Increasing multimorbidity and the evolving peri-operative model of care

Abstract

I read with interest the recent study by the STARSurg and EuroSurg Collaboratives examining the association between multimorbidity and postoperative mortality in patients undergoing major surgery [1]. The evolution of peri-operative medicine to date has been varied and unstandardised. Surprisingly, while this analysis did not show a difference in mortality or complications among multimorbid patients who received pre-operative assessment and those who did not, there is a large body of evidence that supports the individual and systemic benefits of achieving best practice in peri-operative care [1, 2]. Hence, it raises the questions; what is the anaesthetist's role in the peri-operative pathway and what are the persistent challenges and positive enablers for the creation of a comprehensive, multidisciplinary and collaborative care model in response to the growing complexity and multimorbidity of surgical populations?

Providing high-quality care before, during and after surgery reduces complications, and improves outcomes, efficiency and patient experience [2]. Peri-operative care programmes have been well implemented in Australia and the USA, but in the UK and Ireland, there is a lack of consistency despite several initiatives to create a patient-centred, integrated programme including the Getting It Right First Time (GIRFT) initiative that started in 2012 [2, 3]. In this post-pandemic period where elective surgery waiting times are at a record high, establishing widespread, multidisciplinary peri-operative medical teams should be key in lowering morbidity and mortality, hospital stay duration and need for critical care after surgery.

The advancement of modern healthcare means that both patients and procedures are becoming increasingly complex, amplifying the benefit of a sustainable, cost-effective, peri-operative care pathway. Furthermore, with unprecedented demand for anaesthetic input in new environments outside of the traditional operating theatre setting, the expanding demand for anaesthesia emphasises the importance of workforce planning, training and clinical education. A survey on challenges to improving peri-operative care showed that 76% of anaesthetists felt they had no time to engage and 66% felt they were understaffed [4]. A recent Health Service Executive report said that, by March 2023, Ireland had much fewer consultant anaesthetists than other countries, at 10.4 per 100,000 people [5]. These figures highlight the current limitations and the urgency to address these obstacles and incorporate them into recruitment, workforce planning and training schemes.

Although it is clear there has been a positive change in the attitude towards peri-operative medicine in recent years, there is an abundance of work that still needs to be done to develop a model of care with increased multidisciplinary collaboration to provide exemplary patient care [4]. Anaesthesia trainees should learn more about the role of the peri-operative physician. Training bodies should endeavour to increase clinical exposure, integrate high-fidelity collaborative simulation scenarios as well as promote divergent training pathways to ameliorate this multidimensional role.

Advances in modern surgical techniques, coupled with a growing, ageing, multimorbid patient population, require a peri-operative care model that is multidisciplinary, evidence-based, cost-effective and focused on improving patient outcomes.