Coordinated perioperative care-a high value proposition?

The merits of a coordinated consistent approach to the perioperative journey appear obvious, but only relatively recently has there been a substantial focus on this area through initiatives such as the ASA’s Perioperative Surgical Home (POSH) and the Royal College of Anaesthetists Perioperative Medicine Programme. These approaches include consistent structured elements in the patient pathway, such as preoperative assessment and management, triage, high quality intraoperative care, and postoperative management matched to a patient’s needs. A large survey of perioperative activity in the UK in 2011, and recent coronial findings and recommendations in Australia, both indicate an unmet need in this area. This is especially concerning when the increasing numbers of high-risk cases associated with changing population characteristics are considered. Evidence of high value care, using Porter’s definition of outcome and cost, is highly relevant to all aspects of healthcare, including the systems, structures and processes which combine to create a POSH. In this edition of BJA, a report by Swart and colleagues examines patient outcomes and heath care costs associated with triage by a preoperative clinic to either high acuity or ward-based postoperative care after bowel surgery, and provides important insights into what perioperative elements can be effective, and how these should be evaluated. It is acknowledged that there are limitations in these data, as this was a single-centre observational study from one time period, in one field of surgery, and with triage in part dependent on availability of high acuity beds. However, the findings that intermediate-risk patients sent to high acuity beds had better outcomes at a lesser overall nominal cost than those initially sent to the ward, provide important lessons for future work in this area. The elements in a system for preoperative assessment and management come in many forms, ranging from highly structured multidisciplinary clinics to assessment at the door of the operating theatre. From this manuscript by Swart and colleagues we do know that consultant anaesthetists were involved in risk assessment, and that detailed data was required for risk calculations. Separate to specific interventions, such as correction of anaemia or cessation of smoking, a major challenge into the future is to identify what structural and process elements of the system provide value. For example, a recent large retrospective analysis of patients who had attended a structured anaesthesialed preoperative clinic, staffed by both anaesthetists and nursing staff, found lower overall mortality than when preoperative workup was managed by surgery. The authors specifically comment that it is unknown what elements of the clinic contributed to the observed association, although patient engagement and team communication are two suggestions. Detailed analysis is possible when determining the value of preoperative assessment and clinics. There are published data associating preoperative clinics with efficiency outcomes such as cancellations. 9 Further, there are studies revealing potentially value-adding (or valueremoving) preoperative practice changes, such as task delegation, computer-assisted pre-screening, structured questionnaires, or video conferenced assessment with and without remote physical examination, although these are often small or qualitative studies in single sites. Larger scale studies of these types of processes and pathways seems a logical direction in order to identify those with genuine high value. Inclusion of a risk prediction tool was an important part of the triage decisions in Swart and colleagues. Whilst its effectiveness in other healthcare jurisdictions is unknown, at a minimum its components provide insight into what data are relevant, at least for prediction of 30-day mortality. Many other perioperative risk identification tools exist, although some were not originally intended for prospective clinical decision-making, and they vary greatly in their evidence base, predictors, weightings, sophistication and performance. The sensitivity and specificity of these tools (often measured using ROC curves) are low compared with diagnostic tools in medicine, nevertheless they appear to have a place in the context of an appropriately structured and staffed preoperative setting. These tools often focus on readily collected endpoints such as 30-day mortality and, in this study by Swart and colleagues, this was adequate to predict those who would benefit from early high acuity care. It is plausible, but not proved, that preoperative prediction of shorter-term endpoints, such as postoperative complications, 19 may provide additional information to better guide decisions, such as early referral to high acuity postoperative units. Also relevant to the value proposition are the resource requirements of such tools, which may necessitate objective data from specialised testing, such as CPEX, or experienced specialist opinion. Considering the potential benefit from these types of tools, and the increasing data on co-morbidities and postoperative events available from international multi-centre clinical trials and outcomes registers, there is an opportunity to systematically expand the evidence base for risk predictions tools, and to prospectively examine their value as part of perioperative systems. The capacity provided in standard postoperative wards, and high dependency or intensive care units, is also relevant to Editorials | 3