STARTING BLOCKS Your prospective anesthesia group should have ample experience with regional anesthesia and continuous nerve blocks, says Dr. Szlyk, shown here administering an ultrasound-guided block.

Due to frenetic consolidation in the anesthesia market, an anesthesia group may now comprise more than a thousand anesthesiologists and CRNAs spread over a dozen or so states. That can feel daunting when it comes to choosing a group to partner with. How can you tell whether that group is going to be willing to own the process in terms of optimizing pain management and patient outcomes?

You can learn a lot by looking at a group's patient satisfaction scores, and by talking to administrators and surgeons who've worked with that group at other sites. That may get you a thumbs-up or thumbs-down, but you also want specifics and details before you commit to such an important, potentially long-term, relationship. Here are 10 questions to ask before you sign on the dotted line with an anesthesia group.

1. Do they know the dynamics of outpatient surgery?
Efficiency is paramount at outpatient centers, where the cases, the recovery and the turnover times are short. The setting is often more limited in terms of resources, especially when it comes to the number of pre-op and PACU bays. A group might be able to get away with having inpatients linger in the recovery room for hours at a hospital — not that they should let it happen there, either — but they have to know that it's unacceptable in an outpatient setting. The ability to manage pain and prevent nausea are essential skills.

SITE SEEING Your anesthesia group should be perfectly happy to meet with you in person to address concerns.

2. How will they help you improve efficiency?
The more effort your anesthesia team puts into optimizing patients before surgery, the better your outcomes will be, both in the OR and afterward. Whether they work with your staff or provide their own, it's crucial that they identify any issues — a history of difficult intubation, coronary artery disease, untreated or poorly managed diabetes, or obstructive sleep apnea, for example — before the scheduled day of surgery to minimize surprises and cancellations. You want time to address these concerns well beforehand. You may need to tell a patient to bring in his CPAP machine. Or maybe you need to dig a little deeper into the patient's cardiac history. Do you have the proper lab work and pre-op testing (while containing expenses by not ordering unnecessary lab work or imaging)?

Your anesthesia team should work closely with pre-op nurses on health history phone interviews. The information they gather should be based on the type of procedure (low-, intermediate- or high-risk) and the patient's comorbidities to determine whether additional testing is needed.

3. Are they approachable and accountable?
Running a surgical facility is like cultivating a garden. There's always something to tend to. Your anesthesia group needs to be reachable at all times — not only by the administrator, but by surgeons and patients as well. Depending on the concern, you also need to know you can reach the right members of the group quickly. If you'd prefer to meet in person, they should accommodate that as well.

4. Are they experienced in the types of cases your facility specializes in?
Make certain they've been providing anesthesia on a regular basis for the types of cases your facility hosts, especially if you're a high-volume center with a specialty like vascular, ENT, urology, spine or orthopedics. You should have complete reassurance that they're the right match for you — that they know how to manage those cases and provide the ideal anesthetic for your patients.

5. Are they proficient in regional anesthesia?
This has become a real differentiator, and something that's enabled more complex cases covering a broad range of surgical specialties to be performed on an outpatient basis. An anesthesia group that's at the forefront of employing regional anesthesia can be invaluable in that regard. Do they have the ability to administer ultrasound-guided nerve blocks and catheters? What do they bring to the table when it comes to enabling outpatient total joint replacements?

6. Do they use multimodal regimens?
Multimodal premeds as part of an ERAS (enhanced recovery after surgery) protocol should be used for most cases. Along with regional anesthesia and nerve blocks, opioid-sparing techniques play a tremendously important role, especially for outpatient spine, and total hip and knee replacements. Being able to control pain and prevent nausea lets patients get up and moving, and maybe even start physical therapy on the day of surgery.

7. Can they provide detailed quality metrics?
One of the benefits of dealing with a larger group is the potential to take advantage of a database that comprises tens of thousands of patient encounters. In the era of MACRA (The Medicare Access and CHIP Reauthorization Act, under which a growing percentage of physician payment will be based on value, not volume) the ability to measure performance outcomes such as difficult airways, PONV, corneal abrasions and ASC-to-hospital transfers is extremely valuable.

Your anesthesia group should be able to provide strategic information related not just to what goes on in the OR, but also what goes on both before and after. If case cancellations are a chronic issue, are they preventable? Are patients arriving in PACU with temperatures above 35.5 ?C? Are re-intubations occurring in recovery? Are patients receiving PONV prophylaxis? Groups that routinely monitor performance data can help enhance patient satisfaction and reduce undesirable outcomes.

8. Can they help you preserve existing relationships?
Clearly, there are benefits to having consistent teams in the OR, and your group should respect that. If certain anesthesia providers work well with certain surgeons, and have for years, your group should make every effort to accommodate that. If you've worked with a smaller group that's recently joined a larger practice, try to maintain those relationships, instead of trying to start over again.

9. How do they handle questions from patients?
If patients have questions about billing — whether the group is in network, for example — your anesthesia group should be easy to reach and responsive. Ideally, they'll also have a website your patients can access to find out ahead of time what their bills will be.

10. Are they growing?
Growth can be a marker of a group's ability to provide quality care and maintain relationships with administrators, surgeons and patients. A group that's grown little or not at all may not be keeping up with the increasingly complex procedures being performed in outpatient facilities, especially with orthopedics and spine. Anesthesia groups need to respond to the constantly evolving landscape of outpatient surgery.

Smart choice
As long as you ask the right questions — and make sure you get the right answers — you can feel confident that not only will your patients consistently receive optimal anesthesia care, but also that the group you choose will understand the unique features of your facility and provide resources that improve ?both efficiency and profitability. OSM