We appreciate the response from Drs. Carlson and Martin1  in their comment on our recent article, “Anesthesiologists’ Role in Value-based Perioperative Care and Healthcare Transformation,”2  and we welcome the opportunity to address their comment.

As stated in our article, we agree that the focus of the anesthesiologist should expand beyond directly providing anesthetic care at a procedural site to innovation in clinical pathway development that will reduce mortality and complications. Anesthesiologists, as clinical experts and leaders in the perioperative space, should guide the development of optimal care delivery models at their healthcare facilities. The comment cited two studies that suggested that nurse-delivered sedation under the guidance of an anesthesiologist for some cardiac procedures, including transcatheter aortic valve replacement, was safe, reliable, and cost-effective and resulted in shorter hospital stays.3,4  Indeed, other care delivery models will be proposed as hospitals and clinicians seek value-based care, as long as the key patient outcomes are not compromised. Technology will also be an important driver in such healthcare changes, and anesthesia practitioners should consider disruptive innovation such as automation and algorithm-based approaches that further impact the value of their practices in the future. Joosten et al.5  recently published a randomized controlled trial in a single center that evaluated the performance of multiple, algorithm-driven, independently working closed-loop systems for administration of anesthesia (hypnosis and analgesia), fluids, and ventilation management in 90 patients undergoing major noncardiac surgery. The automated system outperformed manual (in-room personnel) control and had a significant and beneficial impact on neurocognitive recovery after surgery. Although the indications for automation- and algorithm-driven/supported are still evolving, such evidence adds greater importance to the idea that anesthesiologists gradually expand their domain of practice without losing any of our current focus, a framework presented in our study, as the comment affirmed. Segmentation of patients based on their medical and surgical risk can help anesthesiologists and hospitals drive value-based care and allow best use of resources in the perioperative period. However, it is essential that as new care delivery models are developed, we don’t only focus on cutting cost as a driver for these changes but also attend to improving patient-centric outcomes. Future clinical studies that investigate the efficacy and safety of new practice models should incorporate a robust design that accounts for the patient and surgical risks and complexity.

The key theme of our article2  is a framework for future growth of our specialty and the unique contributions anesthesiologists can make regarding the health and healthcare of our patients. We must continue to work at the top end of the value curve, and indeed to innovate and find new areas to improve what matters most to patients—their healthspan.

Dr. Mahajan is the founder of Sensydia, Inc. (Los Angeles, California; activity not related to the subject matter of the letter). Dr. Mahajan received grants and stipend from the National Institutes of Health (NIH; Bethesda, Maryland) as an NIH investigator and a study section reviewer (activity not related to the subject matter of the letter). The other authors declare no competing interests.

1.
Carlson
RE
,
Martin
JA
:
Anesthesiologists and value-based care: Comment.
Anesthesiology
.
2021
;
135
:
925
2.
Mahajan
A
,
Esper
SA
,
Cole
DJ
,
Fleisher
LA
:
Anesthesiologists’ role in value-based perioperative care and healthcare transformation.
Anesthesiology
.
2021
;
134
:
526
40
3.
Kezerashvili
A
,
Fisher
JD
,
DeLaney
J
,
Mushiyev
S
,
Monahan
E
,
Taylor
V
,
Kim
SG
,
Ferrick
KJ
,
Gross
JN
,
Palma
EC
,
Krumerman
AK
:
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
JC
,
Kamioka
N
,
Maidman
S
,
Binongo
JN
,
Wei
J
:
Nurse led sedation: The clinical and echocardiography outcomes of the 5-year Emory experience.
Structural Heart
.
2020
;
4
:
302
9
5.
Joosten
A
,
Rinehart
J
,
Bardaji
A
,
Van der Linden
P
,
Jame
V
,
Van Obbergh
L
,
Alexander
B
,
Cannesson
M
,
Vacas
S
,
Liu
N
,
Slama
H
,
Barvais
L
:
Anesthetic management using multiple closed-loop systems and delayed neurocognitive recovery: A randomized controlled trial.
Anesthesiology
.
2020
;
132
:
253
66