General physicians and perioperative medicine. What is on the horizon?

Surgical care has been an essential component of health care worldwide for more than a century. Surgery is the preferred or only treatment to prevent mortality, relieve pain or restore normal structure or function in many conditions, ranging from trauma and intra-abdominal emergencies to cancer and osteoarthritis. While surgical procedures are intended to improve lives, complications from surgical care can cause significant harm. Postoperative complications affect 21% to 45% of adult surgical patients by 30 days, although reported rates depend on measurement definitions and methods1-3 as well as patient and surgical characteristics, and patterns do not seem to have changed appreciably over the past decade.4 Surgical complications significantly affect a patient's quality of life2, 5 as well as mortality, length of stay and care needs.1 Among Australian surgical deaths, half involve patients aged 75 years or older, 90% have multiple comorbidities, two-thirds are American Society of Anaesthesiologists (ASA) score 4 or more, and 85% are non-elective surgery, highlighting the increasing complexity of the surgical patient population.6 Age, frailty, functional limitations, dementia and multimorbidity are important risk factors for surgical morbidity and mortality,7-9 which will continue to increase as our Australian population ages. The way we deliver perioperative care must adapt to the growing numbers and complexity of surgical patients at risk of increased postoperative complications and poorer functional recovery. Patients often require more nuanced risk–benefit considerations for shared decision-making and coordinated complex discharge planning. Currently, there is variation in perioperative services throughout Australia and New Zealand.10 While robust structures exist for assessing fitness for surgery and optimising intraoperative care, most models of care for surgical patients rely on a reactive response when complications occur.11 A more systematic approach to the perioperative care journey could offer more precise risk stratification, better preoperative optimisation and earlier identification and management of complications. The increasing medical complexity seen in the surgical population has led to the development and evolution of collaborative models of perioperative care. Perioperative care is defined as the multidisciplinary, individualised, integrated care of patients from the moment surgery is contemplated through to their optimal outcomes.12 Perioperative medicine is the science and practice of optimising patients’ health prior to surgery, minimising the risk of postoperative complications and optimising recovery.12 The perioperative medicine team is led by medically qualified specialists (e.g. physicians, geriatricians, anaesthetists and intensivists) who collaborate with other members of the perioperative care team, including surgeons/proceduralists, nurses, allied health professionals, primary care physicians and, most importantly, the patient, their family and carers. Each craft group has specific, but overlapping, roles in the patient's journey. General practitioners, surgeons, anaesthetists, physicians, allied health professionals and nurses contribute to preoperative risk assessment, shared decision-making and preoperative optimisation. Intraoperative care and early postoperative monitoring are managed by anaesthetists, surgeons and nurses. Intensive care physicians contribute to the postoperative care of very high-risk patients and contribute to shared decision-making both before and after the procedure. General physicians and geriatricians are well placed to predict, prevent and manage postoperative complications and promote recovery in collaboration with multidisciplinary surgical teams. Rehabilitation physicians, general physicians and geriatricians play a crucial role in discharge planning and rehabilitation in collaboration with allied health practitioners and nurses, and general practitioners and surgeons collaborate in patient follow-up. All perioperative medicine specialists play a role in clear communication with the patient and family, supporting informed consent. General physicians have attributes and skills that prepare them well for an important role within perioperative medicine. They provide holistic and pragmatic care and are experienced in patient-centred care through advocacy for patient preferences, facilitating goals-of-care discussions and coordinating shared decision-making processes. General physicians care for patients with complex conditions across a wide age range with multimorbidity and/or frailty. They have wide experience in evaluating the risks and benefits of drugs, such as anticoagulants, immunosuppressants, cardiovascular medicines and diabetes therapeutics, in the perioperative setting. General physicians are skilled in multidisciplinary teamwork and complex discharge planning. They are experienced in managing the common medical events that occur in surgical patients, including delirium, myocardial ischaemia, arrhythmias, acute kidney injury and glucose and electrolyte disturbances. General physicians can provide diagnostic input where perioperative clinical concerns are poorly defined, leading to expertise as the ‘first port of call’ specialist physician, and efficiently coordinate input from other medical specialties. They often provide education and support for junior surgical staff. These skills add high value to the procedural and prognostic expertise of surgeons, anaesthetists and intensivists. The evidence for how physicians best add value through these skills and attributes to the perioperative care journey is evolving. Findings remain inconclusive, partly because of the range of patient groups, interventions and outcome variables reported, as well as challenges inherent in designing robust studies of complex system-level interventions. Preoperative outpatient risk assessment and optimisation of baseline health and health behaviours (including ‘prehabilitation’ models) have attracted substantial interest, although the roles of anaesthetists and physicians in these models remain imperfectly defined.13, 14 An Australian systematic review of preoperative physician consultations suggested reduced surgical cancellations and fewer unnecessary admissions, but it also suggested an increase in length of stay, complications, readmissions and costs.15 A qualitative study by the same group concluded that referring surgeons valued physician support for difficult shared decision-making in high-risk patients.16 A UK evidence review by the National Institute of Clinical Excellence of preoperative optimisation clinics for older people reported mortality benefits but conflicting findings for a length of stay and potential increased risk of harm for complications and readmissions.17 The reviewers recognised the challenge of requiring skilled human resources and recommended further research into costs and benefits.17 Physician co-management, where physicians provide clinical inpatient care throughout the perioperative journey, has also been studied following established evidence for geriatrician co-management in hip fracture patients. An Australian systematic review of general physician-led co-management demonstrated a reduction in mortality and length of stay in models that included multidisciplinary team-based inpatient care rather than a consultative model.14 Other features of successful models included systematic collaboration with the surgical service such as order sets, audit and feedback and quality improvement initiatives. There was insufficient evidence regarding complications or functional outcomes and inconsistent reporting of costs and benefits.18 In response to an increasingly complex surgical cohort, the Australian and New Zealand College of Anaesthetists (ANZCA) has spearheaded the development of a Perioperative Care Framework12 with accompanying resources to guide perioperative medicine service structure and establishment of the Diploma of Perioperative Medicine (DipPOM) qualification pathway to support specialised training. These initiatives are supported by the Royal Australasian College of Physicians, in particular by the Internal Medicine Society of Australia and New Zealand (IMSANZ), the Australia and New Zealand Society for Geriatric Medicine, the Australasian Faculty of Rehabilitation Medicine, the College of Intensive Care Medicine, the Royal Australasian College of Surgeons, the Australian College of Remote and Rural Medicine and the Royal Australian and Royal New Zealand Colleges of General Practitioners. The post-fellowship diploma qualification will be available to specialists from multiple craft groups to enhance their skills and knowledge in perioperative medicine, shared decision-making and interprofessional collaboration. General physicians will continue to play a valuable role in perioperative medicine and care coordination for surgical patients, and this has been recognised within the DipPOM. In view of the inconclusive evidence regarding the benefits and costs of different perioperative medicine models, it is important that we continue to evaluate the effectiveness and costs of collaborative perioperative pathways using appropriate methods. Health service evaluation frameworks can be applied to assess the quality and structural effectiveness of these models of care.19 Process measures for periodic monitoring and evaluation may be informed by the Perioperative Care Framework (i.e. surgical review and risk assessment, shared decision-making, optimisation, intraoperative care, safe recovery, handover and follow-up12). Outcome measures need to focus on patient outcomes (including quality of life, physical and cognitive recovery, return to usual roles and activities as well as mortality and complications), system outcomes (including surgical delays or cancellations, length of stay, intensive care and subsequent service use) and measures of patient and staff satisfaction (such as decisional regret). It is important to consider equity of access and include groups at greatest risk and to measure outcomes for those patients who choose non-operative management after shared decision-making. It is inevitable that frailty, disability, multimorbidity and complexity will continue to increase in surgical patients as our population ages. The subsequent complexity throughout the perioperative care journey provides an opportunity for the physician to contribute unique expertise at multiple points of the journey to the perioperative care team, who must collaborate and understand one another's skill to provide each patient with an individualised, optimised journey. Development of a collaborative multi-specialty Perioperative Care Framework and a perioperative medicine curriculum are important steps in the evolution of Australian perioperative medicine services, but continuing innovation, advocacy and evaluation are required to develop affordable, equitable care models for surgical patients to achieve optimal outcomes.