Study analyzes how often patients receive preoperative medical consultation

Researchers in Toronto, Canada found that whether a patient received a preoperative medical consultation was not tied to his/her health or the risk of the operation, rather which hospital he/she was having surgery was a large determining factor.

The study published in the January issue of Anesthesiology analyzed how often patients were given these consultations prior to surgery. The findings demonstrated that patients received this counsel for about one-third of the surgeries.

"Preoperative medical consultations are often performed to better prepare patients for major surgery. These consultations allow for more accurate recording of pre-existing medical conditions, estimation of patients' risks for undergoing surgery, conduct of specialized tests to better estimate patients' surgical risks and implementation of interventions intended to decrease patients' risks of having major surgery," said lead study investigator Duminda N. Wijeysundera, M.D., Ph.D. "However, despite these theoretical benefits, there are no conclusive data indicating that patients' outcomes after surgery are improved as a consequence of medical consultations."

The study's major objectives included determining the degree of variation in rates of preoperative medical consultation across different hospitals and identifying what patient- and surgery-related factors determined whether a patient underwent consultation.

The study achieved its objectives. In this large study of more than 200,000 patients undergoing major elective surgery in Ontario, the results showed that the rate of consultations varied considerably between hospitals. Depending on where the surgery took place, the chance of having a medical consultation could be as low as 5 percent to as high as 90 percent. These differences were not explained by how sick patients were.

In addition, researchers found that the rate at which different surgical services referred patients for consultation was not consistent with the varying risk of surgical procedures. Surgical procedures with lower risks often had higher rates of consultation than procedures with much higher associated risks.

Two previous studies found that patients' outcomes were not improved after consultation and perhaps were made even worse. This study reinforced these previous findings and potentially identified two important problems related to the large variation in consultation rates. First, at hospitals with very low consultation rates, high-risk patients (who may benefit from consultation) might not be referred for consultation. Second, at hospitals with very high consultation rates, low-risk patients (who are very unlikely to benefit from consultation) were referred for consultation regardless, which exposed them to the risks and costs of unnecessary testing and interventions.

"More research is needed to determine which patients benefit from preoperative consultation," said Dr. Wijeysundera.

In an accompanying editorial, Sachin Kheterpal, M.D., M.B.A. offered the perspective that as these care variations are identified and compared to the resulting patient outcomes and complications, we will begin to understand the optimal perioperative process for major surgical procedures.

Dr. Kheterpal stated in the editorial: "This process of identifying variation, understanding variation, establishing optimal care and measuring adherence to optimal care must be performed for each anesthesiology intervention. Only then can we continue to hail ourselves as patient safety leaders of the future, not just the past and present."