Ambulatory anesthesia: past, present, and future.

Ambulatory anesthesia has become recognized as an anesthetic subspecialty, with formal postgraduate training programs. With increasing clinical experience, it is possible to determine which patients will derive the greatest clinical benefit from ambulatory surgery. Further expansion of the specialty of ambulatory anesthesia and surgery is likely to occur in the near future. The rate of expansion of ambulatory anesthesia will probably vary from country to country, depending on local needs, the level and availability of ancillary home health-care services, and economic considerations. Many recently developed drugs have pharmacological profiles that make them ideally suited for use in the ambulatory setting. Although these new drugs are valuable additions to the anesthesiologist's armamentarium, their cost is obviously higher than the drugs they were designed to replace. Given the changing pattern of health-care reimbursement, it is incumbent upon all practitioners to carefully examine the impact of new drugs and techniques on the quality of ambulatory anesthesia. It is obvious that these more rapid and shorter-acting anesthetic, analgesic, and muscle relaxant drugs have facilitated the early recovery process, thereby allowing our surgical colleagues to perform more extensive surgical procedures on an ambulatory basis. Future studies of new drugs and techniques for ambulatory anesthesia need to focus not only on subjective improvements for the patient during the perioperative period, but also on the overall cost-effectiveness of the care provided. These studies must compare the increased cost of new treatments with the potential financial savings resulting from earlier hospital discharge, reduced consumption of supplemental drugs, and earlier return to work. Recent pharmacological and technological advances in anesthesia and surgery allow outpatients with complex medical problems to undergo a wide variety of diagnostic and surgical procedures on an ambulatory basis. Increasingly, anesthesia practitioners as well as pharmacy and therapeutic committees are demanding evidence that new drugs and medical devices are superior to existing products--that they work better, have fewer adverse effects, and enhance efficiency, thereby reducing healthcare costs. As new biomedical technology is introduced to facilitate the perioperative management of patients (e.g., computerized anesthesia information management systems), evidence that these systems enhance our ability to provide high-quality, cost-effective health care will assume greater importance. The challenge that all practitioners face is to provide high-quality ambulatory anesthesia care at a reduced cost.