The role of anesthesiology as a specialty transforming perioperative medicine is evolving rapidly. Over the years, Anesthesia & Analgesia has served an important role in this transformation by promoting innovations in perioperative health care delivery and publishing special issues dedicated to the perioperative surgical home (PSH) and to enhanced recovery after surgery (ERAS).1–6
Continuing with this tradition, the current issue of Anesthesia & Analgesia features a study by Vetter et al7 describing improvements in outcomes after the implementation of a PSH health care delivery model. In this proof-of-concept clinical study, the authors suggest that a PSH model of care in which anesthesiologists act as perioperative physicians has the potential to improve operational outcomes (increased on-time surgery starts, reduced anesthesia-related delays and same-day cancelation, and decreased selected costs) in patients undergoing total hip and total knee arthroplasties. This study adds a new, important milestone to the already well-established PSH/ERAS concept and helps move forward the role of anesthesiologists outside of the operating room. Some may argue, however, that the evidence provided by previous prospective clinical trials or proof-of-concept studies is not enough to make anesthesiologists fully embrace the practice of perioperative medicine.
In essence, the outstanding question is whether the evidence from historical studies is robust enough to allow dissemination of new models of care such as PSH and/or ERAS.7,8 Answering this question is not an easy task.9 A few years ago, an editorial published in Anesthesiology called for large clinical studies in perioperative medicine,10 claiming that “unlike cardiology, large clinical studies remain uncommon in perioperative medicine. Further, there has been a tendency to believe the results of small perioperative clinical studies.”
We strongly believe that this is necessary for the evolution of anesthesiology as it is matures to become a strong and established academic medical specialty. In the past 5 years, however, health care has changed dramatically, and a major thrust of our specialty has been to promote innovations in health care design and delivery. With these changes, the question of evidence-based medicine and implementation of new models of care has become even more critical. In a recent editorial, Rathmell and Sandberg11 argued that only robust science will be able to answer whether models such as the PSH or ERAS truly improve outcome and should be implemented. This echoes an editorial published in 2014 by Anesthesia & Analgesia in which Steven Shaffer,4 related to his collection of PSH articles, pointing out that the specialty needed data to show improved outcomes versus opinions and reflections. Vetter et al7 themselves were the first to emphasize clearly how important robust data and rigorous scientific experiments in care redesign are to help us assess the impact and potential for adoptions of these herculean endeavors.9
However, although we agree with the scientific approach supported by our community, we also believe that we may not be able to wait for such evidence to trigger changes as that may never ever happen. Unlike a new drug or a new device, implementing changes in the delivery of care in the perioperative setting is a complex process for which randomized trials may not be ideally suited, or even possible in many instances. Further, it is unlikely that what has been shown to improve health care in one part of the world could be implemented in the same manner elsewhere, as all politics is local and health care redesign is, to some extent, local politics and culture (think about the difference between a major academic center—where most of the evidence would come from—and the practice of a large anesthesia private group).
Finally, the equipoise of clinical practice is based on the balance between risks and benefits of the intervention. When it comes to models such as PSH or ERAS, one significant risk associated with their implementation is the economic cost. Can we wait until we have made the demonstration that such models of coordinated care improve outcome at lower costs before we start implementing them? Have other systems around the world waited for this evidence to come before they decided to change the way they deliver perioperative care? We believe that repeatable local experiences may speak volumes and will move the needle significantly. It may be that one day a large, definitive trial will show the effect of coordinated care on patient outcome and cost of care (value). We postulate that, when this day arrives, care will have already been redesigned and will not have waited for the comprehensive evidence to be established.
Finally, although it is now clear that the involvement of anesthesiologists in the development of comprehensive perioperative quality improvement processes and care redesign pathways is critical, the tasks involved in the actual delivery of such new health care innovations in real life often are considered so overwhelming that very few institutions actually are able to implement these. Further, the absence of strong evidence and the lack of a simplified implementation framework or a construct that can guide institutions on how to implement these multiple perioperative processes in a systematic and orderly fashion make the implementation even more challenging. Initiatives such as the PSH collaborative or ERAS programs have attempted to help the various institutions come together and develop improved implementation approaches while generating data and evidence at the national level.12 To date, none of them has delivered any definitive conclusion or clear recommendations on how to approach these Herculean endeavors.
The manuscripts published by Vetter et al and by others3,6–8,13 have provided a simplified framework or construct to facilitate implementation of comprehensive care redesign in the perioperative settings. Such a model will allow better integration and coordination among the involved teams enabling long-term success of the perioperative medicine initiatives that are being undertaken by various anesthesiology departments across the country. The study by Vetter et al5,7,9 is a good attempt to answer the call made by Shaffer, Rathmell, Sandberg and others, and it provides data on outcomes from redesign for both clinical and administrative decision-makers. This makes the study unique by including multiple outcome variables that address various stakeholders’ needs. Until recently, there have only been dialogues regarding the PSH model. The study by Vetter et al5,7 presented in this issue of Anesthesia & Analgesia moves beyond that by providing clinical and financial outcomes of the implementation of a PSH model, a need that they had described 3 years earlier in their Anesthesiology article “An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care.”9
We also believe that besides data, clinicians, clinician leaders, and change agents need simple constructs and/or simplified implementation framework to help them develop and implement PSH/ERAS models of care in real life. This will finally enable anesthesiology to move the needle of perioperative medicine and create value outside of the operating room.
Name: Maxime Cannesson, MD, PhD.
Contribution: This author helped write the manuscript.
Name: Aman Mahajan, MD, PhD.
Contribution: This author helped write the manuscript.
This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.
1. Cannesson M, Kain Z. Enhanced recovery after surgery versus perioperative surgical home: is it all in the name? Anesth Analg2014;118:901–902.
2. Garson L, Schwarzkopf R, Vakharia S, et al. Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg2014;118:1081–1089.
3. Kain ZN, Vakharia S, Garson L, et al. The perioperative surgical home as a future perioperative practice model. Anesth Analg2014;118:1126–1130.
4. Shaffer S. Anesthesia & Analgesia’
s collection on the perioperative surgical home. Anesth Analg2014;118:893–895.
5. Vetter TR, Boudreaux AM, Jones KA, Hunter JM Jr, Pittet JF. The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg. 2014;118:1131–1136.
6. Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg2014;118:1052–1061.
7. Vetter TR, Barman J, Hunter JM Jr, Jones KA, Pittet JF. The effect of implementation of preoperative and postoperative care elements of a perioperative surgical home model on outcomes in patients undergoing hip arthroplasty or knee arthroplasty. Anesth Analg2017;124:1450–1458.
8. Qiu C, Cannesson M, Morkos A, et al. Practice and outcomes of the perioperative surgical home in a California integrated delivery system. Anesth Analg2016;123:597–606.
9. Vetter TR, Ivankova NV, Goeddel LA, McGwin G Jr, Pittet JF; UAB Perioperative Surgical Home Group. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology. 2013;119:1261–1274.
10. Devereaux PJ, Chan MT, Eisenach J, Schricker T, Sessler DI. The need for large clinical studies in perioperative medicine. Anesthesiology2012;116:1169–1175.
11. Rathmell JP, Sandberg WS. Anesthesiologists and healthcare redesign: time to team up with experts. Anesthesiology2016;125:618–621.
12. Saver C. Nurse leaders play pivotal role in implementing enhanced recovery programs. OR Manager. 2016;32:11, 13.
13. King AB, McEvoy MD, Fowler LC, et al. Disruptive education: training the future generation of perioperative physicians. Anesthesiology2016;125:266–268.