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Moving Toward Preoperative Optimization and Value-based Perioperative Care

Aronson, Solomon MD, MBA, FASA, FACC, FCCP, FAHA, FASE

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Techniques in Orthopaedics: March 2020 - Volume 35 - Issue 1 - p 2
doi: 10.1097/BTO.0000000000000436
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There is an expectation for 6.6 million orthopedic surgeries to be performed in the United States in 2020, an increase from the 5.3 million orthopedic surgeries performed a decade earlier. This increase in orthopedic surgery corresponds with the growth in the aging population who require orthopedic surgeries with >3 million orthopedic surgeries occurring among patients older than 65 years. Among orthopedic surgeries performed, total joint arthroplasty remains one of the most cost-effective and successful interventions in medicine. There are >1 million total joint arthroplasty performed in the United States annually and this number is expected to increase to nearly 4 million by 2030.1 Moreover, there are ∼1.6 million instrumented spinal procedures performed annually in the United States (

Although perioperative complications affect relatively few of these patients, when complications do occur, management of perioperative adverse events consume a disproportionally large amount of health care resources.2–4

Evidence strongly supports that the opportunity for greatest value enhancement in health care lies within the management of care for the sickest patients.5 The goal of preoperative preparation should be to enhance the value proposition of surgery. Therefore, one is left to wonder why preoperative patient preparation continues to have a wide variability of effectiveness and gaps in implementation.

Currently, most preoperative practice models enable a preoperative history and examination but do not proactively engage in preoperative patient preparation. Up to 20% of patients seen in a presurgical clinic have modifiable medical risks which are commonly not addressed before surgery. Indeed, by the time patients are typically scheduled to be seen in a preoperative clinic before an established surgery date, it is typically too late to modify their “modifiable” risk without an uneasy disruption of expectation.

Ideally, the primary goal of preoperative patient preparation is to identify and reduce the risks associated with comorbid medical conditions affecting patients’ postoperative outcomes. Although there remains great variability among programs in their approach to preoperative patient preparation, in this symposium we provide descriptions of the state of the science for preoperative anemia, nutrition, and pain management as well as promoting lifestyle modification for best patient preparation to more fully enhance the value proposition of orthopedic surgery in the United States. Finally, we offer calibration of perioperative enhancement efforts in the United States to the longer-standing experiences observed in the United Kingdom.


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3. Dimick JB, Chen SL, Taheri PA, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531–537.
4. Davenport DL, Henderson WG, Khuri SF, et al. Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications: a case study using the National Surgical Quality Improvement Program (NSQIP) database. Ann Surg. 2005;242:463–468.
5. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368–1375.
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