Innovations in Practices and Technologies That Will Shape Perioperative Medicine

Perioperative medicine continues to evolve as a field focused on improving outcomes for patients undergoing surgery. While some progress has recently been made, substantial opportunity still exists in understanding and implementing the changes needed to reduce postoperative morbidity and improve quality of life for patients. This issue of Anesthesia & Analgesia includes a high-impact bundle of 6 articles that address distinct approaches to advancing perioperative medicine and broadening its scope in health care.1–6 The articles review the value of (1) clearly defining and standardizing outcomes after surgery,1 (2) implementing principles of narrative medicine and shared decision-making in perioperative care,5 (3) using perioperative medicine as a platform for advocating public health,4 (4) exploring the role of nascent but burgeoning technologies, specifically, wearable biosensors and artificial intelligence (AI) in the care of surgical patients,2,3 and (5) providing a view on the future of perioperative medicine for the anesthesiologist in the United States.6 Collectively, these articles present the innovations in concepts, practices, and technologies in perioperative medicine that may deliver both meaningful and significant benefits for patients. In their review, Harvie et al1 astutely point to a major gap that exists in the road to improving health for surgical patients—that is, accurately defining and standardizing outcomes after surgery. Without a clear understanding of the outcomes, assessment and stratification of risk are performed in a murky space without clear benchmarks. Further decisions regarding surgical care, as they relate to patient choice, clinical care to be rendered, or resources to be utilized, are likely inadequate, or at worse, flawed. The authors correctly point to initiatives such as the Core Outcome Measures in Perioperative and Anaesthetic Care (COMPAC), which involved a comprehensive and systematic review of perioperative outcomes based on a survey of patients, caregivers, and clinicians.7 The final set of outcomes was comprised of 5 domains that would be arguably most relevant to all health care stakeholders in any part of the world. These include (1) mortality/survival (postoperative mortality and long-term survival); (2) perioperative complications (major postoperative complications/adverse events); (3) resource use (length of hospital stay and unplanned readmission within 30 days); (4) short-term recovery (discharge destination and level of dependence); and (5) long-term recovery (overall health-related quality of life). The authors, however, do not address how the worldwide surgical health care community can be brought together to accept these common norms and standards. In a thoughtful article, Vetter5 has chosen to highlight the principles of Narrative Medicine and their potential meaningful applications in determining the appropriate care of surgical patients. Narrative medicine espouses the critical importance of patient’s story, the clinician’s story, or a story developed together by the patient and clinician for promoting optimal patient care. These principles are also key to the core concepts advocated in shared decision-making models that are essential to advancing quality of life of the individual patient and appropriate utilization of resources in health care. Having the ability to determine standardized outcomes and allowing patients to understand the potential impact of surgery and anesthesia on their postoperative journey through discussion of best case–worse case scenarios can help reduce the burden of futile or low-value surgeries in health care. Vetter advocates imparting formal training in narrative medicine to perioperative clinicians. While laudable as an aspirational goal, it is also essential to recognize that one of the overwhelming challenges for delivering health care worldwide today is lack of trained clinical staff and the burn out that exists among the ones who are still engaged. Requiring additional training in such an environment needs to be considered carefully and perhaps selectively. In the interim, we could all try to remember to start by asking our patients what matters to them rather than “what is the matter.” Moonesinghe4 in an Open Mind article calls upon the anesthesiologists and perioperative physicians to embrace their role in improving public health. Moonesinghe points to the US Centers for Disease Control and Prevention (CDC) definition of public health as being the “... the science of protecting and improving the health of people and their communities,” which aligns with many of the clinical activities in the purview of the perioperative physicians when screening for risk, optimizing medical comorbidities before surgery, and ensuring long-term health. Evidence-based pathways and value-based care practices have shown to improve outcomes for patients and health systems.8,9 While practice in the realm of public health is more accepted and prevalent among anesthesiologists and perioperative physicians in many European countries, similar notions of anesthesiologists being integral to value-based care are more nascent in the United States, and at this time, limited to major health systems that have made investments in establishing perioperative clinics/centers designed to manage many modifiable risk factors before surgery, including malnutrition, anemia, diabetes, and pain, while coordinating care throughout the perioperative period.10,11 Indeed, anesthesiologists embracing activities in promoting public or population health should not be seen as abandonment of their important care in the operating room, but an expansion of their role in providing value-based care. It is likely that not all anesthesiologists will be able to accomplish this role, or have an interest in doing so, but the ones who do should be supported on this path. Incidentally, technology-enabled platforms that include virtual/tele-care, wearable biosensors, and remote patient monitoring (RPM) devices, and advanced analytics can aid in both promoting patient access to better health care and in expanding the reach of perioperative physicians to larger subsets of at-risk patients, enabling their greater engagement in population health. Thus, the review provided by Jin et al2 is notable in demonstrating the potential value afforded by routine consumer grade wearable pedometer devices in assessing patient functional capacity both presurgery and postsurgery and showing an association of these measurements with outcomes such as postoperative length of stay, complications, and readmission rates. It is important to recognize that the pedometers measure patient activity (steps and motion), which may not directly equate to functional capacity. And, even though the studies included in this review had several significant limitations—including modest sample sizes, heterogenous populations, nonstandardized measurement techniques, and strength of associations with the outcomes—the relevance and potential impact of research in this field cannot be overstated. The current studies reflect early stages in the development technology (wearables and RPM) and its integration into the health care data stream, as well as lack comprehensive and methodical study designs to assess the impact of modifying nontraditional activity or other physiological measures in improving outcomes. Given the widespread availability of the wearables and mobile devices that track activity and other biomarkers, including many in low- and middle-income countries, we are likely to experience a greater application of these technologies in perioperative care. A succinct review by Maheshwari et al3 highlights the enormous role AI should play in advancing perioperative care. The authors address a key question in their work: are anesthesiologists prepared to take more ownership of perioperative morbidity and mortality? The examples cited by the authors are prescient and represent a finite fraction of applications where AI, machine learning, natural language processing, and computer vision technologies may provide immense value to patients and clinicians in the coming years. AI and machine learning techniques have existed for decades but have recently become increasingly utilized in health care as a result of availability of large data sets, improved computing power, and access to cloud systems. Using AI to analyze data from electronic health records, physiologic monitors, or image/videos in the operating room can provide highly reliable predictive or prescriptive insights, enabling the clinicians to make better care delivery decisions in real time even in complex situations. AI adoption can be met with skepticism among some clinicians. Several challenges to adoption of algorithms have been outlined by the authors, including the black box nature of many AI techniques, although greater emphasis is now being placed on identifying the variables responsible for the predictive models (including use of Shapley values’ method).12 The promise of AI is so profound that we sometimes forget these algorithms are developed by people. And assumptions are made by people in building the algorithms, thus the potential for some inadvertent errors. Health systems should enact guidelines for how a new AI model is introduced, tested, and applied to various population segments, ensuring efforts to eliminate conscious and subconscious bias. Furthermore, health systems should maintain accountability and clarify to their staff and the public what protocols are in place if mistakes occur. Finally, Gottumukkala et al6 present a view the future may hold for anesthesiology and a framework for this change. These authors emphasize the need to socialize perioperative medicine as a patient-centered program, to build coalitions with other professional societies, and to develop a framework for education—while emphasizing that perioperative medicine is a continuous quality improvement and “value-based” program. They further extend the population health angle by suggesting that perioperative medicine can be used to evaluate social determinants of health by studying health disparities versus equity in surgical patients. An important question that needs to be addressed is who will pay whom for all the extra work. Importantly, they explore training the current and next generation of anesthesiologists to be an invaluable asset and partner in the integrated care delivery paradigms. While they understandably present a US-centric view, some countries have possibly made more rapid progress toward the “future” they describe. For example, in 2014, the Royal College of Anaesthetists in the United Kingdom launched a perioperative medicine program.13 A network of perioperative medicine leads was established through the UK National Health Service (NHS), and the higher specialist anesthetist’s curriculum approved by the UK General Medical Council was revised to include specific competencies and advanced perioperative medicine training.14 Postgraduate qualifications (eg, a University awarded Certificate, Diploma, or Masters) combined with a clinical fellowship are now quite common and long established in many countries.15 More recently, the United Kingdom saw the formation of a new Centre for Perioperative Care (CPOC), which is multidisciplinary and supported by various professional colleges and societies.16 Given the increasing number of patients needing surgery worldwide, perioperative medicine remains a fertile ground for seeking innovations that will improve patient outcomes, lead to greater population health, and advance value-based care. Significant opportunity exists in promoting new discoveries in this interdisciplinary field, while recognizing that we also need to seek more effective means for implementing the substantial knowledge in evidence-based perioperative medicine that has already been gained from prior works. The authors of the 6 articles published in this issue of Anesthesia & Analgesia are to be commended for sharing their insights and presenting new opportunities for promoting perioperative medicine. DISCLOSURES Name: Aman Mahajan, MD, PhD, MBA. Contribution: This author helped with concept and design, drafted and edited the manscript, and approved the final version to be published. Conflicts of Interest: A. Mahajan is a founder of Sensydia Corp and Hytek Corp, medical technology corporations, and a board advisor for PIPCare Inc, a digital health platform. Name: Monty (Michael) Mythen, MBBS, MD, FRCA. Contribution: This author helped with concept and design, drafted and edited the manscript, and approved the final version to be published. Conflicts of Interest: M. Mythen is a Director of TopMedTalk Ltd; EBPOM Global Ltd; Medinspire Ltd; and Medical Defense Technologies LLC. M. Mythen is a paid Consultant for Edwards Lifesciences. This manuscript was handled by: Jean-Francois Pittet, MD.