Enhanced Recovery After Surgery in the Setting of the Perioperative Surgical Home

Pro-Con Debate: Anesthesiologist- Versus Hospitalist- Run Preoperative Clinics and Perioperative Care

In this Pro-Con commentary article, we discuss the models, value propositions, and opportunities of preoperative clinics run by anesthesiologists versus hospitalists and their role in perioperative care. The medical and anesthesia evaluation before surgery has pivoted from the model of "clearance" to the model of risk assessment, preparation, and optimization of medical and psychosocial risk factors. Assessment of these risk factors, optimization, and care coordination in the preoperative period has expanded the roles of anesthesiologists and hospitalists as members of the perioperative care team. There is ongoing debate regarding which model of preoperative assessment provides the most optimal preparation for the patient undergoing surgery. This article hopes to shed light on this debate with the data and perspectives on these care models.

The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis.