Anesthesiology, and indeed all of US health care, is influenced currently by four dominant trends. First, the passage of the Patient Protection and Affordable Care Act (PPACA) of 2010 demonstrated an enhanced national commitment to access to health care. Second, it underscored that such care must be affordable, that is, more efficient and cost effective. These two principles are now well established and will likely persist, although structural details may vary depending on national policy and political preference. Third, the emphasis on quality and safety in health care has gained even greater momentum. Fourth, the national burden of illness is magnified by a US population that is aging rapidly, resulting in over 10,000 new Medicare enrollees daily. Collectively, these trends have led to the development of alternative payment models that reward value, not volume of services, and that further emphasize the role of patient choice in the care process. We believe these trends will be dominant themes for many years to come, and they are guiding principles in the current edition of this text.
Fortunately, the specialty of anesthesiology is well positioned to lead these initiatives. Anesthesiology is already recognized as the pioneering leader in patient safety, and we see no reason why anesthesiologists and anesthesia teams should not be leaders in efficiency, value, and patient choice in health care as well. Indeed, we believe that continuing to position our specialty at the forefront of these initiatives is a key strategy for both the current and future success of anesthesiology and its practitioners.
In 2000, the Institute of Medicine (IOM; renamed the National Academy of Medicine in 2015) published its landmark analysis of American health care, “To Err Is Human,” a treatise that emphasized the fallibility of even highly motivated humans and that systems of safe care must be constructed to protect patients from potential harm. That report specifically cited anesthesiology as a leader in the patient safety movement and urged other disciplines to follow, which many have done subsequently. Another IOM publication, “Crossing the Quality Chasm; A New Health System for the 21st Century” (2001), described the attributes of a model health care system that is safe, timely, efficient, effective, patient centered, and equitable to all.
The PPACA legislation underscored these principles, and subsequent regulations translated them into operational policies and practices. We agree with these principles and have worked diligently to adopt them in our own practices and departments, for they are guideposts to the professional and ethical practice of health care and anesthesiology. Further, we have designed this text around the concepts of safe, effective, efficient, and patient-centered care, and we urge all clinicians to approach their practice with a similar commitment to these principles.
Our goal is to provide the practitioner with a single resource that captures the essence of the full spectrum of anesthesia practice. There are multiple sources of information about anesthesiology, but many ignore the full breadth of the practice. Further, there are numerous focused texts that delve into specific subdisciplines in great detail, often more detail than the trainee or practitioner desires or needs.
In this text, we focus on what is truly important for the clinical practice of anesthesiology in all its dimensions, while being efficient in the presentation of this essential material. Throughout, we have asked: What is important? Why is it important? When should it be applied? and How should it be applied? In brief, we have written for practitioners, not physician scientists. That said, this is not a user's manual of anesthesia care, but rather a text that constantly builds on the concepts of safe, effective (i.e., evidence-based), efficient, and patient-centered care, distilled in a manner that facilitates easy access to the key scientific concepts that underpin high-quality practice. Thus, one finds Key Points and Key References in each chapter, while an extensive reference list is provided online for those who seek in-depth research-based documentation.
Throughout, we embrace an encompassing view of modern anesthesiology practice, underscoring the role of the anesthesiologist as perioperative physician. We emphasize important trends, both in the specialty and in health care in general, to ensure that the reader is not required to go elsewhere for additional information to support the mainstream of their practice. These trends include team-based anesthesia care, the remarkable explosion in pain medicine practice, and the expanded need for practitioners who are skilled in the practice of critical care medicine. No careful observer of the specialty could miss these trends, and no text could be considered “comprehensive” if it did not embrace them as full components of the modern practice of anesthesiology.
Further, we have woven the concepts of quality, safety, cost-effectiveness, and value into the text by emphasizing that perioperative anesthesia care is one system of care within a larger system of care that focuses on overall patient outcomes, not independent events by individual practitioners working in isolated clinical disciplines.
We have approached these and other key “drivers” of contemporary and future anesthesia practice with care, commitment, and enthusiasm for the future of the specialty. We trust that you share this enthusiasm and hope our efforts will serve you well as you continue to translate your knowledge and skills into safe, effective, efficient, and patient-centered care; our patients want nothing less, and our surgical and medical colleagues are looking to anesthesiology to continue to set the example for implementation of these principles. We are honored to serve you through our efforts here.
David E. Longnecker, MD
Sean C. Mackey, MD, PhD
Mark F. Newman, MD
Warren S. Sandberg, MD, PhD
Warren M. Zapol, MD