affairs study published in December 2017, inpatient mortality for opioid-related hospitalizations increased fourfold from 1993 to 2014. Opioid-free or reduced opioid anesthesia and multimodal pain management techniques have the opportunity to improve care and reduce costs by reducing opioid-related adverse events. Yet perhaps most importantly, these programs can limit opioid exposure among those who may be vulnerable to addiction and no longer perpetuate pain management practices that helped spur a national crisis. n

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