The Critical Role of Perioperative Medicine in Improving 30-Day Outcomes

Perioperative medicine (POM) is a growing field emanating from basic preoperative evaluation or pre anesthesia testing (PAT) clinics to involve more comprehensive multidisciplinary care designed improve surgical outcomes.1-3 Preparing patients for the perioperative continuum begins with the time of contemplating surgery, addressing preoperative risk factors, physical fitness, comorbidities, social determinants of health, nutritional status, frailty, and cognitive function. Qualified patients undergo a comprehensive assessment by POM clinicians, who contribute to the overall assessment with recommendations for further optimization and shared decision-making with patients, their families, and surgical teams. Preoperative optimization addresses patients' coexisting conditions, social drivers of health, and modifiable risk factors that extend beyond routine medical management to optimize frailty, mitigate complications, and engage stakeholders to ensure a multidisciplinary approach to perioperative care.4When considering the 300 million-plus surgeries performed annually worldwide, the significance of complications occurring within 30 days post-surgery cannot be overlooked. Postoperative deaths represent 7.7% of all fatalities, making surgery the third-leading cause of death, following ischemic heart disease and stroke.5 As a result, research and educational efforts focused on POM in recent years have led to significant improvements in care design, team development, and clinical outcomes.6 This stems primarily from an understanding of surgical pathology and improved techniques, as well as the adoption of Enhanced Recovery After Surgery (ERAS) pathways and updated guidelines.7-8 However, with advances in surgical and anesthetic techniques, as well as medical management of comorbid conditions, perioperative clinicians face the challenge of navigating care design for high-risk patients undergoing time-sensitive surgical procedures with limited opportunities for medical optimization, prehabilitation, or patients' engaged understanding of potential adverse outcomes.1,9 Indeed, POM has evolved significantly, enabling high-risk patients to undergo surgery more safely through a multidisciplinary approach that extends from the decision to have surgery until their highest plane of functional recovery. Evidence strongly suggests that each POM touchpoint throughout the episode of surgical care is an opportunity to impact the overall patient experience. Examples include ERAS pathways improving quality of recovery, reducing complications, improving 30-day outcomes, and positively impacting discharge disposition for high-risk patients of all ages.10,11 Furthermore, perioperative clinicians continue to face challenges in meeting the rising demand and cost of performing surgery in an aging population. This patient demographic is at higher risk of complications, morbidity, mortality, and health care resource utilization.12 The challenges posed in caring for the aging population stem from limited resources, including funding and workforce, as well as technological barriers that inhibit clinicians from receiving real-time feedback on their work and outcomes. Fragmented care across service lines poses challenges across different institutions and poses challenges to the implementation of standardized care pathways. Finally, patient engagement and efforts to apply shared decision-making for high-risk populations require a patient-centered approach emphasizing personalized care plans.13 Over the past two decades, the evolution of POM has had a positive impact on 30-day outcomes and the quality of recovery in surgical patients. We present a summary of progress made in research, education, and clinical care. Conceptual framework: POM and 30-day outcomes A conceptual framework for POM and 30-day outcomes includes a focus on standardized, patient-centered, clinically applicable measures to evaluate and continually improve POC. Recent consensus initiatives, such as the Standardized Endpoints in POM (StEP) and Core Outcome Measures for Perioperative and Anesthetic Care (COMPAC), recommend a set of core outcome measures to be used as the standardized endpoints in POM research.14,15 Outcome measures have been categorized into four groups: 1) Individual adverse events, often due to tissue injury from surgery or perioperative stress, or consequential to a patient's age, frailty, and comorbidities 2) Composite outcome measures, such as major adverse cardiac events (MACE), myocardial injury after noncardiac surgery (MINS), acute kidney injury (AKI), and/or included in postoperative morbidity surveys 3) Health care resource utilization, such as length of hospital and ICU stays, readmission rates, and non-home discharge 4) Quality-of-life measures, including patient-reported outcome measures (PROMs) and quality of recovery (QOR) scores.16 These internationally recognized standardized definitions will guide perioperative clinicians and researchers in adopting a standard approach to addressing both short-term and long-term perioperative outcomes. A focus on patient-centered outcomes recommends including one health related quality-of-life measure (EuroQol 5-Dimension (EQ-5D), 5-Level with Visual Analogue Scale), one functional status measure (World Health Organization Disability Assessment Schedule (WHODAS), and one life impact measure (days alive at home and out of hospital 30 days after surgery).17 Definition standardization will facilitate cross-study comparison, translation to clinical care, and further enhance quality improvement initiatives in POM. Perioperative optimization at different time points in the perioperative continuum Traditional approaches to preoperative risk assessment focus on the complexity of the surgical procedure, preexisting medical conditions, and evaluation of functional capacity. Resuming normal activity following surgery requires a coordinated physiological response that involves cardiopulmonary, musculoskeletal, metabolic, and psychological factors. The clinical implementation of research advocates for a more comprehensive assessment of fitness and defined risk, including the degree of physical resilience, to ensure effective postoperative recovery. As such, a thorough evaluation of physical fitness, nutritional health, psychological preparedness, and cognitive status in a separate setting is a crucial phase of care.3 Poor dietary habits, inadequate nutrition, and a sedentary lifestyle can initiate inflammatory, metabolic, and endocrine processes that inhibit the recovery process.4 In special populations such as cancer patients, this may further contribute to cancer development through accumulated DNA damage and continuous proliferative signaling.4,18 A robust preoperative program can identify individuals at risk who require more thorough evaluation and referral for prehabilitation to a skilled team within a health care setting. The intraoperative and postoperative phases of care have undergone significant evolution over the last two decades, with the adoption of ERAS pathways as standard care. Perioperative goal-directed fluid therapy remains the optimum strategy for significantly reducing postoperative cardiopulmonary and renal complications in patients undergoing major noncardiac surgery, as shown in multiple systematic reviews and meta-analyses.19-22 In addition, multimodal analgesia techniques, prevention of postoperative nausea and vomiting, and early return of physiological function, such as early mobilization, nutrition, and measures to achieve early bowel and bladder function, have been shown to improve both clinical and patient-reported outcomes.23 Special population considerations Cancer patients with pending time-sensitive surgeries are typically categorized as elective in some institutions. However, time may be of the essence given the propensity for local and/or metastatic spread. This may leave insufficient time to optimize frailty, prehabilitation, nutritional status, and postoperative disposition and support planning. Nonetheless, there is still a role for POM beyond the preoperative phase, as ERAS pathways can improve the quality of patients' recovery.4,24 Moreover, the evolving paradigm surrounding oncological care includes enhancing physical resilience in relation to the timing of chemotherapy, adjuvant therapy, and surgery, which may provide a greater window to optimize patients' physical, nutritional, and psychological status. Geriatric patients represent another special population, given their propensity to develop delirium and postoperative neurocognitive disorders, which impact 30-day and longer-term outcomes. Neurocognitive screening, which is a common element in POM, has been shown to decrease the incidence of postoperative delirium by 40%.25-26 Awareness of preexisting cognitive changes introduces the possibility of prehabilitation training and enables clinicians to make appropriate adjustments in intraoperative management and postoperative care plans. Monitoring and discharge plans may change based upon early recognition of cognitive change often unrecognized by family or caregivers. Indeed, a multidisciplinary approach is essential to address specific syndromes, cognitive decline, frailty, and psychosocial factors impacting recovery.27,28 The role of technology and artificial intelligence in POM and 30-day outcomes The use of e-health and digital health in the perioperative setting has shown promise in various aspects, including early patient activation, engagement, preoperative preparation and education, and provision of postoperative programs to expedite recovery.29 The role of e-health interventions, such as educational support, telemonitoring, telerehabilitation, teleconsultation, wearables, and remote monitoring, has become increasingly popular in POM. Its impact has been evaluated through patient-reported outcomes, including physical functioning and pain control, costs, return to work, patient satisfaction, and pain-related outcomes.29 As artificial intelligence evolves, e-health data may raise the bar for tailored perioperative risk prediction. For instance, artificial neural networks and machine learning programs are superior to standard prediction models in predicting sepsis, quality of life after breast cancer surgery, and long-term mortality after surgery for hepatocellular carcinoma.11 The future of POM Multidisciplinary collaboration is crucial for POM care pathways to have the most impact, thereby continuing to improve perioperative outcomes. There is an opportunity to expand the population-health-based framework of POM, enabling benchmarking of outcomes across institutions and incorporating evidence-based best practices to improve value-based care. Leveraging technology and electronic health records to incorporate decision support tools, as well as databases and analytics that inform clinicians of their outcomes, is also crucial for the continued growth and evolution of the field. The role of technology tools can enhance longitudinal collaboration and communication throughout the entire perioperative continuum, from the time of surgery contemplation to 30 days after discharge and beyond. In addition, as payers continue to focus on value-based and performance-based compensation, it is essential to provide information and data that reflect the impact of POM as a population health-based model to improve patient outcomes. Disclosures: Dr. Edwards serves as an advisor for Perioperative Consultants, LLC and Vertex Pharmaceuticals, LLC. Dr. Gan is a consultant for Haisco, and Heron Therapeutics, Inc.Angela F. Edwards, MD, FASA, DFPM, ASA Center for Perioperative Medicine, and Past President and Founding Director, Perioperative Medicine Fellowship and Certificate Program, Society for Perioperative Assessment and Quality Improvement, Winston-Salem, North Carolina.Tong J. Gan, MD, MBA, MHS, FASA, FRCA, ASA Steering Committee, ASA Center for Perioperative Medicine, Professor and Mildred M. Oppenheimer Distinguished Endowed Chair and Head, Division of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas.Marc Koch, MSc, MD, MBA, FASA, ASA Center for Perioperative Medicine, and President and CEO, Somnia Inc., Harrison, New York.Basma Mohamed, MBChB, ASA Center for Perioperative Medicine, Associate Professor, Department of Anesthesiology, Duke University, Durham, North Carolina.