The Perioperative Surgical Home: Cui Bono?

In recentyears,attentionhasbeendirected to theconcept of the Perioperative Surgical Home (PSH). The origin of this concept can be attributed to the introductionof ambulatory surgery and the riseofpreadmission testing centers, which led to improvements in the preoperative recognition and management of risk factors and a reduction in the use of preoperative screening services and tests that provided no clear benefits.1 Beginning in the 1990s, a number of institutions began to formally address the problem of a perioperative system of anesthetic management for nonurgent procedures,viewing it throughtheDonabedian lensofquality2 that focuses attention on structure, process, andmeasurement of outcomes. Most recently, it has been recognized thatoutcomesofmajor electiveoperations can improve with the proactive, goal-directed, preoperative preparation of the patient coupledwith early planning for discharge and postprocedure rehabilitation.3,4 The PSH is a vehicle for integrating preoperative, intraoperative, and postoperative phases of care on the theory that thehighest valuewill beachieved for thepatient and the payer. But it seems fair to ask, who actually will benefit? As proposed by the American Society of Anesthesiologists,5 a PSH has 3 appealing qualities: first, it would share decisionmaking among specialties; second, it would include the patient as an equal stakeholder and be centered on optimizing the patient’s experience; third, it would be structured to foster ongoing communication and coordination of surgical and anesthesia care. Impediments to thesuccessful achievement of these goals include the realities of care for individual surgical patients and the surgical problems that they may encounter. Each patient may have individual requirements that influence the preoperative preparation for the general risks of the operation and anesthesia, and each type of surgical problemmay require specialized programs of preoperative preparation and postoperative rehabilitation. The evolving literature emphasizes the value that may be expected from a PSH and on which its sustainability should be judged. Relevant here is Porter’s general analysisofvalue inhealthcare.6His formulation that value is defined as outcomes relative to costs underscores the idea that valueandcostsought tobecoupled to the full cycle of care for the patient’s medical condition,not thecostsof individual services.Porter6hasalso noted the potential for conflicts in the perception of value by the different stakeholders, which can lead, he believes, to thewrong kinds of competition and to less value for intended beneficiaries. Several insights follow, the most important of which is that the proposed treatmentplanshouldhaveas its fundamentalgoals that health statuswill be restored as quickly as possible and sustained as long as possible. A second insight is that a profileofmetrics isneededto fullyunderstand thevalue of thecycleofcare topatientsandpayers, includingclinical outcomes, theefficiencyof resourceutilization, and the costs connected to each phase of care. One last insight is that optimizing value in the cycle of care requires that noonecomponentbeallowed todisproportionately influence the allocation of resources. Ideally, a PSH should oversee and integrate prehabilitation and rehabilitation programs with perioperative care. A PSH adds value by taking responsibility for the cycle of care that starts at the timewhen it is recognized that surgery may be indicated and is completed when the patient has recovered as well as can be expected. Meeting this responsibility requires that a PSH overseeand integrate the institutional resourcesandefforts of the health care groups involved in the cycle of surgical care. Moreover, a PSH should be able to adapt theallocationof thesystem’s resourcesspecifically toaddress the needs of the patient who is medically complex or has unusual requirements for anesthesia resources. Suchpatientsbenefitting fromaPSHstructure would include thosewithadvanceddiseaseand its complications and, perhaps, the patientwho requires semiurgent surgery and rapid mobilization of resources before reaching the inpatient setting. A critical consideration is that a PSH should add value to existing alternatives, and to do this, the PSH must be able to connect to larger programs throughout the health care system that exist to “restore and sustain” health generallyandnot justasameansto improvingoutcomesthat may be attached to specific operations. Porter6 provides a framework for comparing alternativemodelsofperioperative systemswithin the cycle of care for a patient with a surgical problem. The spectrum of alternatives includes the traditional, preadmission testing center of a general hospital, which focuses on optimizing the use of preoperative testing procedures for optimizing risk assessment and intervention, as well as efficient use of the operating room and its resources.3Anotheralternative is theconceptof theservice line, sometimes housed in a separate facility, using multidisciplinary expertise and requiring unique and shareable resources to address a recognizable grouping of clinical problems such as cancers, cardiovascular diseases, or neurologic disorders. A third set of alternatives include enhanced recovery pathways that focus closely alignedgroupsof surgical problems (ie, colorectal operations, joint replacements, or bariatric procedures).Enhancedpostoperativerecoverypathwayshave beenshowntoworkwell forelectiveprocedures inwhich the patients are likely to be similar in their requireVIEWPOINT