Faculty
- Stephen A. Esper, MD, MBA, Medical Director
- Jennifer M. Holder-Murray, MD, FACS, FASCRS, Surgical Director
- Michael L. Boisen, MD, FASE
- Kathirvel Subramaniam, MD, MPH, FASE
Staff
In the current healthcare landscape, identifying and reducing mortal and morbid surgical risks is important for patients, families, providers, and healthcare systems. Patients identified as “high risk” based on their underlying physical status and co-existing medical conditions are associated with considerable morbidity and mortality and low-value care, accounting for more than 30% of ICU admissions, 70% of post-operative deaths, and 90% of the care provided during hospitalization. “Prehabilitation” of high-risk patients prior to surgery has been shown to help reduce hospital length of stay, hospital acquired conditions, and readmission rates, translating into better quality care, higher patient satisfaction, and cost savings.
The Center for Perioperative Care (CPC), a team-based, multidisciplinary prehabilitation clinic, identifies and screens high-risk patients prior to non-emergency surgery. The CPC accepts all patients under consideration for these surgical procedures and tailors the surgical experience to each patient's specific needs. This “surgical pause” provides the opportunity to mitigate risk and optimize patients’ health before surgery to improve outcomes or refer patients to safer non-surgical approaches if warranted. Anesthesiologists specializing in perioperative medicine facilitate the multidisciplinary CPC team, which includes the surgeon, primary care provider, and specialists working with the patient in a shared-decision-making approach. The first CPC clinic opened in June of 2016 at UPMC Shadyside; a second CPC site opened at UPMC Presbyterian in August of 2017. On April 1, 2019, UPMC Presbyterian’s Preoperative Evaluation Center (PEC) and CPC services were integrated into a single service.
Patients seen in the CPC are assessed using a validated and accepted Risk Analysis Index tool developed by the CPC team to identify those at high-risk for poor surgical outcomes (see Arya S et al. Recalibration and External Validation of the Risk Analysis Index: A Surgical Frailty Assessment Tool. Ann Surg. 2019 Mar 19). The team’s comprehensive system addresses patients’ anesthetic and medical concerns, nutritional status, physical and cardiopulmonary therapy, weight loss, chronic pain assessment, and tobacco, drug, and alcohol cessation and provides mental health therapy and social work support services. At-risk patients are provided with a supportive “Surgery Coach” specifically trained in surgical preparation who mentors patients, readying them for their surgical experience.
Thus far, the two CPC sites have screened more than 1,000 patients. In a subset of that cohort (n=132) evaluated between February and September 2018, 25% decided to pursue non-surgical therapy; 55% had their health optimized with prehabilitation prior to surgery; and 20% proceeded to surgery without delay. A snap shot of 24 patients referred from orthopedic surgical clinics showed a 32-pound average weight loss per patient. Analyses suggests that CPC consultation is associated with an approximately one-day reduction in postoperative length of hospital stay when compared to frailty, procedure, and comorbidity-matched controls. Furthermore, initial data indicates overwhelmingly positive responses from both patients and surgeons regarding CPC experiences.
Plans are for the CPC to continue to expand to additional UPMC hospitals, leveraging telemedicine to deliver services to outpatients distant from urban centers. The team is already in the process of launching multiple additional clinics at other UPMC hospital sites.