Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients’ health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients.
Health care is in the midst of historic change, and anesthesiologists need to incorporate strategies that align with a value-based framework.1 This change has been further accelerated by the coronavirus disease 2019 (COVID-19) pandemic and the near collapse of the healthcare system and financial model for healthcare delivery. While the return of essential surgical care to previous levels remains dependent upon the control of the pandemic, there is an increased recognition among all healthcare practices that financial viability and sustainability will require cost of care to be further controlled in the face of decreasing reimbursements, and there will be continued transition to risk- and value-based payment models. Anesthesiologists have made enormous gains through the years in reducing intraoperative risk, and their continued engagement with patients and various stakeholders across the continuum of surgical care will lead to long-term improvements in health care. Given their primary focus on safe, episodic hospital-based care, anesthesiologists have a unique opportunity to demonstrate what it means to redesign perioperative care to improve clinical outcomes and efficiency. Patients and insurance payors will benefit from improved outcomes with an associated cost avoidance secondary to reduced complications and discharge disposition, while hospital administrators will appreciate improved efficiency and coordination of care.
This concept is hardly new and has been developed on the heels of other individuals who have shaped the field of anesthesiology. In 2005, Mark Warner, M.D., broached the thought that in a healthcare environment already changing at that time, we, as a field, should no longer be simply confined to the operating room; we should expand our horizons into other areas where our expertise would be valuable including genomics, pharmaceutical avenues, and management.2 In his 2009 Rovenstine Lecture, Ronald Miller, M.D., further expounded on the “parade of challenges…to address,” including other technologies or medical personnel doing the traditional operating room management.3 He asked our specialty to address how we will respond to this issue and still pursue excellence, and suggested that the solution is to think beyond the box of the operating theatre. In 2011, Patricia Kapur, M.D., asked us the hard question to which she already had the answer: “…are we leveraging our costly knowledge and skills to the greatest extent, to provide components of the patient care process for which our education and training are necessary?”4 Shortly thereafter, the American Society of Anesthesiologists (Schaumburg, Illinois) developed the concept of perioperative surgical home,5,6 and had a series of editorials on “how anesthesiologists can participate in and lead the transformation of health care with focus on patient value throughout the episode of care.”7 The ability for the anesthesiologist to work in concert with our surgical and medical colleagues to practice population health is even more valid today than it was in the past.8
You may be asking, “In the natural progression of our specialty, we have been able to adapt. So why the urgency?” Imagine two scenarios where the operating room anesthesiologist becomes obsolete or not needed. The first: The entire world practices preventative and personalized medicine through the ability to target genes causing disease. Operations and disease, even in underdeveloped countries, are no longer required with our current world’s frequency. This is futuristic and bordering on fantasy. The second: Hospitals no longer allow surgical teams to provide nonurgent or even potentially urgent operations because of a disaster during which (1) operating rooms are required to treat the critically ill; and (2) one operation will exponentially heighten the casualties and create a vicious cycle perpetuating the disaster. Sound vaguely familiar?
As many hospitals, administrators, and physicians continued to focus on the fee-for-service model, reinforcing volume (vs. value), COVID-19 instantaneously laid waste to the hospitals’ primary revenue generator: the operating room. The subsequent, swift collapse of the financial model for healthcare delivery exposed the vulnerabilities of not only our hospitals and hospital systems, but of our specialty. Because there has been an estimated 19.5% reduction in inpatient volumes and 34.5% reduction in outpatient volumes, it is estimated that hospitals lost $202.6 billion between March 2020 and June 2020 because of low patient volumes, and hospitals are estimated to lose an additional minimum of $120.5 billion from July to December 2020, for a total of a $320.5 billion loss.9 If a surge continues, losses will be even greater. Total relief dollars available for hospitals and providers by the Coronavirus Aid, Relief, and Economic Security Act in the United States are estimated to be $175 billion, only half of the total losses.9,10 What happens to the operating room fee-for-service model when these services are suspended? Will it be strategically sustainable for the anesthesiologists to practice only in the operating room? During the COVID-19 public health emergency, a great deal of nonemergent care was not performed, and it is unclear if it will return to baseline levels after the public health emergency.
The call to action before was well received, but there was no impetus to change. Fee-for-service has been the standard. The financial model seemed reliable. Because anesthesiologists were secured in the reliability of the operating room, some felt we would never experience a shortage in patients, and the premise of diversifying our field was seen as a luxury, not a must. In January 2020, health care in the United States stood on the cliff of such a model. COVID-19 seemed to push us over that cliff. Alongside the tsunami of sweeping regulatory and economic changes in health care, it is in this space that anesthesiologists can and must innovate in and create further value.
Rationale for Value-based Care
In 2019, U.S. healthcare spending reached $3.81 trillion, approximately $11,559 per person.11 This healthcare spending is projected to nearly double during the next 10 yr, to more than $6.2 trillion (fig. 1A). The percentage of U.S. gross domestic product that will be attributed to health care during the next decade will rise by nearly 2%, from 17.8% in 2018 to at least 19.4% in 202711 (fig. 1B). However, this does not necessarily mean that health and health care has improved. Life expectancy (a key metric in the assessment of population health) in the United States remains low compared to the other countries who are part of the Organisation for Economic Co-operative Development (Paris, France), in spite of the higher healthcare spending.12–17 The Institute of Medicine’s (now the National Academy of Medicine, Washington, D.C.) 1999 report estimated that 98,000 deaths occurred each year in the U.S. healthcare systems due to preventable harm. Health outcomes after surgical care demonstrate significant variability across different hospitals and providers, with a high incidence of postoperative complications and mortality after surgery.18,19 Additionally, many surgical procedures may not be associated with improved quality or quantity in life-years and therefore are of low or no value.20
Why is there a disparity between so much expenditure for potentially so little gain? The reasons for this apparent disparity are complex and multifactorial1,21,22 for several reasons. (1) There is no requirement for new drugs/devices to be more effective or less costly than current and approved treatments; thus, expensive new therapies are adapted without good evidence that outcomes are improved over other drugs/devices, and patients may have little to gain from them.23 For example, survival after myocardial infarction is similar between the United States and Canada, but invasive testing, procedures, and surgery were 5 to 10 times higher in the United States than Canada.24 (2) There is significant variation in prices paid by private insurers, which is not secondary to quality of care, but bargains struck with health systems or private physicians. Medicare uses an adjusted cost model based on multiple factors including geographic region and medical education. (3) Delivery of surgical care is frequently marred by avoidable and costly events—patients do not receive the right care, procedures/tests are performed with questionable benefit, and complications lead to prolonged hospital stays, or worse, unnecessary readmissions and reinterventions. The focus should shift from quantity of life (lifespan) to quality of life (health span). Value-based care has been advocated as a healthcare delivery model in which providers (hospitals and physicians) are reimbursed for their services based on improved patient health outcomes delivered at the same or decreased cost. As a provision of value-based care, providers are rewarded for helping patients improve their health and live healthier lives in an evidence-based manner.
Indeed, in health care, “Value” is defined as “Quality (or Outcomes) ÷ Cost,” although a more nuanced description of quality includes the six key domains identified by Institute of Medicine: safety, effectiveness, patient-centered, efficiency, timeliness, and equity.25
Drivers of Value-based Care
There are multiple drivers and initiatives of value-based health care that have been developed to help improve health outcomes and reduce spending (fig. 2; table 1). While fee-for-service is a significant component of current practices, the drivers for change in U.S. health care continue to move the delivery systems to payment models with increased value-based care, alternative payment, and risk-based models in nearly every U.S. market.
If anything, COVID-19 has further established the need for acceleration of value-based care. A recent (October 2020) report from the Centers for Medicare and Medicaid Services (Baltimore, Maryland) has provided guidance that Medicare, Medicaid, and private insurance payers should coordinate with one another, and also calls on the state healthcare services to advance value-based care payment models.26 To provide some context, 34% of total U.S. healthcare payments were tied to alternative payment models in 2017, a steady increase from 23% 2 yr ago. The Centers for Medicare and Medicaid Services have a goal of all payments by 2025 being associated with value-based care.27 The move to value-based payment has bipartisan support, and therefore, the change in administration will not change the goals. Thus, during the next 5 yr, every healthcare organization in the country will face changes in their Medicare reimbursement.
Most commercial health insurance providers are also participating in value-based care models and are accelerating the trend for providers/healthcare practices to assume greater risk. For instance, Humana (Louisville, Kentucky) reported decreased costs for its members/patients in its 2020 Value-based Care Report.28 Humana Medicare Advantage members would have incurred an estimated $4 billion in plan-covered medical expenses if they had been under the original fee-for-service model, instead of in value-based agreements.
The value-based programs reward healthcare providers with incentivized payments for the improved quality of care they provide to patients. This is an opportunity for anesthesiologists to partner with their surgical/medical colleagues and the hospital in realizing these incentives/savings. The anesthesiologist should become familiar with such value-based programs and whether their hospital/practice successfully participates in them (fig. 2; table 1). For instance, large employers have driven the creation of Centers of Excellence, a multidisciplinary and comprehensive program, that utilizes an institution’s expertise and resources to provide patients care in a very focused area of medical practice.29,30 This involves integrated practice and in some cases involves an integrated delivery and financial system. While benefits of participation in such multidisciplinary programs exist, in some specialties, such as bariatric surgery, the outcomes for patients who undergo surgery at Centers of Excellence sites may be no better than undergoing surgery at non–Centers of Excellence sites.31 Further disadvantages cited in the literature include decreased access to care (bariatric/orthopedic surgery) despite no difference in outcomes and the need for continued validation of Centers of Excellence criteria.32,33 A key issue is that the definition of Centers of Excellence can vary significantly, and this variability may affect the ability to judge quality.34 Another value-based care delivery model promoted by the Centers for Medicare and Medicaid Services, accountable care organizations, is comprised of a group of physicians, hospitals, and other healthcare providers, joining together to coordinate care among Medicare patients. The accountable care organizations are meant to ensure that patients receive appropriate care at the appropriate time, streamline communication, reduce medical errors, reduce duplication of services35 and, potentially, reduce mortality.36 But an accountable care organization does not guarantee success. A recent (2019) study of patients after spine surgeries failed to demonstrate a reduction in 90-day morbidity and mortality for patients who received care at an accountable care organization versus a non–accountable care organization.37 Further, the capital required to set up the information technology infrastructure for an accountable care organization and potential unequal sharing of costs between providers may be prohibitive. Regional care organizations have similar advantages and disadvantages when compared to accountable care organizations, except that they offer the services to Medicaid patients, and there is a much greater shared financial risk between provider and the organization.
Many insurers (payors) have specialty programs such as bundled payments, shared cost savings, population-based payments, and pay-for-performance. The bundled payment model was introduced by the Centers for Medicare and Medicaid Services in 2009 under the Acute Care Episode. Results from the Acute Care Episode program focusing on orthopedic total hip and knee arthroplasties have shown overall hospital cost-savings, largely through reduction of supply costs including implants, improvements in staffing models, and reduction of length of stay.38 The Centers for Medicare and Medicaid Services have championed bundled payment incentives through their Bundled Payments for Care Improvement initiative, which linked payments for the multiple services beneficiaries received during an episode of care. Under the initiative, organizations entered into payment arrangements that included financial and performance accountability for episodes of care. Some of the pay-for-performance programs have been controversial and, indeed, some studies indicated that not only did pay-for-performance not improve quality or reduce cost, but it penalized physicians for caring for the poorest and sickest patients.39 Finally, universal health care has been proposed as an answer to population health, and indeed, in theory, this sounds like a perfect solution: All patients, everywhere, can receive diagnosis of and treatment for disease states. But as measured in a study from The Lancet in 2016, the issue is far more complex than all patients receiving “some kind of health care.” Indeed, the study states, “the pursuit of universal healthcare coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view and subsequent provision of quality health care for all populations.”40
Many hospitals, administrators, and physicians continue to be focused on the fee-for-service model, which reinforces volume (vs. value), reinforces siloed work, and provides little incentive for real integration. In fact, some believe that it incentivizes futile surgery, waste, and low-value care. The COVID-19 pandemic is the stimulus for change to a more value-based marketplace. During the pandemic, there was a tectonic shift to telemedicine with delay in both nonurgent surgery and treatment of many medical conditions. Accountable care organizations offer the opportunity for health systems to preserve income during a potential resurgence of COVID-19 or a future pandemic.41 It would also allow innovation in care delivery like telemedicine or automatic hovering without concerns for fraud and abuse from inappropriate use in a fee-for-service environment. Similarly, bundles focused on conditions (e.g., back pain) rather than procedures will allow clinicians to determine the most cost-effective and patient-centered care rather than care dictated by the ability to send a bill or meet some insurer conditions of participation, and the potential development of such bundles was signaled by discussions at the 2019 Healthcare Learning and Action Network meeting (Washington, D.C.). At the time of the writing of this article, many of the regulations remain suspended, and the final decision on telehealth and the status of waivers could change future directions leading to an increased efficiency with the utilization of telemedicine.42,43
If value-based payments, shared savings, and global/bundled payments are the way of the future, this would require resources and better integration between the anesthesiology and surgical services. Anesthesiology requires innovation and strategies that pave the way for the future healthcare paradigm: to be paid not just for the quantity of services provided but for how well those services are delivered according to accepted outcome metrics that are patient-centered and team-based.
Perioperative Care Transformation
Worldwide, the two leading causes of mortality are attributed to heart disease and stroke, which, when combined, account for more than 25% (15 million) of mortal events.43 The third leading cause is 30-day postoperative mortality, which lays claim to 7.7% of all global deaths (4.2 million people).44 Previous literature in the United States established that 30-day postoperative mortality is third behind heart disease and cancer.45 Improving health outcomes after surgery is an opportunity for innovation and for creating greater value. In that regard, anesthesiologists can make significant impact through a few key approaches in the pre-, intra-, and postoperative periods. First, instead of using the preoperative encounter to only gather information to prevent same day delay or cancellation, we can use that sentinel surgical experience as a touchpoint for proactively improving population health as opposed to reactive medicine. Second, segmenting patients based upon their risk for low versus high variance procedures will not only help the hospital maintain efficiency but also help personalize care and garner significant societal benefits (figs. 3 and 4). Finally, for the patient to receive the best recovery possible, an evidence-based and data-guided approach to the standardization of processes for routine care and design of in-hospital and value-based perioperative pathways should be implemented. This will likely include greater patient engagement in their own care and “steerage” toward best postoperative care delivery such as the best rehabilitation programs.
Surgical Event: Proactive and Preventative Medicine versus Reactive Medicine
In perioperative care, as in all businesses, the needs of the patient (customer), not the characteristics of the provider, define value. Thus, the entire surgical and concurrent medical pathway for the patient, not simply a component, should define the metrics used to measure success for all patients.46 For example, care delivery algorithms, such as enhanced recovery protocols, are not defined by only multimodal analgesia or early ambulation, but by compliance with the majority of measures in the pathway itself.47 The longitudinal cycle of care on the order of weeks to months, which encompasses the patient’s responsibility toward their health through the distant postoperative future and continued engagement to stay healthy, is far more important than the operative episode of only a few hours or days. Focusing only on the “inputs and outputs” of the system on these short episodic levels obscures the true relationship from a patient perspective, making the shorter cycle of care far less important than the longer cycle of care.46,48 This includes the decision to perform the surgery or procedure itself. In more direct terms: Once the decision for surgery is made, the use of sevoflurane versus isoflurane during an operative episode of care may not matter nearly as much as the patient’s reduction in body mass index, which may reduce the risk of diabetes, malnutrition, stroke, cardiovascular disease, and polypharmacy—all of which keep the patient from requiring the next, more invasive, procedure. Reactive medicine (the ability to help manage the patient from one episode to another) then becomes preventative medicine, and the surgical encounter, in many cases, becomes the first touchpoint for a patient to engage in and improve upon their own medical care.
This may not require hospital administration to invest in new resources for an anesthesiology department but may be accomplished through a reapplication of current resources. While at one time, our core function in the preoperative period was to gather and summarize all available and relevant information to help patients for their procedure, and to optimize throughput in the operating room, we should focus on utilizing intensive clinical databases to stratify risk, coordinate the entire perioperative process, and reduce silo-driven care. In many ways, this may even start before the final decision to undergo surgery, and we must be able to provide the patient with resources to understand the perioperative journey from best case to worse case.49 Only by understanding the patient’s goals, needs, values, and lifestyle can we make their health care work within that framework, and while many elements of perioperative medicine have been implemented at different institutions, few centers, if any, have successfully implemented the complete package of perioperative care.
Several anesthesiology departments across the country have established comprehensive preoperative care centers to achieve these goals. Duke University (Durham, North Carolina) has a series of preoperative clinics designed to treat many modifiable risk factors before surgery including malnutrition, anemia, diabetes, and pain, while coordinating care throughout the perioperative period.50 Duke also provides a specific pathway for geriatric patients, who may be at increased risk of adverse outcomes postoperatively.50 Brigham and Women’s Hospital (Boston, Massachusetts) has established a Center for Perioperative Management and Medical Informatics, as well as a Center for Perioperative Research, analyzing short- and long-term patient outcomes, improvement of patient safety, and increasing efficiency, while facilitating pilot research projects designed to test strategies to promote high-quality perioperative care.51 Further, given the mounting evidence of postoperative delirium and cognitive dysfunction, they have also engaged in a robust program for the assessment and identification of risks to the brain postprocedure.52–55 At University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania), the Center for Perioperative Care, which exists as series of outpatient clinics and an inpatient service, focuses not only on a cardiopulmonary assessment of patients but also on a holistic view of the patient, looking to modify risk and lifestyle and re-engage the patient in their community care.56 Utilizing machine-learning predictive algorithms and protocol-driven care, the program’s main goals are to (1) identify patients who are at high-risk for short- and long-term poor surgical outcomes, encouraging a “surgical pause” for the opportunity to mitigate risk; (2) design a program that provides a comprehensive menu of services aimed at improving both physiologic and psychosocial conditions that contribute to vulnerability of high risk, before their nonurgent or even urgent surgical procedure (e.g., comprehensive medical assessment, measurement of frailty and cognitive status, nutrition and weight management, cardiopulmonary rehabilitation, chronic pain and opioid management, drug and alcohol use, mental health evaluation, assessment for delirium and potential for postoperative cognitive decline, and supportive care [finances, transportation, and postoperative planning]); (3) provide at-risk patients with a supportive “surgery coach,” specifically trained in surgical preparation, who mentors patients, readying them for their surgical experience; and (4) engage an anesthesiologist-directed multidisciplinary team comprised of surgeons, primary care providers, and physician specialists all working in concert with the patient in a shared decision-making approach.
Implementation of this clinic can be challenging within a fee-for-service system. Physicians and hospital administration must be convinced of several points: (1) healthier patients undergoing surgery will result in cost avoidance and reduced readmission; (2) healthy patients will always require surgery; and (3) focusing on cost avoidance and doing the right thing for the patient may reduce revenue, but will substantially increase profit margins. At the same time, it has been our experience that, in the past, many surgeons receive referrals for which they feel the only option is surgery, even though they are aware that the patients are not reasonable surgical candidates. Many times, they may feel “pushed into” the surgery by the patients and/or patient families because the medical personnel (internists, oncologists, cardiologists, and so forth) do not understand the postoperative course of an ill individual and assume that the patient will return to a normal quality of life. Additionally, this is how the surgical teams build their referral base. We, as anesthesiologists, are accustomed to the serious complications that can occur intra- and postoperatively. Because we know this well, we should see ourselves—and be seen—as vital to resetting the expectations of patients for their postoperative care in collaboration with the surgeons. In this way, we can present a united team with the surgeons in reducing mortality and complications, which ultimately results in cost avoidance and increased profit margins to both insurance payors and healthcare services.
We recognize smaller private practices might not be in the best position to implement some of these programs because those practices may not have the same resources and structures that already exist for large, multispecialty practices. Notwithstanding, their participation in cross-disciplinary programs such as enhanced recovery after surgery, perioperative surgical home, operating room cost reduction initiatives, and so forth, will enhance their role in improving healthcare delivery. Indeed, one of the best methods to become involved may be to establish a perioperative surgical home or participate in an accountable care organization.
Managing Risk and Personalizing Care: Intraoperatively and Perioperatively
Segmenting patients based on risk and complexity is important. While many of the care processes for patients seeking routine care can be implemented with a Focused Factory Model (standardization and established protocols), some patients and processes demonstrate significant complexity that requires management through a complex adaptive system approach.57 Hospitals are generally arranged as networks designed for interaction within multiple specialties/individuals/groups.57 A program should make use of a team of experts to develop protocols and decision logic, based upon current evidence, that can be executed with large swaths of patients, without requiring intensive resource utilization, of which the American College of Cardiology (Washington, D.C.)/American Heart Association (Dallas, Texas) Approach to Perioperative Cardiac Assessment for Coronary Artery Disease is a prime example.58 Patient risk and required assessment are categorized depending on severity of illness and procedure. Linear processes can drive standardized care for patients who are not complex. However, more complex patients require multiple interactions, nuanced in a tailored approach as in an adaptive system.57 The standardized or factory approach consists of low-complexity surgeries, which have lower risk, occur in higher volumes, and have less variance in procedure, where potential gains are related to high efficiency, care coordination, and discharge planning. Higher-complexity procedures are ones in which the population may have a higher variance and incidence of postoperative complications, where improved clinical outcomes are brought forth by a network of experts. For example, orthopedic procedures, such as total joint replacements, occur in high volumes and are lower-risk. Although many older elective orthopedic surgical patients most likely have some degree of preoperative cognitive impairment, such impairment is associated with development of delirium postoperatively, longer hospital stay, less likelihood of going home upon hospital discharge,53 and delayed return to cognitive health. This at-risk subset requires a more adaptive approach. This approach can also be used to determine the optimal location of care. These patients can be stratified preoperatively, but the innovation in intraoperative care is extremely important for their postoperative recovery.
Three terrific examples have been reported. The Mayo Clinic (Rochester, Minnesota) implemented a focused-factory model for cardiac surgery in five stages: identification and segmentation of the population; creation of clinical pathways and protocols for all areas of care; design, building, and adoption of health information technology systems for communication and decision support; empowerment of bedside providers to advance (de-escalate) care by such protocols, when appropriate; and locating similar patients with similar complexity near each other.59 They found significant decreases in mortality across their population and significant improvement in complication rates for sepsis, pneumonia, and renal failure.
Another report describes patients requiring transaortic valve replacement being segmented based on underlying risk into distinct intraoperative conscious sedation and general anesthesia care and postoperative clinical care pathways, in an attempt to reduce cost and improve outcomes.60 They reported that conscious sedation for transaortic valve replacement was safe and could significantly reduce cost and improve outcomes (reduced length of stay and intensive care unit time) if the patient parameters were favorable, which included a transfemoral approach, no perfusion or operating room nurses on standby, and a surgeon in house but not scrubbed, with a fast-track recovery plan. This enables personnel to be available for other cases, as necessary.
Finally, Anesthesiology published a study regarding value of patient segmentation for improving intra/perioperative care delivery and operating room throughput in orthopedic surgery.61 This study showed that with appropriately selected patients, spinal anesthesia for arthroplasties and parallel processing using induction rooms can result in patient out-of-room time of only 14 min and increase the number of cases per operating room per day. This style of operating room management can achieve high efficiency because of patient selection/segmentation. The selection criteria for more facile patients included those undergoing a primary joint replacement, an anticipated easy spinal anesthetic without contraindication, and patient willingness. Patients who did not meet these criteria had to have their care in regular operating rooms with more personalized care.
These examples are only a small subset of all surgeries that occur, and risk assessment is required in all specialties. It requires significant information technology, design, building, and testing in order to establish such a risk assessment algorithm that can accurately predict postoperative mortality and complications with anesthesia and surgery. Recent reports suggest successful development of such risk models using various machine-learning approaches. Several anesthesiology and perioperative care groups have developed adaptive models through “deep learning” to predict 30-day mortality.62,63 However, few have reported the results from implementation of these models in changing care delivery or clinical practice at the current time. With the ability to diagnose complications in the operating room well before they happen would come revolutionized intraoperative care, prevention of significant events, and further enhancement of postoperative recovery.
While patients are risk-stratified, educated, given realistic expectations, and empowered to understand that they are the most important person in their care and recovery, this is only the beginning of the clinical pathway, and challenges remain in both the intra- and postoperative arenas. Requirements include integrating care outside of the hospital before and after surgery, standardizing intraoperative care, and effective use of in-hospital resources in the postoperative period. This brings about the concept of vertical and horizontal integration of pathways.64 Each surgical service line has a pathway by which they care for their patients. But there are disease states and treatment methodologies that will cross all surgical service lines, guided by the same tenets. The patient with hyperglycemia or diabetes still requires glucose control. The patient with congestive heart failure still requires specific care whether or not they have a total joint replacement or a Whipple procedure. Patients will still have discomfort and requiring pain management regardless of their procedure.
Enhanced recovery protocols are a good example of innovation within the intraoperative and postoperative realm.65–75 Based on five major tenets of limiting preoperative fasting, minimally invasive surgical procedures, multimodal analgesia, early feeding, and early ambulation, these cross multiple surgeries. At the Kaiser Permanente (Oakland, California) integrated healthcare delivery system, two populations—colorectal and orthopedic surgery—saw the controlled and prospective implementation of the enhanced recovery protocol clinical pathway, with certain minor differences based upon the type of surgery. They found significantly reduced length of stay, reduced mortality, and reduced postoperative complications.76 At the University of Pittsburgh Medical Center, utilization of an enhanced recovery protocol across eight service lines in approximately 6,000 patients was significantly associated with improved discharge disposition and a reduction in mortality at 30 days and 1 and 2 yr, and compliance with only five or more elements of the enhanced recovery protocol was associated with better outcomes.77
Clinical pathways are important not only for patients and hospital systems but also for the significant value added for society in general. More than 100 million Americans experience chronic pain, and the treatments are upwards of $635 billion, which is more than the amount spent on heart disease and cancer combined ($552 billion).78 In 2014, 21.5 million American patients were diagnosed with a substance use disorder, and 10% of those involved prescription pain medications.79 There are 259 million opioid prescriptions written annually, more than enough to give every American adult their own bottle of pills.79 Drug overdose has been listed as the leading cause of accidental death in the United States, and the opioid epidemic is, in part, caused by these prescription opioids, many of which are given postsurgery.80 As anesthesiologists, we can have a direct impact on this epidemic, by coordinating perioperative pain medicine within the preoperative arena, partnering with surgical teams to coordinating team treatments, offering opioid-sparing/-free analgesia through our regional anesthesia teams, and developing a postsurgical and postdischarge pain plan for them. Two excellent examples from the literature show that anesthesiology-led acute and chronic pain services as part of a perioperative surgical home/comprehensive program have a significant role in improving outcomes and improving the opioid epidemic.81,82 Acute postoperative pain is usually well controlled in those institutions that have an anesthesia pain management service. The addition of multimodal analgesia and complimentary regional anesthesia has transformed perioperative care and can reduce the use of opioids for postoperative pain.83 Importantly, pain is frequently less well-controlled on general medical wards, even in institutions with an anesthesia pain management service, since the service usually focuses on management of epidural analgesia and peripheral nerve catheters. Improving the process of pain assessment and treatment in all hospitalized patients presents a significant opportunity for anesthesiologists to improve patient outcomes and decrease the overall cost of health care, thus improving value. Finally, we can add value by establishing pathways for who is discharged with opioids and how much they should have when they go home. Anesthesiologists can also be trained in palliative care and would be able to offer a more diverse repertoire of treatments to patients undergoing palliative procedures. Overall, increased training in perioperative medicine and critical care is essential for anesthesiologists to effectively participate in many such initiatives that can bring healthcare change for the surgical patients. All of these taken together create significant value for healthcare systems and for all of society.
Gap between Intention and Reality: Data and Variability
Critical to successful implementation of these integrative pathways is the ability to garner reliable and meaningful data to inform us to continue on a current path or to help us fail quickly. The transition to an electronic record promised free-flowing data for rapid transformation of health care. The current dystopic state of somewhat poorly recorded and difficult-to-access medical record information creates a major barrier to defining success metrics. Healthcare data analytics and information technology are required platforms for any performance improvement initiative that is sustainable, and the data gathered should be used as an advantage and strength to help a department and organization compete more effectively. Anesthesiologists with direct knowledge of complications, perioperative mortality, and other metrics that impact performance can affect a hospital system’s and insurance payor’s ability to compete in a value-based system.
In that regard, anesthesiology departments can use their perioperative domain knowledge to help build or partner with the hospitals’ information technology groups in creating scalable and validated clinical and financial data marts and dashboards to implement value-based care initiatives.84 It can also help identify clinical comorbidities that can be used to help risk-adjust their value-based payments.
With continued growth of digital technology and software applications for improving health, several programs have implemented clinical decision support systems in their clinical practices, either as tools built within the institutions’ electronic health record or as standalone applications that interface with electronic health records. Digital health solutions can enable implementation of the clinical pathways and monitoring of compliance, all of which can help positively affect the course of patient success. As an example, clinical decision support was used to calculate a patient’s risk for postoperative nausea and vomiting based upon the information in the electronic health record.85 After institution, there was a clear reduction in postoperative nausea and vomiting with high compliance for the pathway. A reality in several critical care units,86 we can develop intraoperative clinical decision support by utilizing machine learning to predict adverse hemodynamic events and other crises in patients intraoperatively, leading to the practice of proactive, instead of reactive, perioperative medicine.87
Anesthesiology and perioperative care are also beset with variability and lack of standardization in many of the routine clinical practices, which has been shown to negatively impact both outcomes and costs.88–93 For example, anesthesiologists demonstrate a lack of consensus on how much crystalloid to give during abdominal surgery. A two-center retrospective analysis of total crystalloid administration in nearly 6,000 patients during abdominal surgery revealed a widely variable range of administration anywhere between 2.3 ml · kg–1 · h–1 and 14 ml · kg–1 · h–1.92 Another example comes from a study describing significant interinstitutional difference in failure to rescue from complications after surgery. Among the majority of U.S. hospitals, while types and rates of postsurgical complications were similar (24 to 26%), mortality rates ranged from 12.5 to 21.4% depending upon how effective the failure-to-rescue processes were established in a given hospital.94 There are other barriers to practice that may account for such variability. Amalberti et al. discuss said barriers to change within the medical field, comparing safety profiles of surgical procedures and anesthesia to other unrelated medical fields. For example, cardiac surgery in American Society of Anesthesiology physical class III to V is only slightly safer than Himalayan mountaineering above 8,000 meters, but it is less safe than traveling by planes, trains, and automobiles, and is more than 1,000-fold less safe than the nuclear industry.95 Thus, an important role for anesthesiologists will be in trying to address the variability in perioperative practices and partnering with the other stakeholders in reducing the overall risk for the patients. As our focus expands from the operating theater to the continuum of care, we have a great opportunity to impact preventable harm and fully participate in population health goals of returning our patients to better physical, cognitive, and psychologic health. Relatively new tools of improvement science, safety science, implementation, and system safety science should be accelerators of change and integrate into evidence-based pathways of care for medical and surgical conditions.
Finally, it is important to highlight that currently, while there are not a great deal of data to advocate for the programs that we have discussed, data are not generated without studies and deep dives into the issues surrounding patient care. Indeed, perhaps one of the most important contributions we can make as anesthesiologists is to directly involve ourselves in the research to assess and develop evidence-based approaches.
Anesthesiologists have much to contribute to the advancement of value-based care through their multitude of interactions and influences on various aspects of surgical care. Perioperative medicine is not as much an expansion of our current roles as a rediscovery of our value to the healthcare community at large, whether it be patient or provider. It doesn’t imply abdication of our excellence in providing care in the operating rooms. Not all anesthesiologists, however, will be able or willing to play a role in these new activities, but a subset will need to do so, and should be supported by their colleagues in their efforts. Nonetheless, the time has come for us to increase our value, to work as an integrated unit with hospital and surgeon leadership, and to become leaders ourselves, realizing that our goals are the same: providing better care at decreased cost, increasing standardization, establishing clinical pathways and quality metrics, utilizing data and clinical decision support along the way for iterative improvement, and sharing of results with other institutions for our continued improvement across the nation and world.
Support was provided solely from institutional and/or departmental sources.
Dr. Mahajan is Founder of Sensydia, Inc. (activity not related to the subject matter of the manuscript); and received a stipend from the National Institutes of Health (Bethesda, Maryland) as a National Institutes of Health Study Section Reviewer (activity not related to the subject matter of the manuscript). The other authors declare no competing interests.