Continued Evolution of Perioperative Medicine: Realizing Its Full Potential

Abstract

See Articles, p 803, p 808, p 811 For time and the world do not stand still. Change is the law of life. And those who look only to the past or the present are certain to miss the future. —US President John F. Kennedy Frankfurt, Germany, June 25, 1963 As prophetically observed by Lee1 in 1949: "I think that an anaesthetic outpatient department could contribute considerably to preventive medicine. The anaesthetist is frequently confronted with a patient … who is not in the best possible state for operation. He has not … been made as safe for surgery as possible … For the anaesthetist to see the patient the evening before operation, or even two or three days before that, is not enough." In 1952, Green and Howat2 reported on their experience in hence establishing an anesthetic outpatient clinic at St George's Hospital in London. Continued advancements have been made in the scope and the clinical, operational, and financial impact of such outpatient preoperative clinics.3–5 The interim 70 years have also witnessed the advent of perioperative medicine and, more recently, perioperative population health management.6–10 But has the situation really changed since the above prescient observation by Lee1 in 1949? In this issue of Anesthesia & Analgesia, Aronson et al11 posit in their intentionally thought-provoking commentary that there still remains a strong imperative ("a continued call to action") to legitimize preoperative optimization by overcoming its continued, innate implementation challenges—thereby further demonstrating its added value. WHAT ARE THE MAIN BARRIERS TO VALUE-BASED PERIOPERATIVE SYSTEMS? Many perioperative clinicians remain hindered by an administrative and leadership culture that unfortunately is not primarily aligned with the goal of providing value-based, patient-centered care. A recent New England Journal of Medicine publication highlights this disconnect, noting remarkable gaps among key stakeholders.12 Although 91% of respondents believe that it is extremely necessary for frontline clinicians and hospital administration to be aligned, only 5% report common goals in clinical and financial models. This lack of alignment is particularly apparent in the typical metrics applied to judge the success of preoperative assessment systems. For example, given the short window of time allotted between assessment and procedure, efforts are focused on ensuring that the surgery proceeds at the scheduled time, and efforts to delay for optimization may be met with resistance. Success has traditionally been associated with process metrics that are not based on population health management and that fail to include the important impact that a more robust preoperative program can have on patient-centered outcomes and overall health care costs. Efforts are often made to minimize preoperative care resources as "nonbillable" cost centers, neglecting the fact that time spent with the patient, although "nonbillable," can have significant impact on overall outcomes―especially by using population health management and triaging patients to identify risk factors that can be addressed and optimized preoperatively. For example, taking the time for cognitive assessment of geriatric patients is rarely considered a standard element of preoperative assessment, despite the significant incidence of postoperative delirium and the opportunity to utilize delirium prevention pathways. We, thus, need to fundamentally change the key performance indicators and metrics. HOW DO WE ALIGN COMPETING PRIORITIES OF STAKEHOLDERS? Competing priorities can only be aligned if all stakeholders are willing to define common goals. While procedural volume is one measure of operating room "success," attention must also be paid to intermediate- and long-term metrics, lasting well beyond the day of discharge, which determine the actual value (ie, quality/cost) that the procedure provides to the patient. Cost is certainly the important denominator of the value equation; however, quality in its numerator must be patient centered. Although 30-day morbidity and mortality are important, the patient would certainly hope that the results of a procedure are of far more benefit than just avoiding complications and death. Preoperative services should be available that will maximize the value of the overall continuum of care rather than simply attempting to reduce costs in often siloed organizational cost centers with their individual budgets. Lowering costs in siloed budgets, resulting in less robust preoperative assessment and optimization, could actually increase overall costs of the surgical episode if downstream impact is not considered. Innovative patient-centered perioperative pathways that allow for risk assessment and optimization are thus essential in a value-based system in which the goals shared by all stakeholders are to maximize not only short-term but also intermediate- and long-term outcomes relative to the cost of achieving these outcomes. Achieving these common goals will require organizations to develop comprehensive perioperative pathways, led by innovators in this area. HOW CAN WE ACHIEVE THE TRANSFORMATION FROM CONVENTIONAL TO COMPREHENSIVE PREOPERATIVE MANAGEMENT? While changing the framework of traditional preoperative assessment systems to undertake population health management may seem daunting, fortunately, we have leaders and innovators guiding the way. In a second article in this issue of Anesthesia & Analgesia, Aronson et al13 in turn provide a comprehensive description ("a roadmap") for transforming a conventional preoperative assessment clinic into a more comprehensive and robust preoperative optimization clinic. This separate article by Aronson et al13 demonstrates that this transformation is clinically and financially feasible and can have a significant impact on increasing the value of preoperative assessment. The main requirement is a perioperative leadership group that is willing: (a) to become knowledgeable on these issues; (b) to understand the impact on value for the patient, the care providers, and the institution; and (c) to redefine resource allocation and metrics to achieve these desired results. Aronson et al13 have described in depth the importance of a perioperative medicine model for population health. Multiple perioperative risk evaluation and optimization programs at Duke University Health System are focused on modifiable risk, beginning as soon as the decision for surgery is even contemplated. WHY ARE SEMANTICS RELEVANT? Rebranding is a strategy intended to associate a newly differentiated identity in the minds of stakeholders. The continued evolution of preoperative clinic nomenclature has implied much more than just a name change (Figure), reflecting transformation from conventional patient assessment to comprehensive medical management. Rebranding has enhanced identification of expanding clinical domains and associated metrics.Figure.: The evolution of the semantics or nomenclature of an outpatient clinic, ultimately participating in and contributing to perioperative (both preoperative and postdischarge) patient management (used with permission of Thomas R. Vetter, MD, MPH). PAC indicates preanesthesia clinic or preanesthesia assessment clinic; PACT, preoperative assessment, consultation, and treatment; PASS, preoperative anesthesia and surgical screening; PASS-GO, perioperative assessment and global optimization; PAT, preadmission testing or preanesthesia testing.The initial role of a preadmission testing or preanesthesia testing (PAT) clinic basically provided a place where outpatient testing could replace admission before the procedure. Common definitions of emergency and elective surgery, therefore, needed to be defined. Over time, the focus became assessment as well as testing and associated metrics reflected impact on preventing delays and cancellations on the day of procedure. As the importance of evidence-based risk assessment and optimization became clear, further rebranding to include screening, assessment, consultation, and treatment has occurred. Metrics were expanded beyond traditional same-day delays and cancellations and now include preoperative identification and management of medical issues as well as measurement of patient satisfaction. With development of comprehensive perioperative frameworks as described by Aronson et al13 in this issue, nomenclature has again changed to reflect expanding scope and functions. Evidence-based, individualized, and patient-centered triaging affords management of modifiable risk, and metrics now extend far beyond identification of issues that could impact the day of surgery. Metrics now reflect the impact of this optimization on longer-term variables like pain control, delirium prevention, acute care length of stay, skilled nursing facility admission rates, and hospital readmission rates. In addition, preoperative assessment has become a pause-point where long-term population health can be improved by including programs like smoking cessation and medical weight loss. With more prevalent and robust global optimization programs, metrics reflecting impact on patient-centered outcomes long after acute care discharge will become increasingly relevant. Metrics reflecting real health care value from preoperative assessment and optimization will mandate investment in more comprehensive systems. WHAT LIES AHEAD? Continued evolution of perioperative pathways must occur. Multidisciplinary collaboration is critical for these perioperative frameworks to be most effective. Although innovators have achieved initial expansion of these frameworks, there needs to be the ability to benchmark outcomes across institutions so that best practices can be further incorporated, and health care value hence enhanced. This requires the consistent use of evidence-based templates that function through a longitudinal information technology framework that can provide decision support, common databases, and analytics. Unfortunately, currently available electronic medical/health records are generally encounter based and not aligned with longitudinal value-based documentation and analysis. Identification and integration of newer technologies with these existing and relatively cumbersome systems will be essential to allow accurate data acquisition and analysis. Enhancements in information technology will also need to facilitate interdisciplinary collaboration and communication instead of focusing on individual encounter-based documentation. In addition, downstream communication of planned care pathways based on collaborative discussions is necessary. Patient engagement portals that can triage, educate, and collect data from initial contemplation of surgery to well after surgical discharge will be needed. This information technology infrastructure is not only important at the institutional level; it will also be essential for national benchmarking of outcomes. In addition, as payors increasingly focus on models that reward quality and value instead of volume, this infrastructure will become essential for contract negotiations as well as payments. It will be invaluable information for payors looking to encourage population health, increase long-term value from surgeries performed, and reduce unnecessary and potentially inappropriate elements of procedural care. Collaborative discussions to ensure high-value, evidence-based care need to include the patient and family as well as clinicians. Albeit a lofty goal, true patient-centered care must be based on high-quality shared decision-making. Defining the elements of this process so that decisional quality can be assessed is an active area of research. Unfortunately, education in conducting such discussions is neither required nor assessed. In addition, time needs to be allotted for these discussions to occur, but in many institutions, this time is not appropriately allotted due to cost considerations. We look to innovators in perioperative medicine to include this important aspect as they continue to develop effective perioperative care frameworks. Such provider education will be essential not only for effective, individual shared decision-making but also for overall perioperative medicine and population health management. In conclusion, we concur that as insightfully observed by Kehlet et al,14 "future strategies to improve perioperative outcome, within the context of anesthesiology, surgery, nursing care, and perioperative medicine, require a change of tactics going beyond politically and profession-specific approaches, but instead incorporating a multidisciplinary effort to achieve optimal outcomes." Aronson et al11,13 at Duke University Health System are to be commended for having clearly recognized and successfully embraced this vital multidisciplinary and interdisciplinary approach. DISCLOSURES Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write and revise the manuscript. Name: Angela M. Bader, MD, MPH. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Jean-Francois Pittet, MD.

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