Surgeons and Population Health

As population health and the move to value-based payment models progress, changing the practice of primary care continues to be the major area of focus. These shifts prompt health care professionals to adapt and shift to meet the needs of patients while adjusting to newer models. An example I discuss in this article is how surgeons and hospital-based physicians navigate the latest models, including population health.

Value-Based Care and Other Payment Models

In order to participate in the Medicare Shared Savings Program an accountable care organization (ACO) must provide primary care services for at least 5000 Medicare beneficiaries. Primary care practice transformation is evident in programs such as Comprehensive Primary Care Plus (CPC+)¹ and the newer Primary Care First² models. There is heavier emphasis on health promotion, prevention and better management of chronic diseases, and improved care coordination across all venues of care.

The COVID-19 pandemic put a new spotlight on health care disparities, and widespread attention has recently focused on how to capture and address the social determinants of health (SDOH),³ largely through primary care practice.

Hospital-based physicians have a different experience with value-based care, through efforts to reduce lengths of stay, improve inpatient quality, and avoid care complications. Programs focus on discrete conditions and “episodes of care” under the Bundled Payments for Care Improvement (BPCI) initiative— which was first established in 2013 and modified in 2018 as Bundled Payments for Care Improvement-Advanced (BPCI-A) initiative.⁴

There are 30 inpatient, 3 outpatient and 1 multi-setting BPCI-A Clinical Episode categories “triggered” either by an admission to the inpatient setting or by a procedure performed in an outpatient setting. These programs incentivize specialists to focus on outcomes and the total cost of the 90-day incident of care. Episode of care opportunities specific to the surgical disciplines of Gastrointestinal Surgery, Spinal Procedures, and Orthopedics are highlighted in Table 1. 

But how else can surgeons get involved in population health? Are there opportunities beyond the operating room and hospital to participate in these changing care models? And what role, if any, can SDOH play in a surgeon’s work?

Kirsten Edmiston, MD, FACS, is a breast oncology specialist and quality leader at the Inova Health System in Fairfax, VA. She recently earned a Master of Science degree in Population Health. For her capstone project, Dr Edmiston studied how SDOH can be incorporated into surgical practice, beginning with the surgery team’s awareness of SDOH, its impact on their patients’ care and outcomes, and how recent payment changes can reward the new focus. What follows is insight from Dr Edmiston.

A Closer Look at Surgeons, SDOH Data

Physicians and surgeons have traditionally focused on a behavioral modifications paradigm to optimize patients prior to surgery in specific context areas⁵ (nutrition, glycemic control, medication management, smoking cessation, safe and effective postoperative pain management, delirium, pre-habilitation, and patient directives). More recently, the concept of perioperative Surgical Homes has been introduced as a way to further integrate these perioperative elements to improve patient care.⁶ Unfortunately, these approaches have not reached the full potential of patient optimization, in large part because patients are hindered by SDOH that affect them.⁷

The determination of more granular SDOH offer potentially actionable causes that influence outcomes and complications. Khalid and colleagues⁸ conducted a retrospective matched cohort analysis of 16,560 patients undergoing single level lumbar fusion (50% with at least one SDOH and 50% without any SDOH disparity). SDOH disparities were most commonly economic (87%) or social (12%). The authors also identified that the presence of a disparity was associated with 70% increased odds of developing a complication and 70% increased odds of developing symptomatic pseudarthrosis.

There is extensive literature that would suggest that socioeconomic factors have an impact on postsurgical outcomes. Race, insurance status, and median household income were all independent predictors of disparity in readmission in one study.⁹ Medicaid insurance status was a predictor of open colectomies (as opposed to laparoscopic) along with higher mortality, complications, length of stay and charges after colectomy.¹⁰

Current Status

The determination of both medical factors and SDOH prior to surgery offer an opportunity to identify potential opportunities to patient optimization. Identifying SDOH needs such as food insecurity, lack of transportation, and reduced literacy potentially enable the surgical team to facilitate access to additional resources to achieve optimal outcomes.

Fundamentally, the widespread integration of SDOH assessment in the perioperative evaluation will improve the perioperative outcomes for patients undergoing both elective and emergency general surgery procedures.

In January 2021, the American Medical Association began expressly encouraging the evaluation of “diagnoses or treatments significantly limited by social determinants of health.” ICD-10 diagnosis codes have been established to identify specific SDOH diagnoses in each domain.⁸ This was done, in part, to incentivize the expanded use of SDOH in the evaluation and prehabilitation of preoperative surgical patients. Furthermore, the changes in the Evaluation and Management codes enable providers to establish a moderate level of medical decision making (MDM) over a low level of MDM complexity with the resulting increases in coding and billing.

To overcome the barriers to widespread integration of SDOH assessment in the preoperative assessment of surgical patients, we sought to understand the relative utility of the various domains of SDOH in the pre-operative assessment of surgical patients and strategies to overcome these barriers.  We conducted a small (N = 12) cross-sectional survey of general surgeons and teams to assess knowledge, beliefs, and barriers to the assessment of social determinants of health in preoperative patient optimization.

Main takeaways from the results of the survey are shown in Table 2. The survey shows opportunity to increase awareness of SDOH, identifies barriers to increasing attention, and suggests resources needed to incorporate SDOH into routine preoperative care.

Within the intra-disciplinary perioperative management of surgical patients, medical and social determinants of health are both important to assess and mitigate. Specific actionable SDOH can reduce surgical lengths of stay, improve inpatient quality, and avoid surgical complications. SDOH and population health are also integral to surgical value-based care.

On a higher level, surgeons and their teams have an opportunity to expand SDOH risk variables in observed/expected quality outcomes metrics/rankings methodologies. One would anticipate that with the greater identification and understanding of the impact of SDOH, the expected morbidity and mortality rates would more accurately reflect the patient’s condition and risk. This will only be realized as surgeons integrate SDOH into their clinical care.

At the policy level, groups such as the American College of Surgeons, and Socially Responsible Surgery, have begun to focus on social determinates of health and  social responsibility as core values within surgery. They are also expanding their political and social advocacy platforms to address surgical inequalities at the regional, state, and national levels.

Surgeon involvement in population health issues and addressing SDOH is in early stages of development. But as in other areas of medicine, the broader perspective promises to improve patient care. More accurate capture of patient complexity, through identification and reporting of SDOH, is being built into value-based contracts to reward attention to these critical factors for patient health and improved outcomes.

References:

1. Centers for Medicare & Medicaid Services. Comprehensive Primary Care Plus. Updated January 3, 2022. Accessed January 14, 2022. https://innovation.cms.gov/innovation-models/comprehensive-primary-care-plus
2. Centers for Medicare & Medicaid Services. Primary Care First: Foster Independence, Reward Outcomes. April 22, 2019. Accessed January 14, 2022. https://www.cms.gov/newsroom/fact-sheets/primary-care-first-foster-independence-reward-outcomes
3. Kaminski M, Skoufalos, A. The pandemic exposes clear opportunities for population health in the US. Popul Health Manag. 2020;23(3):207-208. doi:10.1089/pop.2020.0071
4. Centers for Medicare & Medicaid Services. BPCI Advanced. Updated December 29, 2021. Accessed January 14, 2022. https://innovation.cms.gov/innovation-models/bpci-advanced
5. Fox M. Social determinants of health and surgery: An overview. Bulletin of the American College of Surgeons. May 4, 2021. Accessed January 14, 2022. https://bulletin.facs.org/2021/05/social-determinants-of-health-and-surgery-an-overview/
6. OR Manager. Overcoming common obstacles to implementing a perioperative surgical home. March 16, 2020. Accessed January 14, 2022. https://www.ormanager.com/overcoming-common-obstacles-implementing-perioperative-surgical-home/
7. Ebrahim S, Taylor F, Ward K, Beswick A, Burke M, Smith G. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database of Systematic Reviews. 2011. doi:10.1002/14651858.CD001561.pub3
8. Khalid SI, Maasarani S, Nunna RS, et al. Association between social determinants of health and postoperative outcomes in patients undergoing single-level lumbar fusions: a matched analysis. Spine. 2021;46(9):E559-E565. doi:10.1097/BRS.0000000000003829
9. Park HS, White RS, Ma X, Lui B, Pryor KO. Social determinants of health and their impact on postcolectomy surgery readmissions: a multistate analysis, 2009-2014. J Comp Eff Res. 2019;8(16):1365-1379. doi:10.2217/cer-2019-0114.
10. Sastow, D., White, R., Mauer, E., Chen, Y., GAber-Baylis, L., & Turnbull, Z. (2019). The Disparity of CAre and Outcomes for Medicaid Patients Undergoing Colectomy. J Surg Res. 2019;235:190-201. doi:10.1016/j.jss.2018.09.056.