The Perioperative Surgical Home (PSH): A Comprehensive Review of US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes

The United States spends about $180 billion per year on inpatient surgical procedures in nonfederal hospitals alone.1 The average cost of surgery continues to climb—from $13,000 per hospitalization in 2000 to $18,000 (inflation adjusted) in 2010—and patient safety, outcomes, and readmissions are ongoing concerns.1 Is the perioperative surgical home (PSH) a part of the solution? The concept of a more rigorously coordinated and integrated perioperative patient management system has been implemented, studied, and reported primarily in Canada, Europe, Australia, and the United States within the last 40 years, but the evolution of the PSH concept in the United States seems to be more recent. Earlier, surgical care in the United States followed a general trend of surgical specialties and capabilities moving toward same-day surgery admissions2; market expectations for high-quality surgical outcomes while controlling cost of surgeries by pursuing service-line strategies3; and value-based payment programs launched as a result of the Patient Protection and Affordable Care Act, which could yield significant savings for payers.4 The PSH continues to be defined in both the literature and clinical practice. One of its most recent definitions is based on the PSH model adopted by the University of Alabama at Birmingham, which describes the PSH model as “an innovative, patient-centered, surgical continuity of care model that incorporates shared decision making.”5 PSH programs in the United States have a variety of names, such as “center for perioperative services,” “reengineered perioperative services,” and “perioperative care pathways.” An initial examination of the literature suggests that most definitions feature 2 points of emphasis: stronger continuity, coordination, and integration of surgical care; and greater patient-focused and shared decision making. Because the terminology used to describe the PSH varies widely, we looked at the most recent comprehensive reviews and definitions of this new concept of perioperative medicine and surgical care. In one, Lee and colleagues broadly use the umbrella term “perioperative system” to encompass all the PSH's activities and developments.6 Consistently emerging evidence in the health care literature supports care coordination models like the well-established patient-centered medical home (PCMH), with its underlying principle of a single physician who coordinates the patient's care and engages a team of health care providers and their patient in an individualized treatment and management plan.7 The PCMH embodies principles laid out by the Institute of Medicine intended to improve care coordination and patient satisfaction.8 The PCMH and the PSH share a vision of higher quality and lower cost while at the same time incorporating similar elements of patient engagement and care coordination.5 Unfortunately, surgical care often is not standardized or coordinated, resulting in duplicative or unnecessary preoperative testing and procedures, which cost an estimated $18 billion annually in the United States alone.9 The PSH concept provides a model that addresses this need for perioperative care standardization and coordination, and its impact on both clinical outcomes and cost has recently been evaluated.10