Documentation of Individualized Preoperative Risk Assessment: A Multi-Center Study

Abstract

Background Individual surgical risk prediction tools that inform shared-decision making, strengthen the consent process and support clinical management are considered important tools to enhance patient experience and outcomes. Neither the use of individual pre-surgical risk assessment (ISRA) tools nor the rate of documented individual risk is known. The primary endpoint of this study was the rate of physician documented ISRAs within the records of patients with poor outcomes. Secondary endpoints included the effects of age, sex, race, ASA class, and time and type of surgery on the rate of documented presurgical risk.Methods The records of non-obstetric surgical patients within 22 hospitals in Arizona, Colorado, Nebraska, Nevada, and Wyoming, between January 1 and December 31, 2017 were evaluated. Logistic regression was used to analyze both individual and group effects associated with ISRA documentation.Results 756 of 140,756 inpatient charts met inclusion criteria [0.54%, 95% CI 0.50% to 0.58%]. ISRAs were documented by 16.08% of surgeons [p<0.0001; R-squared=68.23%] and 4.50% of anesthesiologists [p< 0.0001, R-squared 15.38%]. Cardiac surgeons documented ISRAs more frequently than non-cardiac surgeons (25.87% vs 16.15%) [p=0.0086, R-squared=0.970%]. Elective surgical patients were more likely than emergency surgical patients (19.57 vs 12.03%) to have risk documented [p=0.0226, R-squared=0.730%]. Patients over the age of 65 were more likely than patients under the age of 65 to have ISRA documentation (20.31 vs 14.61%) [p=0.0429, R-squared=0.580%].Conclusions The observed rate of documented individual surgical risk assessment in our sample was low. Surgeons were more likely than anesthesiologists to document individual presurgical risk. In-line with the Salzburg Statement on Shared-Decision Making, information regarding surgical risk represents the bedrock of presurgical decision making and informed consent. The rate and quality of risk documentation must be improved.