Perioperative Medicine: What the Future Can Hold for Anesthesiology.

With changing global demographics and evolving epidemiological trends, the burden of noncommunicable diseases and injuries is increasing at a rapid pace,1 making integration of surgery and anesthesia care—as perioperative care—critical to achieving the United Nations 2030 Agenda for 17 sustainable development goals (SDGs) as a “shared blueprint for peace and prosperity,” and the commitment to good health and well-being.2 It is estimated that 28% to 32% of the global burden of disease is surgical.3 Global surgery specifically contributes to achievement of the SDG 2030 by addressing the elimination of poverty (SDG 1), ensuring good health and well-being (SDG 3), promoting decent work and economic growth (SDG 8), and reducing inequalities (SDGs 5 and 10).4 Without immediate attention and scale-up, not only will absent or subpar surgical and perioperative care continue to result in preventable death and disability for millions worldwide, but it is also estimated to reduce the gross domestic product of low-income and middle-income countries by as much as 2.0% by 2030.5 This will be crippling for those fragile economies struggling to emerge from poverty and instability. Providing safe, timely, and effective surgical care in the low-income and middle-income countries continues to be a challenge due to a lack of trained clinician and availability of basic medications and lifesaving equipment. By the same token, the health care portion of the US gross domestic product continues to increase and is projected to be 19.3% in 2023.6 Such indefinitely continued levels of growth in health care expenditures are not sustainable. Surgical care currently accounts for an estimated 52% of hospital admission expenses in the United States.7 Fragmentation and inefficiencies in delivery of care, defensive medicine, discordant incentives between stakeholders who deliver versus those who pay for care, and a lack of emphasis on value are contributing to excessive surgical expenditures.8,9 Health care delivery and payment systems in the United States must continue to be reformed to address the untenably increasing health care expenditures, while at the same time improving the quality of care.10 The Institute for Healthcare Improvement (IHI) has promulgated the “Triple Aim” as a basic framework for the much-needed overall health care reform in the United States. The IHI Triple Aim comprises 3 interdependent goals: (1) optimizing the individual experience of care, (2) improving the health of populations, and (3) reducing per capita costs of care.11 Perioperative medicine (POM) is now a well-recognized, albeit still evolving, subspecialty that encompasses a wide array of equally invested stakeholders and important contributors. The practice of POM is fundamentally and optimally a collaborative effort, which aims to provide a comprehensive framework encompassing all aspects of the patient’s surgical journey.12 POM is the practice of patient-centered, multidisciplinary, and integrated medical care of patients from the moment of contemplation of surgery until full recovery.13 While defining value in health care can be complex and challenging given the different stakeholders and perspectives, specific efforts, such as collaborative decision-making, lifestyle modification before surgery, standardization of in-hospital perioperative care, and the use of data for quality improvement, add value within the perioperative setting. The impetus for POM includes the ongoing success of Enhanced Recovery after Surgery (ERAS) programs and integrated (bundled) care delivery models, which provide assurance that the journey toward more robust perioperative management is likely to benefit patients and add health care value.14Figure 1.: The future direction of perioperative medicine and the vital roles and contributions that anesthesiologists can make to the subspecialty POM. POM indicates perioperative medicine.Anesthesiologists have significant experience in streamlining perioperative care delivery, improving patient safety, and functioning as leaders in the perioperative environment. The expanding scope of the perioperative management of the surgical patient in (1) optimizing patient’s condition in the preoperative period, (2) minimizing preventable complications during the postoperative period, (3) enhancing functional recovery, (4) meeting patient’s goals of care, (5) coordinating postdischarge care, and (6) focusing on value and population health all represent the expanding role and contribution of anesthesiologists as specialists in POM. In this article, we will propose the future direction of POM and the vital roles and contributions that anesthesiologists can make to this subspecialty (Figure 1). FUTURE DIRECTION FOR THE SPECIALTY: STEPS FOR MEETING THE CHALLENGE Socializing POM as a Patient-Centered, Perioperative-Care Program Future discussions and engaging with all the stakeholders in the health care delivery ecosystem must emphasize that the POM effort is first and foremost a patient-centered program—with the main goal of delivering high-value surgical care and optimal patient experience. Depending on the local culture (leadership and team concept), available resources (quality improvement initiatives and information technology), practice models (financial arrangement: shared risk and savings), and physician employment (staffing models) within an organization, anesthesiologists may have to take sole ownership of leading the POM effort versus co-leading in collaboration with another effective clinician leader. A multidisciplinary team including surgeons, internal medicine hospitalist, nurses, allied health workers, and hospital senior leadership is vital for the success of the POM program. A POM program must be focused on the foundational aspects of patient education and engagement; care coordination among the various clinical teams; and clinical pathways that are patient centered, data driven, recovery focused, outcomes based, and efficient. This will legitimize the POM effort as a collaborative programmatic umbrella under which several related and ongoing initiatives such as ERAS Protocols15 and Clinical Care Integrated (CCI) Pathways can be positioned. Such a comprehensive programmatic focus can streamline the implementation of care pathways, overcome local politics among the various physician groups, mitigate duplicated institutional efforts, and help prioritize finite organizational resources.16 Build Coalitions With Other Professional Societies and Develop Framework for Future Educational Efforts Given the history of the American Society of Anesthesiologists (ASA) working collaboratively with the American Academy of Orthopedic Surgeons, American Urological Association, and American Academy of Physical Medicine and Rehabilitation, there needs to be ongoing dialogue with the other stakeholder groups, such as the American College of Surgeons (ACS) and Society of Hospital Medicine, on further developing core educational and training curriculum for POM programs. Such interdisciplinary collaborative educational efforts, supported at the highest leadership levels of the related professional societies, will pave the path for truly patient-centered integrated models of care focused on enhancing value, patient experience, and population health. Emphasize the POM as a Continuous Quality Improvement and Value-Based Program The long-term success in implementing a POM model of care as a true value-based program requires an effort to adhere to the principles of continuous quality improvement—thereby being iterative, data driven, and outcomes based. It is important to incorporate short, intermediate, and long-term outcome measures that are of relevance to all the stakeholders (patient-provider-institution-payers). As in the typical health care value equation for primary care, the value proposition for POM must include measures for quality, safety, and satisfaction in the numerator and total costs for the episode of care in the denominator.17 However, since the priorities and scoring of the importance of measures in each of the categories may not always align for the key stakeholders (patient-provider-institution-payer), it is important to develop the measures of POM success a priori based on agreed-on goals specific to that disease, procedure, and service line within the organization. POM as a Viable Population Health Management Program With the nonsustainably escalating costs of health care delivery in the United States, there is ongoing transition in payment models from the traditional volume-based to value-based models.18 Each of the alternative value-based payment models—such as accountable care organizations (ACOs), clinically integrated networks (CINs), and bundled payments—aims to improve health of populations of patients covered by those entities at a reasonable cost.19 The ERAS models specifically seek to transform perioperative care through achieving the IHI Triple Aim in the surgical population. Surgeons, anesthesiologists, nurses, internal medicine hospitalists, and other care providers engaged in ERAS and other integrated care delivery programs have a number of equally important goals (Figure 2). The success of a POM program is, therefore, largely predicated on anesthesiologists, surgeons, and other clinicians understanding and applying the principles of population health management in everyday practice.20Figure 2.: The equally important goals of surgeons, anesthesiologists, nurses, internal medicine hospitalists, and other care providers engaged in ERAS and other integrated care delivery programs with a successful perioperative medicine program. ERAS indicates enhance recovery after surgery.Population health management in the context of perioperative and periprocedural care can be best defined as “the iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement, while also reducing costs.”21 One key element to population health management is creating a systematic risk stratification of individual patients and managing each risk category as a specific segment of the population. A transitional care clinic, prehabilitation clinic, or perioperative care clinic within a POM program, dedicated to managing these higher-risk patients in the weeks before and after surgery, is an effective population health management strategy. Utilize POM to Evaluate Social Determinants of Health by Studying Health Disparities and Equity in the Surgical Patient Population The coronavirus disease 2019 (COVID-19) pandemic exposed and highlighted the social issues affecting health care delivery and population health in the United States in a way rarely seen and not previously appreciated. Although COVID-19 affected all segments of the population, racial minorities and individuals of low socioeconomic status experienced disproportionately higher rates of severe infections and death.22 Furthermore, during the same time period, there were national debates on the injustices that Black and Brown Americans face in American society because of racism and discrimination, and the field of medicine also began to reckon with its history of racism.23 These phenomena further emphasized social determinants of health (SDOHs): social, educational, economic, and racial factors that influence health of a subset of the population through disparities in access to health care, insurance coverage, and as beneficiaries of quality and safe care. These determinants have an outsized and under-recognized effect on health, with SDOHs shaping 80% to 90% of the modifiable contributors to population health outcomes versus the 10% to 20% of health dictated by medical care.24 There is growing interest in studying and addressing SDOHs that have a measurable effect on patient access to surgery and surgical outcomes. The ACS, for example, has initiatives that are dedicated to analyzing and improving patient outcomes and population health through programs such as Strong for Surgery, Socially Responsible Surgery,25 and Improving Social Determinants to Attenuate Violence (iSAVE).26 POM efforts and programs have a tremendous opportunity to address the 5 US Centers for Disease Control and Prevention (CDC)-identified domains of SDOH: (1) economic stability, (2) education access and quality, (3) health care access and quality, (4) neighborhood and the built environment, and (5) social and community context to deliver safe, equitable, and high-quality surgical and perioperative care to underserved and at-risk populations within the local and regional network.27 This must be an inclusive and collaborative effort, working with local educational institutions, local governments, nongovernmental agencies, insurance companies, religious institutions, hospital systems, and primary care clinics in the community. While individual, local, and regional health care entities (surgeons, anesthesiologists, primary care physicians, hospital, and health care systems) working together can address the SDOH factors for patients to varying degrees, the most effective solutions to addressing SDOH long term will occur at the health policy level. Therefore, ASA leadership, working along with other partners such as ACS, American Medical Association (AMA), and American Hospital Association (AHA), must advocate for policy recommendations by engaging legislators to have a sustained effect on shaping the health of the entire surgical population. Training the Current and Next Generation of Anesthesiologists to be an Invaluable Asset and Partner in the Integrated Care Delivery Paradigm Anesthesiologists in the United States have traditionally focused on a well-defined role in delivering the highest quality and safest anesthesia services for surgical and procedural needs of our patients. Over the years, our specialty has demonstrated an outstanding track record in improving anesthesia-related morbidity and mortality and reducing avoidable patient harm. Currently, anesthesia-related mortality in the United States is 1.1 per million persons per year.28 The successful effort to improve anesthetic safety has been due to a number of factors: Greater understanding of anesthetic-related deaths (eg, closed claims studies) Setting and standardizing anesthesia-monitoring practices Improved airway management (training-algorithms-devices) strategies Better understanding of organ perfusion and clinical application of hemodynamic resuscitation (eg, volume responsiveness-hemodynamic optimization-blood management) Adoption of evidenced-based practices Sharing of quality and safety data through the creation of national registries Robust peer review. However, we are at a critical juncture where we must meet the increasing demand for our services outside the operating room in hospital-based practice, managing expanding day surgery centers and evolving office-based practice, while balancing staffing shortages, operational efficiency, regulatory and accreditation requirements, and changing payment structure. Simultaneously, to actively participate in the changing paradigm of health care delivery to a value-based care model, we must commit to increased professional engagement locally at an institutional and community level, and nationally working with our partners and costakeholders in shaping national policy—delivering the highest value patient care, while maintaining the interests of our specialty. To prepare for this ever-changing landscape, anesthesiologists must proactively, thoughtfully, and deliberatively look for new opportunities and build the foundational systems for our current and future generation of anesthesiologists to be better educated, trained, and equipped in “institutional engagement and leadership, value-based care models, population health determinants and outcomes for surgical patients, health-systems management, information and technology services, data science literacy, and business acumen.” An invaluable component will also be to promote ongoing efforts to incorporate POM topics and experience into the anesthesiology residency curricula and expand POM fellowship programs. There are currently a few nonaccredited fellowship programs in POM being offered in the United States. The ASA and the American Board of Anesthesiology (ABA) should continue to work together to set forth necessary changes to residency curriculum and training requirements.14 In addition, acquisition of leadership skills and the understanding of organizational processes have explicitly been stated as an essential skillset to become a successful perioperative physician by the Accreditation Council of Graduate Medical Education (ACGME, Program Requirement IV B.1.c.1.a).29 The International Board of Perioperative Medicine was formed at the ASA Annual Meeting in San Francisco in 2018.30 The aim of this board was to formulate a POM syllabus that delivers cost-effective POM education to all countries in the world, leading to an improvement in perioperative outcomes. Educating patients, health care professionals, and policymakers about the scope and significance of the unmet needs of patients undergoing surgery, and as a major determinant of population health and national economics, represents an important future opportunity.29 Furthermore, building on the ASA efforts to date to promote patient-centered care, we need to drive an integrated agenda for health care policy, quality improvement, education, training, and research around the health care challenge of achieving highest value and expert care for the surgical patient.13 Model the POM Program as a Learning Health System Program Recent advances in medical technology, pharmacotherapeutics, data science, and research methodology have significantly improved generation of knowledge and their wider clinical application for progress in medicine and health care delivery. This was achieved by the transition of evidence and knowledge generation from being episodic and insular to being more continuous, data driven, and relational. Recognizing the opportunity to improve the costs and generalizability of innovations in medicine and health to a wider population, the Institute of Medicine (IOM), now National Academy of Medicine (NAM), has helped steward the evolution of a continuously learning health system (LHS). The IOM offered the first working definition of the LHS as a system “in which science, informatics, incentives, and culture are aligned for continuous improvement, innovation, and equity—with best practices and discovery seamlessly embedded in the delivery process, individuals and families as active participants in all elements, and new knowledge generated as an integral by-product of the delivery experience.”31 An LHS is characterized by “continual improvement and innovation” from new knowledge captured as an integral byproduct of the delivery experience.32 A POM program could be a great example of an LHS initiative, as it continually reviews and uncovers opportunities for real-time improvement in the experience, cost, and outcomes of surgical care programs. A comprehensive POM program should include all the domains of an LHS (Figure 3)33:Figure 3.: A comprehensive perioperative medicine program should include all the domains of a learning health system. 1. Science: evidence-driven clinical pathway development 2. Collaboration: multi-institutional cohort or rapid cycle studies 3. Informatics: seamlessly drawing data from the entire perioperative continuum across multiple sites within a system 4. Incentives: economic incentives for a more efficient, effective, and equitable system; professional incentives to accelerate real-time learning and adjustment; and demand incentives from the public for a higher performing health system 5. Culture: change management Rapid-cycle, randomized/quasi-randomized quality improvement projects within a POM program could serve as an extremely effective, low-cost tool in creating an LHS that achieves the IHI Triple Aim of health care.34 Developing a Mechanism for Fair, Transparent, and Just Reimbursement to the Providers From Hospital or Payer The ASA has worked diligently, along with the various stakeholders, to deliver on the goals of the alternative payment models of the US Centers for Medicare and Medicaid Services (CMS) Quality Payment Program, such as the bundled payment programs, comanagement programs, or as an ACO. However, many anesthesiologists and practice groups still have reservations about instituting integrated programs at their institutions. Much of the concerns are due to a lack of understanding regarding the payment arrangements or compensation for performance-related and nonclinical activities within the model. A comanagement agreement is a viable methodology for a sustainable and fair payment structure for physician participation and engagement in the POM model of care. A hospital’s comanagement payment arrangement with a commercial payer, or through CMS as part of its Comprehensive Care for Joint Replacement (CCJR) or Bundled Payment Care Improvement (BPCI) programs, includes shared savings for physicians involved in a surgical patient’s care. Generally, comanagement agreements are structured as contracts between a hospital and the provider group, which may be wholly owned by the physicians or co-owned by physicians and the hospital, for payments for the services rendered. These agreements can be used to engage anesthesiologists, surgeons, hospitalists, and other clinicians in service line–specific as well as institution-wide integrated care delivery models. Comanagement agreements are typically structured to provide both a fixed and variable portion of compensation. Depending on the individual arrangement, fixed compensation is usually allocated for clinical care, committee, and budgetary activities, institutional administrative work-strategic planning, and day-to-day operations such as staff oversight and materials management. The variable performance-based incentive payments are usually structured on meeting specific pre-established performance targets that are aligned with the hospital’s goals. The incentive payments in the comanagement agreements are generally tied directly to key performance indicators of operational efficiency, quality, clinical outcomes, cost savings, and program development. A POM program can become a viable model through which the hospital incentivizes physicians and works toward the IHI Triple Aim of better outcomes and improved patient satisfaction at reduced cost.35 SUMMARY The scope of anesthesiology and POM practice has expanded in recent years. Anesthesiologists have tremendous opportunities to make major clinical contributions and to fulfill leadership roles in the care of surgical patients during the entire perioperative continuum, thereby contributing to improving the population health and health care economics in the United States. These opportunities will stem from anesthesiologists’ active engagement in the entire continuum of a patient’s perioperative journey from assessing and improving the SDOHs in the surgical patient population, undertaking preoperative risk stratification and optimization, introducing prehabilitation programs, implementing patient- and procedure-specific enhanced recovery programs, participating in value-based care delivery models and quality payment programs, influencing population health through transitional care management, managing chronic pain conditions, and helping with opioid stewardship. These varied responsibilities and contributions by anesthesiologists as POM specialists to deliver high-value, patient-centered, recovery-focused perioperative care are vital for bridging the chasm between—and thus meeting—surgeons’ and patients’ expectations, as well as helping control the upwardly spiraling costs of health care in the United States. Moving forward, as a specialty, anesthesiology must achieve 4 primary objectives: (1) focus clinical efforts on the medical needs and life goals of patients; (2) prepare the current and future generation of anesthesiologists to deliver high-quality, patient-centered, recovery-focused care through education and training in POM and population health; (3) build collaborative approaches with all stakeholder groups in providing timely, efficient, and effective perioperative care for our patients; and (4) help anesthesiologists in developing fair and transparent comanagement agreements with hospitals and payers. Our future clinical care and business models—as well as educational, research, and advocacy effort—must ultimately add value for patients and payers. DISCLOSURES Name: Vijaya Gottumukkala, MBBS, MD (Anes), FRCA. Contribution: This author helped develop, write, and edit this article. Conflicts of Interest: V. Gottumukkala is a Consultant in Massimo, the Scientific and Education Committee Chair of the Texas Society of Anesthesiology, and the President-Elect of the American Society of Enhanced Recovery and Perioperative Medicine. Name: Thomas R. Vetter, MD, MPHV. Contribution: This author helped develop, write, and edit this article. Conflicts of Interest: None. Name: Tong J. Gan, MD, MBA, MHS, FRCA. Contribution: This author helped develop, write, and edit this article. Conflicts of Interest: T. J. Gan is a Consultant for Baxter, Eagle, HAISCO, Merck, Edwards, and Medtronic. This manuscript was handled by: Jean-Francois Pittet, MD.