The perioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes

Abstract

Policy Points: The perioperative surgical home (PSH) is complementary to the patient-centered medical home (PCMH) and defines methods for improving the patient experience and clinical outcomes, and controlling costs for the care of surgical patients. The PSH is a physician-led care delivery model that includes multi-specialty care teams and cost-efficient use of resources at all levels through a patient-centered, continuity of care delivery model with shared decision making. The PSH emphasizes "prehabilitation" of the patient before surgery, intraoperative optimization, improved return to function through follow-up, and effective transitions to home or post-acute care to reduce complications and readmissions.

Context: The evolving concept of more rigorously coordinated and integrated perioperative management, often referred to as the perioperative surgical home (PSH), parallels the well-known concept of a patient-centered medical home (PCMH), as they share a vision of improved clinical outcomes and reductions in cost of care through patient engagement and care coordination. Elements of the PSH and similar surgical care coordination models have been studied in the United States and other countries.

Methods: This comprehensive review of peer-reviewed literature investigates the history and evolution of PSH and PSH-like models and summarizes the results of studies of PSH elements in the United States and in other countries. We reviewed more than 250 potentially relevant studies. At the conclusion of the selection process, our search had yielded a total of 152 peer-reviewed articles published between 1980 and 2013.

Findings: The literature reports consistent and significant positive findings related to PSH initiatives. Both US and non-US studies stress the role of anesthesiologists in perioperative patient management. The PSH may have the greatest impact on preparing patients for surgery and ensuring their safe and effective transition to home or other postoperative rehabilitation. There appear to be some subtle differences between US and non-US research on the PSH. The literature in non-US settings seems to focus strictly on the comparison of outcomes from changing policies or practices, whereas US research seems to be more focused on the discovery of innovative practice models and other less direct changes, for example, information technology, that may be contributing to the evolution toward the PSH model.

Conclusions: The PSH model may have significant implications for policymakers, payers, administrators, clinicians, and patients. The potential for policy-relevant cost savings and quality improvement is apparent across the perioperative continuum of care, especially for integrated care organizations, bundled payment, and value-based purchasing.

Keywords: care coordination; early patient engagement; enhanced recovery after surgery; perioperative management.

Figure 1

Studies of Preoperative Initiatives Reporting Significant Positive, Nonsignificant, and Negative Results

Figure 2

Studies of Intraoperative Initiatives Reporting Significant Positive, Nonsignificant, and Negative Results

Figure 3

Studies of Postoperative Initiatives Reporting Significant Positive, Nonsignificant, and Negative Results