The Future of Anesthesia Care

From the 62nd Postgraduate Assembly in Anesthesiology, sponsored by the New York State Society of Anesthesiologists, December 12-16, 2008, New York, NY

Educational Objectives

The goal of this program is to update clinicians on future changes and advancements in the clinical practice of anes­thesiology. After hearing and assimilating this program, the clinician will be better able to:

Provide a view into the future of anesthesiology.

Discuss how the coming changes will impact the safety of anesthesia care.

Review the current status of health care in the United States.

Address the issue of physician shortages vs right-sizing.

Assess the changing practice of health care delivery.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning commit­tee members to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning commit­tee reported nothing to disclose.

Acknowledgments

Drs. Warner and Lema spoke in New York, NY, at the 62nd Annual Postgraduate Assembly in Anesthesiology, held December 12-16, 2008, and sponsored by the New York State Society of Anesthesiologists, Inc. The Audio-Digest Foundation thanks the speakers and the NYSSA for their cooperation in the production of this program.

Ten Years Hence: Whom Will We be Anesthetizing and for What Procedures?

Mark A. Warner, MD, Dean, Mayo School of Graduate Medical Education; Professor, Department of Anesthe­siology, and Chair, Anesthesiology Residency Review Committee, Mayo Clinic College of Medicine, Rochester, MN

Changing demographics: immigration having growing impact on population in United States; 35% of all students in eighth grade and below are first-generation Americans; also impending surge in “baby boomers”

First-generation Americans: increased need for high-risk obstetric services; studies indicate anesthesia provider makes greatest difference in pediatrics; outcomes different when providers subspecialty-trained or have experi­ence providing care for children <2 yr of age; facilities also must be uniquely qualified to provide care (eg, neo­natologists, pediatric intensivists); consolidation of pediatric surgical care will result

Baby boomers: population ³65 yr of age growing; currently, »40 million people; expected to be 85 to 90 million by 2040; in 2008, »40 million surgeries yearly in United States; may be as many as 100 million in 32 yr; will not be enough providers to administer care; key changes expected to modify numbers  —  1) minimally-invasive proce­dures may not require anesthesia-trained providers; 2) patient-targeted therapies may eliminate diseases and pro­cesses that (today) require surgical procedures; 3) safer anesthetics may be administered; regardless of accuracy of projections, dramatic increase in surgery and anesthesia expected over next »30 yr

Human genome: preoperative genetic testing and diagnosis will lead to predictions of drug kinetics (already begin­ning to occur in United States), drug efficacy, and perioperative complications; CYP2D6 enzyme  —  involved in me­tabolism of codeine; some patients do not have CYP2D6 and are poor metabolizers of codeine (do not readily convert codeine to morphine); other patients have several CYP2D6 alleles that cause them to rapidly convert co­deine to morphine, resulting in unexpectedly large amount of narcotic build-up and respiratory depression; several reports of patients who developed respiratory arrest postoperatively after receiving ordinary doses of codeine; in­travenous (IV) ondansetron  —  in poor metabolizers, antiemetic effect increased; in rapid metabolizers, antiemetic effect decreased; additional comments  —  results of human genome testing will lead to patient-tailored interven­tions; anesthesia provider should be leader

New technologies: will lead to reductions in procedures requiring anesthesia services, reductions in patient trauma, and reductions in perioperative complications; nanotechnologies increasingly in use today; image-guided appli­cations of external power will dramatically affect care of patients and drive surgical procedures; improved radia­tion technologies and therapies, and minimally and noninvasive procedures on the horizon

Nanotechnologies: delivery system with immunologically inert carbon outer shell; internal capacity to carry drugs, and heat and cold; outer shell can be signaled to break apart and disperse contents at given time; signals include marker recognitions (eg, tumor-specific markers), ultrasonography (US), heat, and cold; fabric  —  nanocrystals woven into fabric change form rapidly and repeatedly; military has designed undergarments with this fabric; ma­terial impenetrable by bullet; hemostatic liquids  —  artificial blood may not ever be effective because of toxicity of hemoglobin; possible to manufacture protective barriers and polypeptides; polymer capsules skim along blood surface, leak into damaged capillary sites, and aggregate; subsequently form matrix and function as platelets; biodegradable within minutes, leaving matrix for tissue regeneration (similar to using potato starch); heat  —  capsules retain heat without being hot to touch; also release heat and cold when prompted; drug transportation  — drug  released in response to specific biochemical signals

Image-guided applications of external power: magnetic resonance imaging (MRI) of several tumor types suscepti­ble to US-generated heat; uterine fibroids most commonly tested in clinical trials (also certain types of breast tu­mors and osteosarcomas); good initial success; requires only modest sedation and analgesia; scars fibroid internally; abdominal or vaginal hysterectomy no longer required; patients spend 2 hr in MRI scanner, given mid­azolam (Versed) and fentanyl, and then discharged home

Improved radiation therapies: proton particle radiation new technology to treat cancer postoperatively; problems with radiation therapy include scattered energy causing collateral damage; large-particle radiation more precise and results in less scatter beyond tumor; remarkable accuracy to reach borders without causing damage; proton therapy reduces acoustic nerve damage after meduloblastoma treatment in children (survival rate dramatic; only 2 treatments required [vs 35 treatments])

Minimally-invasive or noninvasive procedures: eg, aneurysm coiling, vascular stent placement, cryotherapy, nano­crystal repair or reduction of potential surgical tissues (eg, sclerosis of appendices), and transgastric procedures as replacement for intrapelvic and intra-abdominal procedures (eg, micro-robots introduced via gastroscope for appendectomy)

Expect Change: The Evolving Practice of Perioperative Medicine

Mark J. Lema, MD, PhD, Professor and Chair, Department of Anesthesiology, State University of New York at Buffalo, School of Medicine and Biomedical Sciences; Chair, Department of Anesthesiology, Critical Care and Pain Medicine, Roswell Park Cancer Institute; Past President, American Society of Anesthesiologists

Current status of health care: monograph from Institute of Medicine in 2001 outlined ideas for setting course for new health care system; went largely unrealized; no support for moving in single direction; recent article by Goodman and Fisher stated that underlying disease of current system that it is largely disorganized and frag­mented; characterized by lack of coordination, poor communication, uneven quality, and rising costs; health care delivery in United States actually series of regionally influenced sectors, not system; based on Centers for Medi­care and Medicaid Management (CMS) business model favoring payment; payment correlates with procedures, not contact time; compels physicians to emphasize expensive procedures over office visits to remain viable in current practice; 2004 study (and subsequent studies) by Commonwealth Fund found United States suboptimal for routine health care, when compared to other English-speaking nations

Drivers of health care change in United States: 1) medical technology and innovations; 2) changes in elder care and how innovations impact medical delivery; 3) access to care; 4) intense market competition; currently, no institu­tion taking responsibility for long-term control of health care reform; however, changes likely under current ad­ministration (ie, President Obama); Medicare payment system affecting physicians most; health care expenditures for baby boomers responsible for most significant increase in cost

Issues currently affecting health care reform: health care expenditures account for 16% of gross domestic product (GDP; twice what rest of industrialized world pays); currently, patients receive only 55% of recommended health care, as compared with rest of world; despite these numbers, average health insurance policy »$10  500 per family in United States; currently, $130 billion spent on last 2 yr of life in United States; issue must be addressed in terms of cost-benefit ratio; high cost of drugs in United States subsidizes low cost in foreign countries; United States Congress feels subsidy inequitable and wants change

Physician shortages or rightsizing? media report that in 2020, United States will have shortage of 85  000 to 200  000 physicians; Accreditation Council on Graduate Medical Education (ACGME) requested 30% increase in medical school enrollment by 2015 and lifting of capacity limitations on resident positions; medical school enrollment starting to increase; by 2015, 6 new medical schools in United States and »20 000 students expected to matricu­late

Reasons for physician shortages in United States: aging of population; static medical school enrollment (from 1980 to present, per capita medical student ratio dropped from 7.5 to 5.5 students per 100  000; increase over next 10 yr should improve ratio to »6.6 students per 100  000); physicians aging with patients and near retirement (in 1975, 51  000 physicians in United States >65 yr of age; in 2006, 177  000 physicians >65 yr of age); lifestyle issues of next generation of physicians (seek balance between work [pressure and long hours] and reasonable recreational lifestyle; expected to result in 15%-25% reduction in productivity; shorter work hours for residents places greater demands on attending physicians, nurse practitioners, and physician assistants; ACGME favors giving residents 5 full days off each month and limiting shifts to 16 hr, with 5 hr of sleep afterward); from 1990 through 2006, 54% decrease in number of primary care physicians; causes include static salaries, higher debt, too much paperwork, and longer working hours; average debt of medical school graduate, $150  000 (for public school) or $200  000 (private school); in 2006, repayment burden for $130  000 loan »$2000/month for 10 yr

Goodman and Fisher: more cost-efficient for primary care physician to see established patient than new patient; better to narrow scope of practice and refer often to specialists or send patient to hospital (however, increases cost of care); investigators suggest not removing ACGME cap but, rather, using funding to create programs that im­prove and coordinate care and improve chronic care management

Access problems: rural and inter-city residents must travel great distances or forego necessary care; in 2006, 75% of emergency departments had inadequate on-call specialist coverage (up from 67%)

Changing practice of health care delivery: telemedicine  —video conferencing, e-mail, and home monitoring will reduce need for elderly to travel great distances and will provide greater connectivity; digitizing of health care and universal access to patient health records will make routine care borderless; emergencies will be safer because phy­sicians in remote areas can access patient records online; medical tourism  —  in 2006, 500  000 Americans treated abroad; locations include India, Singapore, Hungary, Dubai, South Africa, Brazil, and Cuba; in-store clinics  —  delivery of basic medical care; staffed by nurse practitioners; designed to be physician-independent; not intended to provide all primary care services; key to success to deliver high-quality standardized intervention and protocol-driven care; competes with routine care that allows physicians to remain viable business; home-centered care  —proactive prevention model; designed to provide educational empowerment for entire family; involves behavior modification to improve wellness; telemonitoring (eg, General Electric [GE] Home Assurance) involves sensor technology that enables caregivers to monitor and assess patient’s condition from remote sites; allows data to be sent to family members and trained practitioners, enabling them to intervene quickly; surgical trends  —  minimally invasive surgery has blurred lines between invasive radiology and surgery; trends include robotic and telesurgery, transgastric surgery, and gamma knife surgery; likely to see advances in proteonomics, genetics, and molecular medicine; shifts traditional surgical care to internal medicine and radiology; advances in cancer genetics and target-specific cardiac therapy will reduce major cancer surgeries and heart surgeries; future of surgery shaped by efforts to curb health care costs

Anticipated changes in anesthesiology

Competing forces: practice may be challenged by lesser-trained personnel, who dominate routine health care deliv­ery to reduce cost; hospital will become intensive care unit (ICU) facility, where lines between surgical care and medical care blurred; many specialties competing for same types of care; goal of reducing payment for expensive surgical and hospital-based services will challenge ability of physicians to provide solo care without engaging in hospital employment or subsidies; complementary and alternative medicine has potential of removing patients from surgical options and challenging provision of care

Cost constraints: decreasing payments and vanishing stipends likely; expanding entitlement programs; less margin (costs increase but payments do not rise proportionally)

Technologic advances: complex medical interactions; disruptive technologies and practices may challenge anesthe­sia provider; expansion of minimal surgical procedures could further reduce need for anesthesiology specialists; techniques have become easier, and perception exists that “anyone can do it, or lesser-trained people can do it”

Changes in anesthesia workforce: anesthesiology shortages affect provision of care; expansion of anesthesia ser­vices into off-site and unusual anesthetizing locations creates greater demand (or reduced efficiency) in many hospital settings; pain medicine subspecialty prevents most pain-trained physicians from providing operating room (OR) coverage, further depleting supply for surgical anesthesiology; increase in preoperative testing cen­ters has similar effects; early retirement also likely to limit workforce; quality-of-life pursuits reduce clinical pro­ductivity

Opportunities: new clinical paradigms in perioperative medicine in which management and coordination of all per­sonnel, supplies, and technology resources would be needed through postoperative period; anesthesia provider most suited to coordinate medical and acute pain care for surgeons, from admission to discharge; requires new evaluation and management codes to compensate for care given outside OR

Short-term and long-term changes: probable short-term changes  —  reduction in hospital subsidies to anesthesia groups; cessation or restriction on payment for endoscopy procedures and cataract surgery; probable long-term changes — expansion of entitlement programs; limit on Medicare spending; limits by private payors; expansion of services outside OR; medical care of surgical patients; preservation of postoperative cognitive functioning; re­turn to medical, surgical, and pediatric ICU and chronic pain service; end-of-life and hospice care; negotiation with hospital executives will help anesthesia departments oversee OR management, procedural sedation, or peri­operative services

Suggested Reading

Bacon DR, Lema MJ: Anaesthetic team and the role of nurses  —  North American perspective. Best Pract Res Clin Anesthesiol 16:401, 2002; Gasche Y et al: Codeine intoxication associated with ultrarapid CYP2D6 metabolism. N Engl J Med 351:2827, 2004; Erratum in: N Engl J Med 352:638, 2005; Goodman DC, Fisher ES: Physician work­force crisis? Wrong diagnosis, wrong prescription. N Engl J Med 358:1658, 2008; Kaiser R et al: Patient-tailored an­tiemetic treatment with 5-hydroxytryptamine type 3 receptor antagonists according to cytochrome P-450 2D6 genotypes. J Clin Oncol 20:2805, 2002; Macario A et al: The demographics of inpatient pediatric anesthesia: impli­cations for credentialing policy. J Clin Anesth 7:507, 1995; Sofowora GG et al: A common b₁-adrenergic receptor polymorphism (Arg389Gly) affects blood pressure response to beta-blockade. Clin Pharmacol Ther 73:366, 2003; Takahashi H et al: Pharmacogenetics of warfarin elimination and its clinical implications. Clin Pharmacokinet 40:587, 2001.