Surgery

The cost of health care is an issue of growing importance throughout the industrialized world. When facing the challenges of limited resources and increased potential for surgical interventions in a larger patient population, it becomes particularly important to recognize patients at increased risk of postoperative morbidity and mortality, and to find interventions to reduce the risk. This is because such patients consume a disproportionate amount of health care resources. Among all surgical specialties, approximately 10% to 20% of patients account for >50% of resources.1 We have methods to identify patients at increased risk of postoperative morbidity and mortality. The American Society of Anesthesiologists (ASA) risk classification is certainly best known by anesthesiologists.2 Other systems exist, some of them aimed at the general surgical population, such as the various versions of the POSSUM score,3 and others at specific patient groups, such as the Goldman cardiac risk classification4 or the EuroSCORE for cardiac surgery.5 Risk classification systems are only useful when coupled with a change in treatment strategy. It is conceivable that, for example, a high ASA class is likely to change the approach taken by an anesthesiologist in individual cases. However, only a systems approach is likely to have a measurable and relevant impact on health care resources. Our ability to identify patients eligible for outpatient or fast-track surgery and to define and implement optimum processes has led to a breakthrough in efficient utilization of resources for those patients. Paradoxically, we are only beginning to link patients at high risk of peri- and postoperative complications with optimum treatment processes to reduce their risk. This issue of Anesthesia & Analgesia marks the beginning of a 3-part series presenting a broad picture of the epidemiology, pathophysiology, and interventions in high-risk surgery. The series, appearing in 3 successive issues, will feature 2 original articles, 3 invited review articles, and 3 invited editorials. This issue begins with a review by Moonesinghe et al.6 and original research by Lobo et al.7 The review by Moonesinghe et al.6 focuses on the epidemiology and outcome of high-risk surgery. This review is based on almost 2 decades of work by the senior author, Professor Michael Mythen, and his group at the Surgical Outcomes Research Centre of the University College of London. They have opened up a whole field of patient-centered outcomes research in the United Kingdom, supported by the National Health Service. The second article in this issue, by Lobo et al.,7 focuses on the causes of death in a specific subset of high-risk surgical patients: those admitted to the intensive care unit within 24 hours after noncardiac major surgery. The overall hospital mortality was approximately 20% in this population, with multiple organ failure as the main cause of death. This study brings into focus the role of the intensive care unit as an important part of the treatment chain. This is also emphasized by the results of a recent large multicenter trial on variation in hospital mortality in inpatient surgery. Ghaferi et al.8 used the American College of Surgeons' National Surgical Quality Improvement Program database to study high-risk surgery, defined as procedures with >1% mortality. There were >84,000 high-risk patients, which represented 23% of patients and 68% of deaths in the database. Mortality between hospitals stratified as having “very low mortality” versus those having “very high mortality” varied from 3.5% to 6.9%, whereas the rates of overall and major complications did not differ between the low- versus high-mortality hospitals. In contrast, mortality in patients with major complications was twice as high in high-mortality hospitals. Accordingly, the treatment of patients with major complications made the difference. Considering that the largest differences were observed in mortality of patients with stroke, deep wound infections, and septic shock, the major role of intensive care becomes obvious. Perhaps not coincidentally, similar or even much larger differences between intensive care units in severity-adjusted mortality have repeatedly been demonstrated.9 In my view, we must focus on a systems approach to high-risk surgery, rather than clinging to the fragmented traditional disease-oriented approach. The modern hospital should be able to identify patients with a substantially increased risk of peri- and postoperative morbidity, and design care paths that include specific interventions to reduce these complications. The last article in our series, focusing on preemptive hemodynamic optimization, presents one possible approach. This will certainly be controversial. However, our goal in presenting this series was to generate discussion. We think you'll find that all the articles make for stimulating reading, and we invite your comments in the coming months.