Authors: Bernstein WK et al.
Anesthesia & Analgesia, 142(1):76–84, January 2026
This article is a roadmap for how anesthesiologists can drive higher-value perioperative care by moving “upstream” into preoperative optimization, especially in regions where resources and access vary (rural/urban underserved as well as higher-resource settings). The authors argue perioperative costs are rising unsustainably, and that preventing complications through targeted preoptimization is one of the highest-yield levers to improve outcomes while controlling spending. They frame anesthesiologists—given the workforce shortage in primary care, growth of PSH/ERAS models, and COVID-era lessons about systems-based care—as well positioned to lead this work through structured clinics, telemedicine, prehabilitation, and technology-enabled monitoring.
The paper reviews several common conditions that strongly influence perioperative risk and that are realistically “movable” before surgery: obstructive sleep apnea, hypertension, anemia, food insecurity/nutrition, diabetes, and cognition/brain health. A recurring theme is that the day of surgery is too late for meaningful optimization; the value comes from earlier identification, triage, and intervention. The authors also highlight operational and policy opportunities—especially for administrators and policymakers—to make this scalable (screening pathways, community programs, affordable devices, and digital tools).
Condition-specific highlights emphasized in the review
Obstructive sleep apnea (OSA)
They stress the large burden of undiagnosed OSA and its perioperative implications (airway risk, sensitivity to sedatives/opioids, postoperative complications). The innovation angle focuses on shifting diagnosis and management out of the sleep lab and closer to patients: home sleep apnea testing, wearables, AI-enabled diagnostics, telemedicine, and more accessible CPAP options. They also discuss emerging devices (e.g., noninvasive stimulation and implanted upper-airway stimulation) as examples of expanding treatment options, while acknowledging real-world access barriers.
Hypertension
They position hypertension as both common and undertreated, with major downstream perioperative cardiovascular risk. Innovations include Bluetooth/cuffless monitoring, AI-assisted therapy adjustment, and mobile health platforms for education and adherence. In low-resource settings, they emphasize scalable public health strategies (salt reduction/substitution), fixed-dose combination therapy to simplify treatment, and community-based frameworks (e.g., WHO-aligned initiatives) to improve control.
Anemia
They describe preoperative anemia as highly prevalent and strongly associated with transfusion and postoperative complications. The key “value” move is routine screening plus early treatment (iron supplementation, targeted therapies) rather than relying on intraoperative restrictive transfusion thresholds. They describe higher-resource precision approaches (better diagnostics and individualized therapy) and lower-resource approaches that lean on point-of-care hemoglobin testing, oral iron, and telehealth-supported outreach. They also note emerging smartphone-based hemoglobin screening as a potential scalable tool.
Food insecurity and nutrition
They connect malnutrition and food insecurity to frailty, wound healing, immune function, altered drug handling (e.g., hypoalbuminemia), and longer LOS. They advocate systematic preop nutrition screening (including tools like PONS and basic biomarkers) and targeted interventions such as immunonutrition and carbohydrate loading as part of ERAS-style optimization. They emphasize that addressing food insecurity can be a practical “value lever,” especially when it reduces complications and length of stay, and they highlight apps, telenutrition, and community programs as access multipliers.
Diabetes
They underscore the link between poor glycemic control and infections, MI, mortality, wound issues, and metabolic complications. They emphasize practical preop identification (HbA1c and glucose screening) and tech-enabled management: CGM, closed-loop insulin delivery, and mobile tools for monitoring and adherence. For low-resource settings, they focus on affordable meters, education, and community health worker support with simple, standardized protocols.
Cognition and brain health
They highlight the growing volume of surgery in older adults and the ongoing burden of POD/POCD. They support structured geriatric assessment and pragmatic cognitive “prehabilitation” (including low-tech paper-based options where needed), and discuss digital cognitive training as a promising approach (with the caveat that optimal dosing/timing still needs study). They also emphasize that social context matters (e.g., social vulnerability) and that intraoperative management may be tailored by recognizing baseline risk and using monitoring tools (processed EEG) to avoid excess anesthetic exposure.
Implementation reality check
They openly acknowledge the tension: expanding preop optimization increases demand on an already stretched anesthesia workforce. The paper frames this as a systems design problem—triage and targeting are essential. Not every patient needs everything; the goal is to build scalable pathways that identify high-risk patients early and match them to the highest-yield interventions.
Key Points
• Highest-value perioperative improvements often come from earlier preop optimization, not intraoperative tweaks on the day of surgery.
• Anesthesiologists can lead scalable preoptimization through clinics, prehabilitation, telemedicine, and technology-enabled monitoring—especially where primary care access is limited.
• High-impact targets include OSA, hypertension, anemia, nutrition/food insecurity, diabetes, and cognition/brain health because they meaningfully affect complications, LOS, and cost.
• “Administrator/policy” levers (screening programs, access to affordable devices/meds, community nutrition supports, digital infrastructure) are critical for scale in resource-diverse regions.
• Workforce constraints mean optimization must be selective, protocolized, and risk-stratified rather than “one-size-fits-all.”
Thank you to Anesthesia & Analgesia for allowing us to summarize and share insights from this article.