Health optimisation as a strategy for financial saving

I’m distinguishing the financial from clinical benefit here, and mandatory threshold policies and system and pathway to support type approach to implementation.

For those short on patience – it’s a poor strategy for financial saving, it may exacerbate inequalities, it’s a good idea health gain wise.

I’ve been here a few times historically on smoking – you can’t have yer op till you’ve stopped smoking, and similarly on obesity.

The SW Clincial Senate report is excellent. Considering weight loss and smoking cessation criteria to improve surgical outcomes

The recommendations are worth setting out here

  • NHS bans delaying surgery until patients stop smoking or lose weight are not supported and risk widening health inequalities.
  • There is strong evidence and consensus that referral for surgery constitutes a key ‘teachable moment’ or ‘health shock’ to trigger smoking cessation or weight loss. Prompt access to interventional support, particularly smoking cessation services, must be available to take advantage of this opportunity to both optimise surgical outcomes and improve a patient’s longer term health. (Earlier opportunities for dialogue and intervention across pathways and services must also be mapped out by health communities and taken advantage of.)
  • Every effort should be made to negotiate beneficial changes with the patient in smoking and weight loss behaviours, which may include mutually agreed ‘clock stop’ arrangements to allow these risks to be addressed.
  • Delay to surgery alignment to cost savings was not evidenced and was felt, at best, to delay rather than limit expenditure. Furthermore any suggestion of a link with cost reduction questions the NHS’ motivation and is likely to be counterproductive to patient engagement.
  • The Clinical Senate Council was clear that any interventions that delay surgery should be purely for the benefit of the patient with mutual agreement between patient and clinician.

Like all policy zombies, it will rise again.

For the record, my considered view on this one is here:

a. Think carefully about the precise policy proposition

The choices here are:

  1. Mandate (stop before op / absolute thresholds) vs non mandate
  2. Clinician support – across the board, champions
  3. Management / trust support
  4. Which parts of trust / which pathways – those most directly related to stop smoking (cardio / resp) vs more tangiential (stop smoking increases value)
  5. Measuring and audit
  6. Geography – whole of YH / sub regions, CCG v LA, Trust (by geography or type)
  7. Opportunism vs systematic

B)      Evidence There are some questions of evidence

 

Is stopping smoking and advice to encourage someone to stop + referral a good thing

Does stopping smoking improve health.

Yes. The end

Does referral to NHS stop smoking services increase chances of quit

Yes. By about 50% relative to not accessing any support. c15% quit at 1yr.

does being a non smoker at time of op leads to lower complications, faster healing, less wound care problems, less bed days etc

Tricky. You’d like to think so, but not straightforward evidence wise

Obviously its good to be a non smoker and its good to be a non smoker at time of

operation. See below for some refs. There’s even a Cochrane review – read it carefully

 

 

2)      Other consideration

That implementing a mandatory delay till xxxx quit attempts or you’ve lost yyyy KG will lead to savings, and it is ethical, and equitable

a) Ethics and NHS constitution issues

I cant see it how it passes the equity test, and is congruous with an organisation committed to reducing inequality.

The NHS Constitution states that people have rights to;

1 Access NHS services free of charge, apart from certain limited exceptions sanctioned by Parliament

2 Never be refused access on unreasonable grounds

3 Expect the NHS to assess the requirements of your community and put in place the services to meet those needs

4 Not to be unlawfully discriminated against in the provision of NHS services

5 Access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible

Does the proposal square with this??

B) Inequality arguments

More poor folk smoke, more people with pre existing mental illness smoke. We know there is inverse care law in operation already re access to elective care, compared to urgent care.  This type of approach only leads to further inequity.

C) financial

There’s no evidence to my knowledge that a threshold based policy will save money in this format. May be worth remembering that a consultant who hadn’t seen someone for 6 months would probably want repeat diagnostics, X rays etc etc. All adds up etc

May cost more, extra smoking cessation costs. I’d be only too happy to increase spend on that.

This would be a good thing. We SHOULD be looking to have a positive impact on those going through services and of course we should scale up the investment in smoking cessation of course. Everyone wants to “do prevention”. Nobody wants to pay for it. Sadly the treasury aren’t changing their line on PH grant

D). Legal issues

The Legal issues presented by Warick Heale are very useful

And again the legal issues set out here in a rapid response to a BMJ article highlighting the illogical and ethical issues

F). Thus it’s Difficult to justify implementing a hard edged threshold based policy as

1) theres no evidence it will achieve the goal (if the goal is saving £),

2). it simply kicks the can down the road, and may hack people off

3). its inequitable… you cant say “you care about inequity” then implement this. Non congruous.

Re “health optimisation” for its own sake – what’s not to like about a nudge to stop smoking pre op with strong support systems in place. Some may stop for period or op, some may stop for good.

This is good, lower complication rate, wound infection, faster healing etc etc….( see caveat below)

That system must work pre op, be owned by anaesthetists (who to be fair are up for it), anaesthetic nurses and pre op clinics.

If implemented may well have impact on smoking cessation services.

Thanks to the many that have helped me form my view here. You know who you are

Appendix

(Very) selected refs re complications etc

Cochrane review

Can people be helped to stop smoking before they have surgery?

http://www.cochrane.org/CD002294/TOBACCO_can-people-be-helped-to-stop-smoking-before-they-have-surgery

Needs a careful read!

Some bits need careful consideration

Effect on postoperative morbidity and mortality

Any complications

Seven studies reported these outcomes. Two studies, both offering intensive preoperative smoking cessation interventions, found reduced incidence of postoperative complications. InMøller 2002, 18% intervention versus 52% control participants developed any complication, (P = 0.0003). In Lindström 2008, the corresponding figures were 21% versus 41%, (P = 0.03).

None of the four studies offering brief interventions (Sørensen 2003a; Sorensen 2007; Thomsen 2010; Lee 2013) detected significant differences between intervention and control participants in the incidence

of postoperative complications. In Sørensen 2003a, 41% intervention versus 43% control participants developed any type of

complication, in Thomsen 2010 61%intervention and 61%control participants, and in Lee 2013 13.1% intervention and 16.7%

control participants. Lee 2013 monitored intra- and postoperative complications. Sørensen 2007 specifically monitored wound

infections and did not detect any difference between the intervention and control groups. Pooling intensive and brief interventions separately, the RR for developing any complication was 0.42; 95%

CI 0.27 to 0.65 (210 participants) using intensive interventions

and 0.92; 95% CI 0.72 to 1.19 (493 participants) for brief interventions

(Figure 4; Analysis 1.3). There was no evidence of statistical

heterogeneity in either subgroup.

So from this Im thinking that for intensive interventions, there’s a 50-60% relative reduction and taking from Moller and Lindstrom (intensive intervention) 40-50% of patients who DIDN’T get intervention developed a complication and 18-21% of those that GOT intervention developed complication

But…..40-50% of smokers with complication…… seems high???

Maybe something to be said about definition of “complication”…. Would need to go back to the original studies – obviously…..

Wound complications

Møller 2002 found a significantly reduced incidence of wound-related

complications in the intervention group (5% versus 31%, P

= 0.001).Wound complications were divided into infections (positive

culture and antibiotics prescribed), wound haematoma, and

wound complicationwith subfascial involvement. Sørensen 2003a

found non-significant differences in wound-related complications

in 33%of the intervention group and 27%of the control group. In

this study wound-related complications were divided into the following

subgroups: anastomotic leakage, fascial dehiscence, wound

infection, necrotic stoma, haematoma. Sørensen 2007 monitored

wound infections as a secondary outcome and found no significant

difference between intervention and control groups in the incidence

of these (6%versus 8%). Lindström 2008 likewise found no

significant difference between intervention and control groups in

the incidence of wound-related complications (13% versus 26%,

P = 0.13). In this study, wound-related complications were divided

into the following sub-groups: haematoma, wound infection,

seroma, other wound complication requiring intervention.

Thomsen 2010 found identical incidences of wound-related complications

in intervention and control participants (44% versus

45%).Wound-related complications were divided into the following

subgroups: wound infection, haematoma, seroma, epidermolysis/

necrosis requiring intervention.

Pooling studies according to intervention intensity, therewas an effect

of intensive interventions on wound complications: RR 0.31;

95%CI 0.16 to 0.62 (210 participants) but not for brief interventions:

RR 0.99; 95% CI 0.70 to 1.40 (325 participants. Analysis 1.4).

Struggling a little bit with the text. Id need to go to the original papers

Again seems that intensive is what makes the difference – presubably higher quit rate….?

Define intensive – how many sessions, is it doable in real world?

My read of analysis 1.4 – the intensive end only is as follows

In the intensive  intervention group 9 (6+3) / 104 (8.6%) developed  wound complication, vs 30/106 (28%) developed wound complication

Other surgical outcomes

Secondary surgery was performed in 4%of the intervention group and in 15% of the control group participants in Møller 2002.

In the intervention group, one participant had reposition of the prosthesis, and one had wound-related secondary surgery. In the control group seven participants (13%) had wound-related secondary surgery, and one had vascular-related secondary surgery. Althoughit is evident that some participants in Sørensen 2003a had secondary surgery, no data on this are given in the paper. Sørensen 2007 and Lindström 2008 did not report data on secondary surgery. Thomsen 2010 found no difference between groups in the need for secondary surgery due to complication; one participant in the intervention group due to haematoma versus no participants in the control group.

Cardiopulmonary complications

No studies detected significant differences between groups in regard to postoperative pulmonary or cardiovascular complications.

Møller 2002 found 2%intervention versus 2%control group participants suffering from respiratory insufficiency, and 0% versus

10% suffering from cardiovascular insufficiency, needing either ventilatory support or cardiological treatment. Sørensen 2003a

found 11% with pulmonary complications in the intervention group versus 16% in the control group. No cardiac complications

were recorded in this study. Lindström 2008 found 0% with pulmonary complications in the intervention group versus 2% in the control group, and 2% with cardiovascular complications in both the intervention and control groups. Thomsen 2010 found 30% with pulmonary complications in the intervention group

versus 34% in the control group. Pulmonary complications were all minor, primarily desaturation requiring supplemental oxygen after transfer from the postoperative recovery room. Furthermore, Thomsen 2010 found 3% intervention participants with cardiovascular complications versus 2%control participants.Wong 2012 found no differences between groups in pulmonary complications

(0% intervention versus 0.7% control) or in cardiovascular complications (3% intervention versus 1.3% control).

Intensive care admissions

Møller 2002 states the number of days spent in intensive care in the two groups as two days in the intervention group versus 32 days in the control group. The number of participants was not stated.

Length of stay

No studies detected significant differences in duration of hospital admission. Duration of hospital admission was 11 days (range 7 to 55) in the intervention group and 13 (range 8 to 65) in the control group in Møller 2002. Sørensen 2003a found that the median duration of hospital admission was 11 days in both groups (range 8 to 14). Lindström 2008 reported a median duration of hospital admission of one day (range 0 to 10) for the intervention group versus one day for the control group (range 0 to 11). The corresponding numbers in Thomsen 2010 were two days (range one to seven) in the intervention group versus three days (range one to eight) in the control group. Lee 2013 reported 1.75 days (Interquartile Range (IQR) 1.1 to 3.1) in intervention participants versus 2.1 (IQR 1.4 to 3.2) in control participants

Wound healing – recent JAMA surgery study

Association Between Smoking Status, Preoperative Exhaled Carbon Monoxide Levels, and Postoperative Surgical Site Infection in Patients Undergoing Elective Surgery

Sadly paywalled, so can only glean a little from the abstract

·         All types of elective surgery
2% patients develop surgical site infection

·         OR for smoking and SSI is 1.5

·         Higher odds for smoking on day of surgery (1.9)

·         So not insignificant.

·         But remember context = 2% absolute risk, albeit in high volume care process.

·         Still no reason for absolute block till stopped, but adds to reasons for strong, structured and pathway based support to stop, swap – either permanently or as min pre op. might also consider role of e cigs in this

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