“It is not the most intellectual of the species that survives; it is not the strongest that survives; but the species that survives is the one that is able to adapt to and to adjust best to the changing environment in which it finds itself.”
– Leon C. Megginson
The science of value
Surgery accounts for a disproportionately high expense in health care delivery (roughly a third of all health care spending) and consequently also represents a disproportionately large opportunity for enhancing value. In the United States, surgeries account for less than one-third of admissions and greater than two-thirds of hospital costs.21 Postoperative complication costs range from between $8,338 for a surgical site infection (SSI) to greater than $40,000 for a ventilator-associated pneumonia (VAP).22
In business, a value proposition is a statement that answers “why” someone should do business with you. In medicine, a value proposition should convince a patient, a colleague, an institution, a payor, or the population at large why a service brings more value than alternative options, including doing nothing. This approach is particularly relevant to the perioperative environment where the goal is to optimize a patient's medical condition before surgery and improve care throughout the surgical journey.
Value in medicine is generally defined as quality of care for a specific condition over the total cost associated with it. Since nearly 50% of a hospital's revenue and expenses are related to perioperative services,1 anesthesiologists must understand the true cost of care and identify opportunities to improve quality, the patient experience, and reduce unnecessary costs associated with the perioperative environment. This approach to perioperative care has created new opportunities for anesthesiologists to assess practices and create innovative approaches to management throughout the perioperative course. When true cost management is sought, a best approach to enhance value may be to spend more on some services (i.e., perioperative medicine) to reduce the need and cost for other downstream or collateral services. The impact of proceeding with elective surgery in a patient with identified risks versus postponing surgery (or avoiding surgery) to address modifiable medical conditions remains an important and often untested question.
Preoperative clinics: (risk assessment)
Historically, patients were typically admitted to the hospital before their scheduled surgery date so required testing, evaluation, and optimization could be accomplished preoperatively. This process included review of medical history and medications, facilitated assessment by consultants, if needed, and created the opportunity for the anesthesiologist to establish a relationship with the patient. Because of the timing of the assessment, this approach did facilitate substantial mitigation of identified risk factors. With transitions in clinical practice and attempts to improve efficiency of care, inpatient admissions before surgery are now rare and difficult to justify. Consequently, medical centers have established preoperative anesthesia clinics (PACs) to address the need for thorough and coordinated preoperative assessment of patients who arrive to the hospital on the day of surgery. While principally designed to reduce care inefficiencies and day of surgery delays and cancellations, PACs have introduced an opportunity to recognize and modify certain risk factors, optimize the patient's clinical condition, and in doing so, lessen the risk of elective surgery. Table 1 describes the historical evolution of the preoperative evaluation and its impact on perioperative management.
Over the past few decades, attention has shifted from a “straightforward” preoperative evaluation to a preoperative assessment and management strategy to address comorbid conditions and optimize preoperative status prior to surgery. The burden of modifiable co-existing, comorbid medical conditions is high in surgical patients – even among patients scheduled for outpatient surgeries.2,3 Evidence strongly supports that the opportunity for significant value enhancement in health care lies in managing the most complex episodes of care for the sickest patients. While the traditional fee for service (FFS) payment system did not provide the impetus for anesthesiologists to expand their focus, the transitions to value-based care and merit-based incentives have changed the landscape. The acknowledgement that more engaged anesthesiologists can improve quality and reduce costs of perioperative care has created the impetus to develop these new care models. The opportunities to do so are expanding and require new, innovative approaches to manage care, particularly for elderly patients and those with underlying conditions when undergoing procedures in ambulatory care environments.
For most practices, the current model for preoperative assessment includes an in-person clinic visit shortly before the scheduled procedure, a video visit, a phone screen encounter, or a simple chart review. Under this model, the anesthesiologists has little opportunity to effectively manage modifiable comorbid medical conditions identified on screening. For example, studies have demonstrated that reliance on a simple chart review for patient assessment before surgery underrepresents the extent of medical comorbidities, especially for patients who are scheduled for procedures requiring hospital admission.2 Moreover, conditions such as frailty, poor nutrition, anemia, and obstructive sleep apnea are often unrecognized and undertreated.4-6 As important, preoperative evaluation by primary care or specialist providers, rather than anesthesiology-directed care, often fail to appreciate the surgical and anesthesia risks, resulting in the need for more testing, higher costs, and in some cases, surgical delays.7-10
Optimally preparing patients for surgery, managing follow-up care, and tracking outcomes are typically perceived as costly (negative net present value activities) and without significant value only because they are considered in isolation without considering their impact on overall perioperative care. When evaluated within the context of perioperative care beyond costs for a single cost center, these actions significantly contribute to enhancing value.9,11,12 In addition to direct contribution margin, cost reduction results from providing coordinated perioperative care. Based on this approach to perioperative care, the true value of this approach will be realized when perioperative care is fully integrated into population health efforts, as described in Table 2.
In addition to the benefits outlined above, the real benefits are gained as a result of savings realized from improved efficiencies, and elimination of unnecessary or excessive laboratory testing and consultation,9,11,12 as well as cost avoidance attributable to enhanced recovery after surgery and reduced adverse events.13 It has been reported that nearly 15% of surgical patients captured in the Medicare FFS program experienced preventable adverse events that precipitated a hospital readmission within a month after the index hospitalization, with 70.5% readmitted for a medical condition.14 Approximately 40% of postoperative complications occur after the patient is sent home.15 In addition to curtailing the need for or duration of postoperative admission, optimal preoperative preparation is in the best interest of patients and health care systems to minimize the need for postoperative care management. In a study of 21,553 elective surgical patients, an analysis of outpatient preoperative evaluation effect found that the rate of canceled cases for medical reasons decreased from 2.0% to 0.9% and preoperative assessment was associated with a 0.92-day decrease in the length of hospital stays.16 The average cost of an elective surgery cancellation in the U.S. has been estimated to be between $5,000-$8,000,17,18 and this does not account for patient inconvenience, lost wages, and the health impacts of not having needed surgery.
Moving beyond the PAC (optimization, prehabilitation)
The case for optimally preparing patients for surgery is based on reducing the potential compounded effects that chronic comorbid medical conditions have on influencing postoperative outcomes. A PAC visit just before and cursory to surgery provides little opportunity to effectively manage modifiable comorbid medical conditions. Opportunities to expand both assessment and management, including prehabilitation, can be expected to result in better understanding of some of the implications of anesthesia and surgery as well as identify how best to manage or mitigate some of the other responses, such as the inflammatory cascade accompanied by a hypercatabolic, pro-coagulation state with increased oxygen consumption, hyperglycemia, and intravascular fluid redistribution. Efforts to proactively screen, identify, and optimize these and other non-surgical medical comorbid conditions that often go unrecognized preoperatively3 represent an opportunity for anesthesiologists to improve care and provide additional value under a value-based payment model often unrealized in the perioperative domain. With advances in digital health and artificial intelligence, anesthesiologists can provide even better optimization of care and prehabilitation19,20 to better manage the perioperative period (Figure).
Enhanced Recovery after Surgery (ERAS)
The potential to mitigate and prevent costly complications requires coordinated management of these comorbidities across the entire surgical episode of care. Perioperative medicine should focus on reducing modifiable risks associated with surgery (Figure), standardizing evidence-based surgical care protocols, and facilitating functional recovery following surgery. In the value-based payment environment, hospital systems are seeking strategies to enhance patient safety and quality while reducing costs to remain competitive. This is especially evident in the perioperative domain, whereby protocol deviations between the same procedures performed by different surgeons inhibit organizations from offering competitive pricing. ERAS is a multidisciplinary, evidence-based perioperative care pathway that aims to standardize perioperative care.23 Under ERAS protocols, factors such as pain, stress, immobilization, and postoperative ileus in traditional perioperative care pathways can be improved, resulting in shorter length of stay (LOS) and decreased complications24 and costs.25,26 Despite the documented value of ERAS protocols, barriers to their implementation remain. ERAS represents a great opportunity for anesthesiologists to play an important role in addressing and managing institutional implementation barriers.
A variety of ERAS clinical pathways exist with varying implications for care in the preoperative, intraoperative, and postoperative periods. The role of anesthesiologists in the preoperative stage includes patient education, assessment for need and administration of nutrition supplements, instruction for clear fluids up to two hours before induction, and ensuring use of a carbohydrate drink before the day of surgery. Intraoperative elements that rely on anesthesiology include goal-directed fluid management and minimization of opioids. Postoperative assurance of adequate pain management with minimalization of opioids and early drinking and eating and mobilization (DrEaMing) is critical for successful outcomes.27
Perioperative Surgical Home (PSH)
At many hospitals, inconsistent methodologies across the spectrum of surgical care often manifest as delays, cancellations, high variability in outcomes, increased costs, and dissatisfied patients and surgeons. Anesthesiologists interact with every phase of surgical patient care and are therefore uniquely positioned to build stakeholder alignment and affect systemic change.
The PSH is a patient-centered process led by physicians and hospital administrators. It creates a standardized, patient-focused, evidence-based approach to care that increases safety, reduces costs, and improves patient satisfaction. The PSH, therefore, is a process of care well positioned to meet the challenges of transition from FFS to value-based care and bundled payment models characterized from the contemplation of surgery through 90 days post-discharge.
Through re-engineering, PAC evaluation, patient education, risk assessment and management, and providing standardized processes throughout the perioperative care spectrum, the PSH can facilitate reductions in same-day case cancellations, readmissions, LOS, transfusion rates, and net costs for each encounter while improving quality and satisfaction metrics.28 The PSH helps establish a foundation for success in the value-based perioperative care environment by helping enhance patient outcomes at lower costs, thereby enabling anesthesia groups to demonstrate value to key stakeholders.
There are several care coordination models for pre-surgical evaluation of patients' readiness for surgery. No matter the pathway, effective management of chronic conditions as well as recent onset acute illness often requires more time than is sometimes available under current models of care. Early identification and management of these conditions offer greater opportunity to intervene effectively to optimize the surgical procedure and improve outcomes.
Perhaps the most well-described and best-studied care pathway for a modifiable preoperative medical condition is management of preoperative anemia.29-31 Hemoglobin levels obtained early in the pathway to surgery may be routinely screened by the perioperative team, and abnormally low hemoglobin values should trigger analysis of hematinic variables to categorize the type of anemia. For patients identified as iron-deficient, iron therapy is ideally given intravenously to maximize benefits before surgery. The value proposition for preoperative anemia is an area of ongoing discussion.
Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes and enhance value. Screening and optimization of cardiac, respiratory, and other comorbidities (malnutrition, obstructive sleep apnea, pain, depression, frailty) often require more involved investigative routines but can often be managed successfully utilizing diagnostic and treatment algorithms. Preoperative malnutrition for example, is a widely prevalent and modifiable risk factor in patients undergoing surgery. Unfortunately, perioperative malnutrition is rarely screened preoperatively and remains largely unrecognized and undertreated. The adaptation of a user-friendly perioperative nutrition screen and non-invasive point-of-care muscle health diagnostic tools may better identify this unrecognized predictor of poor outcome.4,32
In the opinion of these authors, effective and essential ways to advance anesthesiology within health systems and within the health care ecosystem are through greater clinical involvement, inquiry, and greater scholarly investment in perioperative medicine to secure our professional future over the next decade and beyond. To quote our colleague and friend from the University of Southamptom, Professor Mike Grocott, “Perioperative medicine is the future of anesthesia, if our specialty is to thrive.”