Society of Anesthesia and Sleep Medicine: Looking Back at a Decade, Looking Forward to the Next

Excluding the pandemic year, an estimated 50 million people undergo surgery every year in the United States, along with an additional 200 million others across the rest of the world.1 A significant proportion of these patients have undiagnosed or untreated sleep disorders (SD) and sleep-disordered breathing (SDB).2 While important in improving perioperative outcomes, identifying these conditions has wider value as they substantially contribute to increased health care utilization and comorbid burden. In the United States, associated costs are conservatively estimated to be over $140 billion annually, with direct health care costs far exceeded by the costs associated with sleepiness-related accidents, productivity losses, and medical comorbidities.3,4 As an intersectional state that disrupts the longitudinal course of chronic disease progression, the perioperative period offers opportunities for time-critical diagnosis and treatment of these disorders. Indeed, financial modeling suggests that treatment costs are around one-third of nontreatment costs, indicating significant long-term savings with improved diagnosis and treatment of these conditions. For example, in 2015, excessive sleepiness from obstructive sleep apnea (OSA) is estimated to have cost over $26 billion through road accidents in the United States. Importantly, improvement of sleepiness secondary to treatment of OSA is known to significantly reduce the risk of motor vehicle accidents.5,6 These are real problems that are ignored in the pursuit of the narrower perspective of greater perioperative efficiencies and throughput. Despite these facts, there is a notable paucity of incentives to improve perioperative capture (new diagnosis) and effective treatment of patients with undiagnosed SD or SDB. Indeed, most capitated reimbursement models may in effect, strongly discourage additional perioperative diagnostic or treatment costs being overlaid. Modern perioperative planning prioritizes surgical expediency higher than chronic disease management, even for elective procedures, where there is clear evidence of benefit for preoperative diagnosis of OSA.7–9 This situation magnifies inequities in the management of SD and SDB. There is a large body of evidence that speaks to the impact of social determinants of health and racial or gender-based barriers on both timely diagnosis and treatment of SDB, likely contributing to worse outcomes in these groups.10 If we in anesthesiology are indeed committed toward the fundamental tenets of perioperative medicine, the importance of using the perioperative period to diagnose and initiate long-term medical care of SD or SDB cannot be overstated. Patient Centricity The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary. —William Mayo The mission of the Society of Anesthesia and Sleep Medicine (SASM) is to advance standards of care for clinical problems shared by anesthesiology and sleep medicine, including the perioperative management of SDB, and to promote interdisciplinary communication, education, and research in matters common to these fields. Thus, the perioperative identification and management of SD and SDB has been a core consideration since its foundation over 10 years ago. SASM has excelled on this goal, through nimble academic collaborations resulting in highly cited publications, thereby establishing its position as a reliable source of high-quality medical information. For a young society working on disease conditions with limited perioperative definition at its inception, these are impressive achievements. A noticeable shift in its focus over the past few years has been to move past the initial focus on "dead-in-bed" research11 to a broader portfolio including the impact of suspected or diagnosed SD and SDB on perioperative outcomes,12 health care utilization,13 outcome modification,7 and mechanisms of postoperative risk states. One notable gap, in common with most anesthesia societies has been a lack of direct patient engagement. There are several important reasons that have moved SASM to engage with patients directly, involve them in its annual meeting in 2020 and embark on collaborative work with patient advocates and foundations. These broad-based collaborations should lead to a better understanding of patient perspectives, care challenges, and barriers for several SD or SDB conditions. This in turn will channel SASM's energies to be more effective advocates for patients, focus on patient-centered areas of need, establish platforms for accessible learning, connect patients with key services, and cocreate materials or pathways with patients. Through these efforts, SASM intends to be the preferred source of information and resources for patients with SD or SDB presenting for surgery. THE VALUE OF SUBSPECIALTY SOCIETIES Specialist groups like SASM bring a wealth of focused energy to an area of anesthesia or medical care. However, this model is under pressure. The economic impact of the pandemic on departments and individual clinicians have trickle-down effects on both professional development funds availability and a sharper focus on choice of which society members can feasibly support. This process will likely result in a net reduction in the diversity of expert societies. SASM, with an average of >400 members since inception, and >1000 members for the past few years is certainly not immune from this effect. Why is this bad for the specialty? The loss of these organized efforts would deal a significant blow to trajectory of knowledge transfer from research to practice, advocacy, and partnership. Is this threat all bad? Challenges like these encourage fresh thinking. Expanding the involvement of patient groups and membership from low- and middle-income countries are welcome steps, as is greater engagement with other specialist societies to leverage mutual strengths. The direct voice of our patients will be instructive and possibly disruptive, resulting in significant shifts in organizational mission and strategy. Likewise, the impact of SD and SDB in low-income countries is significant; resources are scarce; and challenges abound. SASM recognizes there is much that can be done to enhance knowledge transfer and improve medical care in this space with the help of our growing international membership and partners. SASM's bold new agenda to provide a learning environment free-of-charge to the world is a powerful way to achieve these goals. One of SASM's great successes in the last 5 years has been the development and publication of highly cited consensus guidelines for preoperative screening, assessment, and intraoperative management of patients with OSA.14,15 This has been possible due to core expertise across anesthesiology, sleep medicine, pulmonology, neurology, surgery, and pain medicine. In early 2021, a task force will begin the painstaking task of developing consensus guidelines for the postoperative care of the patient with OSA. In the spirit of William Mayo's eternally relevant quote that calls on the "union of forces," at least 2 major societies, the Society for Ambulatory Anesthesia and the Society of Critical Care Anesthesiologists, will join SASM in this effort. As SASM expands its horizons through partnerships with patients, fellow societies, and industry, one is also reminded of Goethe's words "Knowing is not enough; we must apply. Willing is not enough; we must do." DISCLOSURES Name: Satya Krishna Ramachandran, MD, FRCA. Contribution: This author drafted and revised the manuscript. Conflicts of Interest: S. K. Ramachandran is the president of SASM, scientific consultant to Fresenius Kabi USA. This manuscript was handled by: Toby N. Weingarten, MD.