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Total Joint Replacement Perioperative Surgical Home Program: 2-Year Follow-Up

Cyriac, James MD*; Garson, Leslie MD*; Schwarzkopf, Ran MD; Ahn, Kyle MD*; Rinehart, Joseph MD*; Vakharia, Shermeen MD, MBA*; Cannesson, Maxime MD, PhD; Kain, Zeev MD, MBA*

doi: 10.1213/ANE.0000000000001308
Ambulatory Anesthesiology and Perioperative Management: Research Report
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BACKGROUND: Previously, our group successfully established one of the nation’s first Perioperative Surgical Homes (PSHs) aimed at coordinating services to patients undergoing primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). As we now focus on extending the PSH to other service lines within the hospital, the long-term sustainability of this practice model is an important factor to consider moving forward.

METHODS: We prospectively collected data from all patients who underwent elective primary TKA and THA at our institution between October 1, 2012, and September 30, 2014. Prospectively collected data included length of stay (LOS), 30-day readmission rate, postoperative pain scores, and complications.

RESULTS: During the 2-year period, there were 328 primary joint arthroplasty patients. Overall, the median LOS was significantly shorter in the second year of the PSH initiative (P = 0.03). Stratified by procedure, the median LOS for patients undergoing THA was significantly shorter in the second year (P = 0.02), whereas the median LOS for patients undergoing TKA did not differ between the 2 time periods. In the second year of the PSH initiative, significantly more patients were discharged home than to a skilled nursing facility compared with year 1 of the PSH initiative (P = 0.02). Readmission rates within 30 days after surgery to our institution were 0.9% (0.0–4.4) in the first year of the PSH initiative and 3.3% (confidence interval, 1.3%–7.2%) in the second year of the PSH initiative (P = not significant). Pain scores did not change significantly from year 1 to year 2 (P = not significant).

CONCLUSIONS: Data for the second year of implementation demonstrate similarly positive results in LOS, pain control, discharge destination, readmission, transfusion rates, and complications.

From the *Department of Anesthesiology and Perioperative Care, Department of Orthopaedic Surgery, University of California Irvine, Irvine, California; and Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.

James Cyriac, MD, is currently affiliated with the EmCare, Clearwater, Florida.

Accepted for publication February 8, 2016.

Funding: Departmental.

Conflict of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to James Cyriac, MD, EmCare, 18167 US Hwy. 19 N., Suite 650, Clearwater, FL 33764. Address e-mail to cyriacj@yahoo.com.

Health care in the United States is in the midst of significant change in both its delivery systems and payment structure. Over the past year, these forces changing and shaping health care delivery in the United States have continued unabated and, by many accounts, have only accelerated. Accountable Care Organizations, bundled payment initiatives, and the continued rollout of the Affordable Care Act have gone from talking points in health care legislation to the point of near inevitability.1–4 The stated hope with implementation of these recent health care initiatives was best described by the triple aim coined by Berwick et al.5: better population health management, higher patient satisfaction, and lower costs.

These changes in health care, although disruptive to many hospital and physician practices, can and should be viewed as an opportunity to improve the existing perioperative system of fragmented, highly variable, and costly care.6 To this end, the Departments of Anesthesiology and Perioperative Care and Orthopedic Surgery at the University of California Irvine (UCI) embarked on a program >2 years ago to develop and implement a Perioperative Surgical Home (PSH) for a number of services including the Total Joint Replacement program. The PSH model is one that recognizes the need for a continuum of care over the entire perioperative process beginning at the moment a patient decides to have a surgical procedure. The PSH model includes coordinated care during the preoperative optimization process, intraoperative management, postoperative care, inpatient management, and extending out up to a 30-day postdischarge follow-up window. The PSH at UCI has as its aim, the transformation of perioperative care by improving clinical outcomes, patient experience, and reducing cost.7 Considerable emphasis is placed on reduction of variability and shared decision making across all disciplines involved in patient care.8 The PSH at UCI Health uses a multidisciplinary construct, which includes anesthesiologists, surgeons, nursing, hospitalists, information technology, decision support, physical therapy, case management, pharmacy and other ancillary services.7

In May 2014, we published our first-year experience with our Total Joint Replacement Perioperative Surgical Home (TJR-PSH) at UCI.9 We have demonstrated that the TJR-PSH program resulted in a short length of stay (LOS), low levels of readmission rates, and reduced rate of complications.10 A second report on our first-year experience presented financial data that indicated the success of the newly instituted TJR-PSH.11 The aim of this follow-up study was to compare a set of quantitative outcome measures within our TJR-PSH during its second year compared with its first year.

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METHODS

The TJR-PSH initiative described in this report includes all patients who underwent elective primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) at UCI Health between October 1, 2012, and September 30, 2014. IRB approval was obtained with the purpose of analyzing and reporting our results, and the need for patient consent was waived (IRB HS#2012–9273). The Strengthening the Reporting of Observational Studies in Epidemiology checklist12 was followed for reporting of the results of this cohort study.

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Setting

Initial implementation of the TJR-PSH at UCI Health was described in detail in an article published in Anesthesia & Analgesia and is, therefore, only briefly summarized in the following paragraph.9

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Planning the Total Joint-PSH Initiative

Table 1.

Table 1.

Figure 1.

Figure 1.

In April 2012, a multidisciplinary task force composed of anesthesiologists, orthopedic surgeons, nurses, pharmacists, physical therapists, case managers, social workers, information technology experts, and others was established. The task force met regularly in an effort to standardize the perioperative processes using Lean Six Sigma methodologies. A review of the evidence and best practices was performed, where evidence was lacking, team consensus was required to adopt a practice guideline. A clinical care pathway was created spanning from the decision for surgery up to and including 30 days postdischarge (Fig. 1). In October 2012, the TJR-PSH initiative was launched, and previously published data from the first year of the program9 demonstrated that the TJR-PSH met or exceeded national benchmarks in LOS (2.9 and 3.1 days for TKA and THA, respectively, nationally versus 3 and 3 days at UCI), complications (3.7% and 2.9% for TKA and THA nationally versus <1% and <1% at UCI), blood transfusions (16.1% and 19.1% for TKA and THA nationally versus 4.2% and 9.8% at UCI), and surgical care improvement project compliance.13 In an effort to maintain and improve on these achievements during the second year of the TJR-PSH initiative, team meetings were conducted monthly along with quarterly leadership meetings. Performance and compliance dashboards were evaluated monthly, and, when needed, revisions were made to the clinical pathways in an effort to address problem areas or as a response to an update in the literature. Multiple changes were made as a result of these efforts. These changes will be described below, and the preoperative changes are summarized in Table 1.

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REVISIONS TO TJR-PSH PATHWAY

Preoperative Components

Standardized testing and management protocols continued as in the previous year, including nasal Staphylococcus aureus screening and nosocomial infection prevention protocol, thromboembolic risk and prevention protocol, and blood-conservation strategies (Fig. 1). On initial implementation of the TJR-PSH, all patients were seen in a preoperative anesthesia clinic staffed by nurse practitioners and supervised by an anesthesiologist. In February 2014, a modification of the preoperative triage system was implemented. This was done in an effort to better risk stratify patients based on their comorbid medical conditions, to improve the use of existing staffing resources, and to further advance our preoperative optimization process. In the new process, a standard anesthesia questionnaire was administered to each patient at the time of surgical booking and was subsequently reviewed by a medical assistant. Specific triage criteria were based on the ASA physical status (as determined by patient responses to our anesthesia questionnaire) and the complexity of the procedure (Table 1). This process better defined those patients who required only data entry, a phone call by a nurse practitioner, and/or further review by a physician for evaluation and implementation of optimization protocols8 (Tables 2 and 3).

Table 2.

Table 2.

Table 3.

Table 3.

Table 4.

Table 4.

In addition to the changes made to the preoperative clinic workflow that were described earlier, technology solutions were also developed to enhance the preoperative phase of care. In November 2013, a risk assessment tool was incorporated into the anesthesia information management system (AIMS). On the basis of their medical history as documented in the AIMS, patients at risk for delirium, renal, or pulmonary complications were flagged in the anesthesia perioperative record. Management guidelines were then offered to mitigate these risks in the preoperative, intraoperative, and postoperative periods (Tables 3 and 4).

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Intraoperative Component

Two changes were made to the pain management pathway during the second year of the TJR-PSH. The first change was the inclusion of a single dose of 15 mg IV ketorolac during skin closure. This was given in conjunction with a single dose of IV famotidine. The administration of ketorolac intraoperatively was instituted on recommendation from our Acute Pain Service in an effort to decrease, if not obviate, the need for IV opioids in the immediate postoperative period in the postanesthesia care unit (PACU). We also instituted the administration of famotidine as an adjunct to help mitigate postoperative stress-related gastrointestinal bleeding.14–16 In addition, the PACU orders were changed to reflect the large use of regional anesthesia. The avoidance of general anesthesia and early termination of intraoperative sedation allowed for early administration of oral medications. The PACU orders were changed from IV opioids for moderate-to-severe pain to oral opioids. Another implemented intraoperative change included revising the antibiotic prophylaxis for penicillin-allergic patients from clindamycin to levofloxacin.

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Postoperative Component

Table 5.

Table 5.

Minimal changes were made to the postoperative multimodal pain management protocols (Table 5), the anticoagulation, thromboembolic event prevention protocols, or the physical therapy protocols (Fig. 1). The most significant change to the postoperative component was the restructuring of the PSH team. Previously, this PSH team consisted of an anesthesia resident, a nurse practitioner, and an anesthesia faculty member available 24/7 through a dedicated pager. On implementation of the PSH, all team members were also part of the acute pain/regional anesthesia service. In July 2014, the team was restructured to include a faculty, perioperative medicine fellow, nurse practitioner, and resident. A distinct faculty, fellow, and resident team now performed regional anesthesia services.

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Postdischarge Component

Planning for discharge remained a priority with minimal changes to the established protocols for discharge orders, discharge instructions, medication prescriptions, wound care, and follow-up clinic visits (Fig. 1). A new concept was created within the second year of the PSH of a “preferred skilled nursing facility.” The concept was to establish working relationships with area facilities to familiarize them with the PSH protocols and for open 2-way communication regarding decisions related to patient care. Working within the patients’ contracted benefits, multiple area institutions agreed to follow the protocols and communicate with a member of the PSH team should the need arise. No financial arrangements were made, and ultimately patient choice of facility was the first consideration.

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Outcome Data Collection

Prospectively collected data included patient demographics, hospital LOS (defined as postoperative number of nights in the hospital after surgery), 30-day readmission rate, and postoperative pain scores (Numerical Rating Scale, between 0 [“no pain”] and 10 [“worst possible pain”]) that were measured every 6 hours and averaged over the first 48 hours. Data on the following perioperative complications were collected: periprosthetic joint infection, mechanical complications, wound healing complications, pulmonary embolism, death, acute myocardial infarction, pneumonia, sepsis, deep vein thrombosis, urinary track infection, stroke, delirium, atrial fibrillation, acute kidney injury, and nausea and vomiting. These complications were defined and categorized as major complications based on the Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation criteria used by the Centers for Medicare and Medicaid Services (CMS) for hospital-level performance measures for elective THA and TKA.17 Periprosthetic joint infection, mechanical complications, wound healing complications, pulmonary embolism, death, acute myocardial infarction, pneumonia, and sepsis were classified as major complications.17

Table 6.

Table 6.

Minor complications (Table 6) were defined as any event noted in the discharge summary unique to routine postoperative hospital course. We also performed an analysis of our patient cohort data for perioperative blood product transfusion rate. Integrity of all data points was confirmed using Decision Support (hospital based), electronic medical record (Allscripts, Chicago, IL), and AIMS (SIS, Alpharetta, GA). Our metrics were based on current peer-reviewed literature prepared for CMS, which established national benchmarks.17 We used CMS benchmarks because Medicare is the single largest payer for these procedures, covering approximately two-thirds of all THAs and TKAs performed in the United States.18

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Data Analysis

Table 7.

Table 7.

Data are presented as median (interquartile range)] or mean ± SD. Incidence data are presented as percent (95% confidence interval for the incidence point estimates for the dichotomous outcomes). The confidence intervals for median and point estimates for incidence rates were calculated using the Clopper-Pearson method.19 Tests of proportions were performed using χ2 test without continuity correction. Group medians and means were compared with Mann-Whitney U test and unpaired 2-sided t test, respectively. Year 1 and 2 cohort baselines were compared with regards to the primary outcome of LOS using a linear regression. All of the patient demographics and case variables (presented in Table 7), as well as PSH year, were used as independent variables (or covariates) in the regression. The assumption was that any variables with significant predictive value that were found not to be similarly distributed in years 1 and 2 would represent confounders, thereby limiting further interpretation of our results.

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RESULTS

Demographics and Case Variables

During the 2-year period, there were 328 primary joint arthroplasty patients who followed the TJR-PSH protocol, with 121 THA and 209 TKA. Baseline demographics and case data are presented in Table 7. A linear regression examining the relationship of these variables with LOS showed that only ASA status was a significant predictor (P = 0.024); the remainder were nonsignificant. Given that there was no significant difference between years in the distribution of ASA scores suggests that baseline differences in group compositions were not responsible for differences in LOS outcomes.

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Efficiency Outcomes

Figure 2.

Figure 2.

Overall, median LOS was significantly shorter in the second year of the PSH initiative than in the first year (P = 0.03397). Stratified by procedure, median LOS for patients undergoing THA was significantly shorter in the second year (P = 0.0279), whereas median LOS for patients undergoing TKA did not differ between the 2 time periods (Fig. 2). In the second year of the PSH initiative, significantly more patients were discharged home rather than to a skilled nursing facility compared with the first year (P = 0.0290). Readmission rates within 30 days after surgery to our institution were 0.9% (0.0–4.4) in the first year of the PSH initiative and 3.3% (1.3–7.2) in the second year (P = 0.350). Although in the first year there was a single same-day cancellation because of an infected ulcer in the ipsilateral limb, there were no same-day cancellations in the second year (0.0%–3.2%).

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Safety Outcomes

Overall 30-day mortality in the first year of the PSH initiative was 0% (0.0%–2.5%), and in the second year, it was 1% (0.0%–3.4%). In the second year of the PSH initiative, there were 2 major complications: the aforementioned death and 1 postsurgical hip dislocation. Our overall minor complication rate was 15.3% (10.0–22.4) in the first year of the PSH initiative and 18.5% (13.2–25.0) in the second year (P = not significant). Minor complications for both years are detailed in Table 6. In the second year of the TJR-PSH, the perioperative transfusion rate was significantly lower compared with the first year (5.0% [2.8–8.8] vs 8.7% [5.1–14.2], P = 0.1633).

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Patient-Centered Outcomes

The median Numerical Rating Scale for pain scores did not change significantly from the first year to the second year (4 [2–7] vs 4 [2–6] for postoperative day [POD] 0, 4 [2–8] vs 4 [2–7] for POD 1, and 4 [2–7] vs 4 [3–7] for POD 2, P = 0.228 by rank-transformation repeated-measures analysis of variance). Rates of nausea and vomiting remained <10% in the second year of the PSH initiative, and patient Press-Ganey satisfaction scores remained in the 98th percentile.

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DISCUSSION

The initial implementation of the TJR-PSH at UCI was a successful demonstration of large-scale organizational change, quality improvement, and a PSH “proof of concept.” One year after implementation of the PSH, we reported that national benchmarks in LOS, complications, blood transfusions, and surgical care improvement project compliance were all met or exceeded.9 The data for the second year of implementation presented in this article demonstrate similarly positive results in LOS, transfusion rates, and complications. These factors and an increased rate of home discharges demonstrate both a sustainable practice model and one capable of improvement and adaptation.

As we noted previously,7 LOS is a significant contributor to overall cost of total joint arthroplasty.20,21 The data for the second year of this initiative continue to demonstrate a short LOS, for both THA and TKA. Although notably lower than national benchmarks,17 improvements in both physiotherapy and pain management protocols may further improve these outcome measures in the future. Other areas of continued success over the second year within our TJR-PSH program are consistently low perioperative transfusions rates for THA and TKA. Proactive discharge planning including both early education and use of home health care resources allowed a significant number of patients to return home.

Implementation of the TJR-PSH relied heavily on Lean Six Sigma strategies because they have consistently proven effective in the management of change in large organizations.22 The next phase after implementation of large-scale organizational change is to demonstrate that the changes instituted are sustainable. Avoidance of the so-called improvement evaporation effect or initiative decay as described by UK National Health Service23 is critical for sustaining change. This occurs when the improvements that have been implemented regress to their original states. In fact, data from the National Health Service show that 33% of large health care organizational changes ultimately fail.23 The results from the second year of our TJR-PSH program verify that our program is not only a viable, successful initiative, but it is also sustainable. Hovlid et al.24 noted that any quality improvements that are achieved but not sustained long term can be viewed as a waste of resources. The overall delivery of quality health care depends primarily on the optimal functioning of the system as a whole rather than the skills of individuals. Therefore, changing the system is the most effective route to improvement rather than focus on individual units. Once an organization succeeds and is able to demonstrate improved outcomes, these changes must also be maintained to sustain these improvements.24

The PSH model is multidisciplinary, and various departments throughout the hospital were involved in the creation of the clinical pathways instituted. To achieve the restructuring required to implement the PSH, many changes were required at an organizational level. Sustained improvement after systemic change has been described as an example of organizational learning.25 Organizational learning becomes manifest through new organizational routines, and the effects of these new routines can be measured.25,26 In the UCI TJR-PSH, organizational learning can thus be reflected as a continued low and perhaps an eventual reduction in LOS, complications, transfusions rates, and other metrics we have noted in our Results section. Our TJR-PSH program is thus an example of sustained improvement through organizational learning. Because all the individuals involved became engaged in clinical pathway implementation and improvement, new understandings of the clinical system and its interdependencies became apparent, and clinical practice was altered as a consequence. As noted by Hovlid et al.,24 an important leadership action required for sustained improvement is the ability to modify and adapt based on new understandings and new evidence.

A number of modifications to our clinical pathway (Fig. 3) were implemented during the second year of our program in response to evidence regarding periprosthetic joint infection and pain management. In particular, based on the evidence reviewed at the 2013 International Consensus Meeting on Periprosthetic Joint Infections,27 the antibiotic prophylaxis for penicillin-allergic patients was changed from clindamycin to levofloxacin. This was an evidence-based recommendation citing concerns of an increased incidence of Clostridium difficile infection after prophylaxis with clindamycin.28 The pain management protocol was modified to improve postoperative pain and reduce opioid-related side effects. An intraoperative dose of 15 mg IV ketorolac was added along with an H-2 blocker to the protocol. This addition was based on multiple studies indicating both efficacy in analgesia, an opioid-sparing effect,29 and safety in the setting of joint arthroplasty.30 Noting the majority of both THA and TKA operations were performed under spinal anesthesia, a recommendation was made to limit the use of IV opioids in the PACU and rely on enteral analgesics consistent with enhanced recovery protocols.31

Figure 3.

Figure 3.

We conclude that the ramifications of our second-year TJR-PSH program are significant. We have shown that deep structural changes to a practice paradigm that is multidisciplinary, iterative, and ongoing can have a significant, sustainable impact on outcomes for patients in a total joint replacement program. A limitation of this report is that, as an observational study, we have no control group for comparison. In addition, although this case management report is essentially an update on previously published work, using comparative effectiveness research methodologies such as the Plan-Do-Study-Act cycle as described by McCarty et al.32 may have better quantified the impact of the improvements during year 2 of the TJR-PSH.

As we continue along this path and expand to other service lines, both within orthopedic surgery and other surgical specialties, we plan to replicate and improve on these findings and continue to fulfill the “triple aim” as expounded upon by Berwick et al.: improved population health, enhanced patient experience, and decreased health care costs.

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APPENDIX 1

Anesthesia Questionnaire

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DISCLOSURES

Name: James Cyriac, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: James Cyriac has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Conflicts of Interest: James Cyriac declares no conflicts of interest.

Name: Leslie Garson, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Leslie Garson has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Conflicts of Interest: Leslie Garson declares no conflicts of interest.

Name: Ran Schwarzkopf, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Ran Schwarzkopf has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Conflicts of Interest: Ran Schwarzkopf declares no conflicts of interest.

Name: Kyle Ahn, MD

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Kyle Ahn has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Conflicts of Interest: Kyle Ahn declares no conflicts of interest.

Name: Joseph Rinehart, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Joseph Rinehart has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Conflicts of Interest: Joseph Rinehart declares no conflicts of interest.

Name: Shermeen Vakharia, MD, MBA.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Shermeen Vakharia has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Conflicts of Interest: Shermeen Vakharia declares no conflicts of interest.

Name: Maxime Cannesson, MD, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Maxime Cannesson has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Conflicts of Interest: Maxime Cannesson consulted for Edwards Lifesciences, received research funding from Edwards Lifesciences, consulted for Masimo, and received research funding from Masimo.

Name: Zeev Kain, MD, MBA.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Zeev Kain has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Conflicts of Interest: Zeev Kain reported a conflict of interest with Merck Speaker Bureau for Merck.

This manuscript was handled by: Tong J. Gan, MD, MHS, FRCA.

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RECUSE NOTE

Dr. Cannesson is the Section Editor for Technology, Computing, and Simulation for Anesthesia & Analgesia. This manuscript was handled by Dr. Tong J. Gan, Section Editor for Ambu latory Anesthesiology and Perioperative Management, and Dr. Cannesson was not involved in any way with the editorial process or decision.

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