The road to recovery

Access to surgical care, and indeed other forms of healthcare, is likely to be unavailable in a timely manner unless initiatives are found that can be shown to improve outcomes at sustainable costs.

Surgery is needed to treat something like one-third of healthcare conditions, yet increasingly long waiting lists were an issue even before COVID. The aetiology is complex but is contributed to by factors including the needs of an ageing comorbid population and economic challenges.

If we turned to just one economic indicator of the future challenges in health care it might be the rapidly climbing old-age dependency ratio in developed populations. A population with more elderly people, and fewer productive younger people, faces the same sustainability challenges as a pyramid investment scheme.

Mechanisms outside health to address this pyramid, and its consequences, include to increase birth rates and immigration. Mechanisms within health include a focus on improved population health and preventative healthcare, but also must include high-value (improved outcome and manageable costs) in surgery and perioperative care.

A group of clinicians and quality and safety organisations, led by CALHN and the University of Adelaide, staged a National Summit on 6 March 2020 to examine what is needed. Attended by 80 key stakeholders and opened by the South Australian and federal health ministers, the Summit identified eight principles on which to base improvement.

At the Royal Adelaide Hospital (RAH) we were aware of a high incidence of early post-operative complications in recovery rooms and the wards, and we had some pilot data to suggest brief high-acuity care might help. We were also aware of a paucity of evidence of benefit of postoperative high acuity units.

We then designed a system of pre-operative risk identification and stratification of medium-risk patients, with referral of medium risk patients to an anaesthesia-led multidisciplinary model of 24 hours of high acuity care. This Advanced Recovery Room Care model, ARRC, adopted seven of the eight Summit Principles – we see inclusion of primary care, Principle 3, as an important future priority. The results of a prospective study of ARRC were published in May 2023, and demonstrate a very large positive impact.

The key findings are shown in the figure from JAMA Surgery 2023 In addition:

• there was no evidence of a shift in burden to primary care

• there is a possible halving of mortality at three months post-surgery; 12-month figures will be reported separately in the literature

• formal cost-effectiveness Markov modelling shows that ARRC is ‘better and cheaper’, and identifies what should be priorities to provide further improvement.

The exact individual mechanisms behind the benefits of ARRC are not certain, but what we feel is important is:

• excellent communication between craft groups before, during and after surgery

• pre-operative formal risk stratification and triage for all scheduled cases

• active management from arrival in recovery, the time when adverse events are most frequent

• avoiding hypotension and precisely assessing and managing fluids – the dangers of hypotension and fluid under- and over-load are well understood for end organs such as the kidney, bowel, brain and heart

• collection of relevant data on outcome and cost – it takes six weeks for return on investment from ARRC (late effects on re-admissions, rehab care etc) and we see patent outcome effects out to at least 12 months.

We know this ARRC model provides benefit at the RAH. It should be, and is being, considered or started in other jurisdictions in Australia and NZ. It is, however, seductive to believe all existing or planned high-acuity units will provide the same benefit. We know there is a large range of capacities in existing high acuitytype postoperative units. The model we use has very strict requirements with very high compliance – poor outcomes with imperfect compliance with existing peri-operative models such as ERAS are now well described

Parallels with TGA processes for therapeutic goods should be considered. Alternatives to proven products which are not shown to have ‘substantive equivalence’, should be carefully studied prior to routine adoption.

The success of the ARRC model is just one example of how we can start to address the hidden pandemic of complications and cost facing surgical care.

Following the success of National Summit I, which engaged stakeholders and generated the Principles which underpinned ARRC, Summit II is planned for 13-15 July, again in Adelaide. It has speakers from key stakeholders across Australia, but is intended to harness expertise and existing ideas through an interactive format. We welcome all to come and share their ideas. Details are available at https://thehiddenpandemic.com

1. Consumer-centric: planning/goals based on consumers’ expectations, needs and values, informed through evidence; individualised to risk.

2. Risk stratification mitigation: formal risk assessment; risk: identified, matched to pathways, with mitigation strategies.

3. Primary care: preventing complications starts with primary care; systems with excellent communication/coordination; cost-effective modes of care.

4. Systems thinking: systems re-engineered with: best evidence, minimal variation, and focus on STEEEPTM. Quality measured and benchmarked.

5. Value-based proposition: Value (outcomes vs cost) as the ultimate focus, with value for all stakeholders.

6. Evidence-based care: Evidence underpinning all care; systems regularly reviewed, and gaps addressed in a structured manner.

7. Performance measures: To guide value, performance capturing structures, processes and outcomes; measures are: consumer-relevant, risk-adjusted, benchmarked, factored into initiatives, openly shared, formally acknowledged.

8. Communication and accountability: shared decision making; clear communication, documentation, and accountability throughout the journey; information accessible to all.