Preoperative Management of the Adult Oncology Patient.

Anesthesiologists are experiencing first-hand the aging population, given older patients more frequently presenting for surgery, often with geriatric syndromes influencing their anesthetic management. The overall incidence and health burden of cancer morbidity and mortality are also rapidly increasing worldwide. This growth in the cancer population, along with the associated risk factors and comorbidities often accompanying a cancer diagnosis, underscores the need for anesthesiologists to become well versed in the preoperative evaluation and management of the adult patient with cancer. This article will focus on the unique challenges and opportunities for the anesthesiologist caring for the adult oncology patient presenting for surgery.

Social Determinants of Health and Preoperative Care.

Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are important, particularly for patients with complex medical histories and those requiring major surgery. Preoperative care improves planning and determines the clinical pathway and discharge disposition. The role of nonmedical social factors in the preoperative planning is not well described in anesthesiology. Research to improve outcomes based on social factors is not well described for anesthesiologists but could be instrumental in decreasing disparities and advancing health equity in surgical patients.

Assuring the Groundwork for Success: Mentorship, Sponsorship, and Allyship for Practicing Anesthesiologists.

The challenges facing the health care industry in the post-coronavirus disease 2019 (COVID-19) pandemic world are numerous, jeopardizing wellness, and performance. Maintaining engagement and fulfillment of anesthesiologists in their work is now a critical issue in various practice settings: academic, private practice, and corporate medicine. In this article, we offer insights on how mentorship, sponsorship, and allyship are important in the advancement of the anesthesiology workforce including women and underrepresented minorities inclusive of race, gender, and disability. Mentorship, sponsorship, and allyship require a framework that intentionally addresses the programmatic structures needed to optimize the environment for increasing women, underrepresented minorities, and other diverse groups. These 3 distinct yet interrelated concepts are defined with a discussion on the value of implementation. In addition, the concept of "belonging" and its importance in enhancing the culture in anesthesiology is explored. We believe that part of the solution to wellness, recruitment and retention and improved job satisfaction of clinicians is having an environment where mentorship, sponsorship, and allyship are foundational.

Sociodemographic Disparities in Postoperative Nausea and Vomiting.

BACKGROUND: Postoperative nausea and vomiting (PONV) prophylaxis is consistently considered a key indicator of anesthesia care quality. PONV may disproportionately impact disadvantaged patients. The primary objectives of this study were to examine the associations between sociodemographic factors and the incidence of PONV and clinician adherence to a PONV prophylaxis protocol. METHODS: We conducted a retrospective analysis of all patients eligible for an institution-specific PONV prophylaxis protocol (2015-2017). Sociodemographic and PONV risk data were collected. Primary outcomes were PONV incidence and clinician adherence to PONV prophylaxis protocol. We used descriptive statistics to compare sociodemographics, procedural characteristics, and protocol adherence for patients with and without PONV. Multivariable logistic regression analysis followed by Tukey-Kramer correction for multiple comparisons was used to test for associations between patient sociodemographics, procedural characteristics, PONV risk, and (1) PONV incidence and (2) adherence to PONV prophylaxis protocol. RESULTS: Within the 8384 patient sample, Black patients had a 17% lower risk of PONV than White patients (adjusted odds ratio [aOR], 0.83; 95% confidence interval [CI], 0.73-0.95; P = .006). When there was adherence to the PONV prophylaxis protocol, Black patients were less likely to experience PONV compared to White patients (aOR, 0.81; 95% CI, 0.70-0.93; P = .003). When there was adherence to the protocol, patients with Medicaid were less likely to experience PONV compared to privately insured patients (aOR, 0.72; 95% CI, 0.64-1.04; P = .017). When the protocol was followed for high-risk patients, Hispanic patients were more likely to experience PONV than White patients (aOR, 2.96; 95% CI, 1.18-7.42; adjusted P = .022). Compared to White patients, protocol adherence was lower for Black patients with moderate (aOR, 0.76; 95% CI, 0.64-0.91; P = .003) and high risk (aOR, 0.57; 95% CI, 0.42-0.78; P = .0004). CONCLUSIONS: Racial and sociodemographic disparities exist in the incidence of PONV and clinician adherence to a PONV prophylaxis protocol. Awareness of such disparities in PONV prophylaxis could improve the quality of perioperative care.

Recognizing and Maximizing the Nexus of Perioperative Medicine and Narrative Medicine.

Perioperative medicine remains an evolving, interdisciplinary subspecialty, which encompasses the unique perspectives and incorporates the respective vital expertise of numerous stakeholders. This integrated model of perioperative medicine and care has a wide-ranging set of clinical, strategic, and operational goals. Among these various programmatic goals, a subset of 4, specific, interdependent goals include (1) enhancing patient-centered care, (2) embracing shared decision-making, (3) optimizing health literacy, and (4) avoiding futile surgery. Achieving and sustaining this subset of 4 goals requires continued innovative approaches to perioperative care. The burgeoning field of narrative medicine represents 1 such innovative approach to perioperative care. Narrative medicine is considered the most prominent recent development in the medical humanities. Its central tenet is that attention to narrative-in the form of the patient's story, the clinician's story, or a story constructed together by the patient and clinician-is essential for optimal patient care. If we can view the health care experience through the patient's eyes, we will become more responsive to patients' needs and, thereby, better clinicians. There is a potential clinical nexus between the perioperative medicine practice and narrative medicine skills, which, if capitalized, can maximize perioperative patient care. There are a number of untapped educational and research opportunities in this fruitful nexus between perioperative medicine and narrative medicine.

Utility of the LET-IN-OUT Clinical Decision Support Tool for Medical Risk Stratification Prior to Outpatient Total Hip or Knee Arthroplasty.

BACKGROUND: Musculoskeletal care teams can benefit from simple, standardized, and reliable preoperative tools for assessing discharge disposition after total joint arthroplasty. Our objective was to compare the predictive strength of the Ascension Seton Lower Extremity Inpatient-Outpatient (LET-IN-OUT) tool versus the American Society of Anesthesiologists Physical Status (ASA-PS) score for predicting early postoperative discharge. METHODS: We retrospectively extracted sociodemographic, surgical admission, postoperative day (POD) of discharge, 90-day readmissions, and predictions of the LET-IN-OUT and ASA-PS tools from the electronic records of 563 consecutive hip or knee arthroplasty patients (mean age 65 [SD 9.6], 54% women). Included patients who underwent a total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a single health system between June 2020 and March 2021. We performed descriptive statistics and analyzed predictive values of each tool, defining "early discharge" primarily as discharge before the second postoperative day (POD 2), and secondarily as before 24 hours, and on the same calendar day (POD 0) as surgery. RESULTS: The LET-IN-OUT tool demonstrated superior predictive power among hip and knee arthroplasty patients compared to the ASA-PS tool for discharge prior to POD 2 (positive predictive value [PPV] 89 versus 83%, positive likelihood ratio [+LR] 2.0 versus 1.2), discharge before 24 hours (PPV 86 versus 70%, +LR 2.9 versus 1.2), and discharge on POD 0 (PPV 34% versus 30%, +LR 1.2 versus 1.1). CONCLUSIONS: The Ascension Seton Lower Extremity Inpatient-Outpatient tool predicted patients suitable for early discharge following THA or TKA and did so more effectively than the ASA-PS score.

Managing a perioperative medicine program.

Perioperative medicine is now a well-recognized albeit still evolving, interdisciplinary subspecialty, which encompasses a wide array of equally invested stakeholders and equally important contributors. The practice of perioperative medicine is fundamentally and optimally a collaborative effort, which aims to provide a comprehensive framework encompassing all aspects of the patient's surgical journey. Moving from a conceptual model of perioperative medicine to an operational perioperative medicine program and clinic requires a methodical management approach. This comprehensive management approach considers a variety of factors, such as defining the mission of a perioperative medicine program, expanding the role of the anesthesiologist and internal medicine hospitalist, recognizing the role of the advanced practice provider, stratifying perioperative management of surgical patients, developing and implementing a program, undertaking a clinical proof-of-concept pilot of a program, scaling up and building out a program, maximizing the electronic health record, leveraging telemedicine and virtual health, and providing adjunctive services.

Narrative Medicine: Perioperative Opportunities and Applicable Health Services Research Methods.

Narrative medicine is a humanities-based discipline that posits that attention to the patient narrative and the collaborative formation of a narrative between the patient and provider is essential for the provision of health care. In this Special Article, we review the basic theoretical constructs of the narrative medicine discipline and apply them to the perioperative setting. We frame our discussion around the 4 primary goals of the current iteration of the perioperative surgical home: enhancing patient-centered care, embracing shared decision making, optimizing health literacy, and avoiding futile surgery. We then examine the importance of incorporating narrative medicine into medical education and residency training and evaluate the literature on such narrative medicine didactics. Finally, we discuss applying health services research, specifically qualitative and mixed methods, in the rigorous evaluation of the efficacy and impact of narrative medicine clinical programs and medical education curricula.

Achieving Greater Health Equity: An Opportunity for Anesthesiology.

Anesthesiology and anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and to achieve health equity. We thus examine health disparity and health equity through the lens of anesthesiology and the perspective of anesthesiologists. In this paper, we define health disparity and health care disparities and provide tangible, representative examples of the latter in the practice of anesthesiology. We define health equity, primarily as the desired antithesis of health disparity. Finally, we propose a framework for anesthesiologists, working toward mitigating health disparity and health care disparities, advancing health equity, and documenting improvements in health care access and health outcomes. This multilevel and interdependent framework includes the perspectives of the patient, clinician, group or department, health care system, and professional societies, including medical journals. We specifically focus on the interrelated roles of social identity and social determinants of health in health outcomes. We explore the foundational role that clinical informatics and valid data collection on race and ethnicity have in achieving health equity. Our ability to ensure patient safety by considering these additional patient-specific factors that affect clinical outcomes throughout the perioperative period could substantially reduce health disparities. Finally, we explore the role of medical journals and their editorial boards in ameliorating health disparities and advancing health equity.