Lee A. Fleisher, M.D.

Robert D. Dripps Professor and Chair

Department of Anesthesiology and Critical Care

Professor of Medicine

Impact of Respiratory Compromise in

U.S. Healthcare

“Respiratory compromise” (RC) is defined as a state in

which there is a high likelihood of decompensation into

respiratory failure or death, but in which continuous

monitoring and early intervention might prevent or mitigate

decompensation.

Respiratory Compromise Institute

Classification of Respiratory Failure

Cascade

Respiratory Compromise

Respiratory Failure

Respiratory Arrest

2016

30%

85%

2018

50%

90%

Target percentage of payments in ‘FFS linked to quality’ and ‘alternative payment models’ by 2016

and 2018

2014

~20%

>80%

2011

0%

68%

Goals Historical Performance

Alternative payment models (Categories 3-4)

FFS linked to quality (Categories 2-4)

All Medicare FFS (Categories 1-4)

The bundled payment model targets 48 conditions with a single payment for an episode of care

Incentivizes providers to take accountability for both cost and quality of care

Growth from 102 Awardees and 167 Episode Initiators in Phase 2 as of January 2015 to

Current Participation at 360 Awardees and 1,755 Episode Initiators across four Models: Model 1: Retrospective acute care hospital stay only

11 Awardees

Model 2: Retrospective acute care hospital stay plus post-acute care

205 Awardees

536 Episode Initiators

Model 3: Retrospective post-acute care only

135 Awardees

1,218 Episode Initiators

Model 4: Prospective Acute care hospital stay only

9 Awardees

Bundled Payments for Care Improvement has grown significantly

6

Respiratory insufficiency on the

general ward • 1,620,985 discharges from AHRQ database

• 0.91% had a diagnosis code for Respiratory Insufficiency, Arrest and Failure

(RIAF) that was not present on admission.

• Mortality rates were higher for RIAF cases (34.6%) than non-RIAF cases (1.2%,

p<0.001).

• Lengths of hospital and ICU stays were higher for RIAF cases (11.5, 5.8 days)

than non-RIAF cases (4.1, 2.9 days), respectively.

• Total hospital costs were higher for RIAF cases ($24,578) than non-RIAF cases

($6,370).

– About 40% of the costs of RIAF cases were attributed to ICU stay.

Kelley et al. Crit Care Med 2012

Surgical Patient

Dimick et al. JACS 2004

Crit Care Med 2011

The cost part of the value equation

Patient Group All No

complications

Major

complications

Total Costs

Mean Median

$18,392 $17,002

$17,718 $16,910

$37,285 $37,285

Contribution Margin

Mean Median

$(2,182) $(1592)

$(1,476) $(1,360)

$(1,434) $(1,434)

Patient Group All No

complications

Major

complications

Total Costs

Mean Median

$38,005 $31,270

$20,070 $20,419

$43,983 $36,751

Contribution Margin

Mean Median

$5,945 $14,028

$21,478 $21,590

$678 $8467

DRG 331: Major small & large bowel procedures w/o CC/MCC

DRG 329: Major small & large bowel procedures w/ MCC

Predicting postoperative pulmonary complications: implications for outcomes and costs.

Sabate, et al. Current Opinion in Anaesthesiology. 27(2):201-209, April 2014.

Can we identify a high risk subset or

condition and intervene?

5 Sabate, et al. Current Opinion in Anaesthesiology. 27(2):201-209, April 2014.

Predicting postoperative pulmonary complications: implications for outcomes and costs.

5

Obesity and Surgical Outcomes

Si lber, et al. Annals of Surgery. 256(1):79-86, July 2012.

Postoperative Opioids

2 Lam, et a l. Current Opinion in Anaesthesiology. 29(1):134-140, February 2016.

Obstructive sleep apnea, pain, and opioids

Cost and Quality Implications of Opioid‐Based

Postsurgical Pain Control

Kessler et al. Pharmacotherapy 2013

Kessler et al.

Pharmacotherapy

2013

Postoperative Opioid Overdose

(POOD) in US Hospitals • Major elective operation from 2002

to 2011 in the Nationwide Inpatient

Sample

• Among 13,982,557 patients, 11,669

(0.083%) had POOD

• POOD died more frequently during

hospitalization (1.7% vs. 0.47).

• Substance abuse history was the

strongest predictor of POOD

• Gender, age, race, income,

geographic location, operation type,

and comorbid diseases were

significant predictors

Cauley et al. Academic Surgical Congress 2015

Development and Validation of a Risk Score to Identify Patients

at High Risk for Opioid-Related Adverse Drug Events

Minkowitz J Manag Care Pharm.

2014

6

Perioperative Complications in Obstructive Sleep Apnea Patients Undergoing Surgery: A Review of the Legal Literature.

Fouladpour, et al. Anesthesia & Analgesia. 122(1):145-151, January 2016.

Time between last nursing check and discovery of opioid-induced

respiratory depression

Postoperative Opioid-induced Respiratory Depression:

A Closed Claims Analysis

Anesthesiology. 2015;122(3):659-665

Monitoring to detect respiratory

compromise

Silber et al. HSR 2016

Silber et al. JAMA Surg 2016

Magnet vs. Non-magnet Hospitals

Capnography

Summary

• Respiratory compromise is a common occurrence

in our hospitals

• It is associated with increased costs and morbidity

and mortality

• OSA and opioids increase the risk

• New opioid prescribing and respiratory

monitoring strategies will be required to reduce

the risk