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Featured Articles: The Open Mind

Preoperative Optimization: A Continued Call to Action

Aronson, Solomon MD, MBA, FASA, FACC, FCCP, FAHA, FASE*; Martin, Gavin MB ChB, MMCi; Gulur, Padma MD*; Lipkin, Mike E. MD, MBA; Lagoo-Deenadayalan, Sandhya A. MD, PhD; Mantyh, Christopher R. MD; Attarian, David E. MD, FACS, FAOA§; Mathew, Joseph P. MD, MSc, MBA, FASE; Kirk, Allan D. MD, PhD, FACS

Author Information
doi: 10.1213/ANE.0000000000004492

See Articles, p 803, p 804, p 811

Surgical outcomes have progressively improved. Although these improvements can be mapped across the entire perioperative spectrum noting increased attention to perioperative technique and process standardization, there remain significant gaps in preoperative patient management and risk mitigation which have been relatively less attended to despite appeals and guidelines to the contrary.1–5 Currently, it remains that most preoperative preparation models are designed to tether the timing of patient evaluation in close proximity to the surgical date, accepting the medical condition of the patient as something to which practitioners must adapt. This temporal paradigm does not enable proactive and meaningful preoperative patient management and optimization. Consequently, when patients are seen in a preoperative clinic, it is typically considered too late to address modifiable risks. An important objective of preoperative management should be to identify and reduce modifiable comorbid medical risk compounding intraoperative management and affecting patients’ postoperative outcomes, balancing the opportunity to mitigate modifiable risk factors with the temporal imperative for surgical intervention, an imperative that is at times artificially emphasized. In our current fee for service volume paradigm with associated productivity tension, issues with hospital, surgeon, and patient pushbacks remain. The question as to whether a surgeon, patient, or health system forfeit a next available slot to allow for optimization, at the cost of operating room (OR) utilization remains and is confronted daily in our current culture.

Whereas, perioperative complications affect a minority of patients, when realized their contribution to morbidity, cost and at times, mortality is disproportionately high compared to nonperioperative complications. Moreover, perioperative outcomes may vary by surgeon, anesthesiologist, and/or institutional experience as well as by adherence to standardized perioperative improvement methods such as enhanced recovery protocols.6–8 Increasingly, perioperative complications can be attributed to patient disease and comorbidity. These risk factors are at least in part related to nonmodifiable conditions such as biologic changes incident with advanced age, and modifiable conditions such as socioeconomic conditions and a growing chronic disease burden including cardiovascular and metabolic syndrome.5,9,10

Nevertheless, preoperative optimization, albeit easy to rationalize, remains a logistical challenge to implement. Opportunities to optimize the care of the most comorbid surgical patients are often lost and complicated by the logistics of surgical platform utilization. Importantly, the growing incidence of comorbidities in the adult patient population, such as frailty, obesity, diabetes mellitus, and cardiovascular disease, has led to a situation in which more than one-third of all inpatient surgical procedures in the United States are performed in populations with conditions known to produce the highest rates of complications, the longest hospital stays, and the greatest loss of postsurgery independence.11 Emergencies and urgencies notwithstanding (dealt with emergently and urgently), it should seem obvious that preoperative preparation should focus on shared decision making, prehabilitation to facilitate functional recovery following surgery and reducing risk related to comorbid medical condition (eg, anemia, malnutrition, poorly controlled glucose, smoking, etc) whenever possible to enhance the value proposition of a surgical option to patient management.2,9,12

WHY ARE WE STILL HAVING THIS DISCUSSION?

The practice of an anesthesiologist assessing a patient just before surgery (in some cases, the day of surgery only) has become a threshold standard, with the scheduled surgery taking on a fixed priority.

While an important goal of preanesthesia and surgical screening is to detect overt unstable disease (eg, active cardiac ischemia or diabetic ketoacidosis) and prevent day-of-surgery case delays or cancellations, up to 20% of patients seen in a preanesthesia/surgical clinic have medical conditions known to impact surgical outcome and cost. More focused efforts on the management of the subtler elements of patient preparation for surgery may represent an important opportunity to enhance value in a total cost of care: 2-sided risk health care delivery system.13 It also, more importantly, is an opportunity to reach for a higher standard of patient health.14 Toward this end, it is salient to recognize that although primary care providers (PCPs) serve patient health care needs in a unique and important manner and in many environments may be responsible for preparing a patient for surgical procedures, they commonly are expected to deliver disparate services with limited staff to broad populations. PCPs must manage practice production pressures and care delivery circumstances that are typically different from specialty care providers and therefore are often unable to efficiently provide for specific perioperative patient care needs. In addition, many patients simply lack access to primary care and may be introduced to the health care system only when they confront a surgery declaration touch point. The consequence is that high-risk patients scheduled to have surgery often arrive on the day of surgery with risk (albeit identified risk) and/or subtler elements of abnormal biology that otherwise could be more optimally reduced and/or managed before surgery.15,16 Commonly, by the time patients are seen in a preoperative clinic before an established surgery date, it is typically too late to modify their operative risk without an uneasy disruption of expectation, for both the patient and the surgeon.

While parsing out the specific contributions of preoperative preparation to overall risk reduction and perioperative value enhancement is important to best inform timing of elective surgery, it remains an understudied area. Timing of elective surgery is a complex medical decision even without understanding the precise contribution of comorbid condition preparation in lieu of all the other factors that contribute to postoperative risk. An effort to understand how to measurably improve perioperative health outcomes through evidence-based care management is needed. Data will help us balance the imperative for surgery with preparation for surgery, develop, and support multidisciplinary protocols for perioperative care and to enable a responsible perioperative transition of care.

An ideal surgical care plan should begin as soon as a patient is identified as a surgical candidate which often contrasts with the current state of perioperative care whereby the organization of screening, care coordination, site of service selection, optimization, and management is aligned to different incentives. The current perioperative care delivery system moreover tends to disproportionately reward cost-shifting, rather than maximize value.17,18 To truly enhance value (increase quality and reduce cost), the best approach may be to accentuate some services to reduce the need for others.

The issue of whether preoperative optimization of comorbid medical conditions should be achieved before surgery is not debatable. The importance of preoperative risk mitigation toward achieving enhanced postoperative value is not in question. However, what the best model is for ensuring preoperative optimization and achieving value remains untested—partly because alignment of short-term interest with long-term interest among patients, providers, and hospitals is a hurdle over which our current culture has not undergone sufficient transformation. Until we do, the call to action for preoperative optimization will unfortunately persist. In the meantime, a more balanced view of preoperative optimization remains an unmet need and an important opportunity that stands to enhance the value proposition of surgery and population health. E

DISCLOSURES

Name: Solomon Aronson, MD, MBA, FASA, FACC, FCCP, FAHA, FASE.

Contribution: This author helped write the manuscript.

Name: Gavin Martin, MB ChB, MMCi.

Contribution: This author helped edit the manuscript.

Name: Padma Gulur, MD.

Contribution: This author helped edit the manuscript.

Name: Mike E. Lipkin, MD, MBA.

Contribution: This author helped edit the manuscript.

Name: Sandhya A. Lagoo-Deenadayalan, MD, PhD.

Contribution: This author helped edit the manuscript.

Name: Christopher R. Mantyh, MD.

Contribution: This author helped edit the manuscript.

Name: David E. Attarian, MD, FACS, FAOA.

Contribution: This author helped edit the manuscript.

Name: Joseph P. Mathew, MD, MSc, MBA, FASE.

Contribution: This author helped edit the manuscript.

Name: Allan D. Kirk, MD, PhD, FACS.

Contribution: This author helped edit the manuscript.

This manuscript was handled by: Thomas R. Vetter, MD, MPH.

FOOTNOTES

GLOSSARY

OR = = operating room;

PCP = = primary care provider

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