We read with great interest the recent Special Article by Mahajan et al.,1  who pointed out the anesthesiologists’ role in value-based perioperative care during the COVID-19 pandemic and the subsequent financial implications facing hospitals. Anesthesiologists should serve as clinical leaders to drive healthcare transformation across the perioperative process, to implement integrated standardized pathways with the goal to improve outcomes, and to manage costs as healthcare systems transition toward value-based care. While we appreciate the notion of the anesthesiologist as a leader, we believe the focus on directly providing anesthetic care misses the opportunity to further develop and implement clinical pathways for procedures, which can be safely performed without the direct presence of an anesthesiologist.

The authors cite an article by Toppen et al.,2  who stratified patients to undergo transcatheter aortic valve replacement with either conscious sedation or general anesthesia. The clinical outcomes suggest that sedation is safe, is cost effective, and results in shorter hospital stays. Although many structural heart teams consist of an anesthesiologist, a cardiologist, and a cardiac surgeon, studies have demonstrated the safety and reliability of sedation without the direct presence of an anesthesiologist. For example, Kezerashvili et al.3  noted the long history of nurse-led sedation in cardiac procedures based on patient safety, clinical efficacy, and cost effectiveness. Similarly, Keegan et al.4  completed a 5-yr review of a minimalist transcatheter aortic valve replacement protocol comparing anesthesia-led sedation with nursing-led sedation. Using a strict protocol based on transcatheter aortic valve replacement and sedation risk, the authors showed that both anesthesia-led sedation and nursing-led sedation groups had comparable survival to discharge (98.3% nursing-led sedation vs. 100% anesthesia-led sedation, P = 0.05), procedural success at discharge, and 1-yr death/readmission rates.4  In short, nurse-led sedation under the guidance and purview of an anesthesiologist in a well-selected patient population maximizes resource allocation and generates cost savings while preserving outcomes, both essential components of value-based care.

Ultimately, we believe that the perspective presented by Mahajan et al. represents a framework for anesthesiologists to leverage their expertise and impact team-based care. Value at the hospital, accountable care organization, and national level requires the efficient application of resources where all healthcare providers work to the top of their license, while remaining within their scope of practice. Reframing the question from what procedures are scheduled with anesthesia services to which patients require the services of an anesthesiologist will greatly assist our specialty in the transformation of value-based care. As the reimbursement landscape changes, staffing flexibility allows hospitals to determine how to efficiently deploy resources to achieve the best possible patient outcomes. We agree that anesthesiologists must remain a leader in the development of procedural sedation protocols, including patient selection, sedation policies, and management of complications, to ensure ongoing patient safety and procedural efficacy. We also humbly recognize that the notion of nurse-led sedation may reduce our presence in the clinical setting, but it may move healthcare systems toward sustainable, value-based care.

The authors declare no competing interests.

1.
Mahajan
A
,
Esper
SA
,
Cole
DJ
,
Fleisher
LA
:
Anesthesiologists’ role in value-based perioperative care and healthcare transformation.
Anesthesiology
.
2021
;
134
:
526
40
2.
Toppen
W
,
Johansen
D
,
Sareh
S
,
Fernandez
J
,
Satou
N
,
Patel
KD
,
Kwon
M
,
Suh
W
,
Aksoy
O
,
Shemin
RJ
,
Benharash
P
:
Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?
PLoS One
.
2017
;
12
:
e0173777
3.
Kezerashvili
A
,
Fisher
J
,
Delaney
J
,
Mushiyey
S
,
Monahan
E
,
Taylor
V
,
Kim
S
,
Ferrick
K
,
Gross
J
,
Palma
E
,
Krumerman
A
:
Intravenous sedation for cardiac procedures can be administered safely and cost effectively by non-anesthesia personnel.
J Interv Card Electrophysiol
.
2008
;
21
:
43
51
4.
Keegan
P
,
Lisko
J
,
Kamioka
N
,
Maidman
S
,
Binongo
J
,
Wei
J
:
Nurse led sedation: The clinical and echocardiography outcomes of the 5year Emory experience.
Structural Heart
.
2020
;
4
:
302
9