Variation in the Practice of Preoperative Medical Consultation for Major Elective Noncardiac Surgery

Wijeysundera, Duminda N.; Austin, Peter C.; Beattie, W. Scott; Hux, Janet E.; Laupacis, Andreas

doi:10.1097/aln.0b013e31823cfc03

Cited by 65 publications

(31 citation statements)

References 40 publications

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“…When compared with adjusted ORs associated with patient demographic characteristics, comorbidities, surgical facility type, and anesthesia provider type, the large value of this median OR suggests a strong geographic influence on whether patients are referred for consultation. The median OR of 3.01 is also consistent with a previous study 19 on geographic variation in the use of preoperative consultations for major surgery in Ontario, Canada. In the absence of guidelines for the use of this intervention, this variation may represent uncertainty about when it is indicated.…”

Section: Discussionsupporting

confidence: 89%

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Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery

et al. 2014

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IMPORTANCE Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service.OBJECTIVE To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure. DESIGN, SETTING, AND PARTICIPANTS Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556 637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89 817 individuals who underwent surgery from 2005 to 2006. MAIN OUTCOMES AND MEASURES Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery. RESULTS The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI,). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics. Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation. CONCLUSIONS AND RELEVANCE

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Section: Discussionsupporting

confidence: 89%

“…19,21–24 Two previous studies have focused on preoperative medical evaluations for patients undergoing ophthalmic surgery. 25,26 Both of these studies have emphasized the opportunity to improve patient care by identifying problems incidental to the surgical condition.…”

Section: Discussionmentioning

confidence: 99%

Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery

et al. 2014

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“…Several previous studies focusing on patients with comorbidities undergoing major surgery did not demonstrate any associated improvement in outcomes from preoperative consultations. 7-9 Consequently, there is reason to believe that preoperative consultations for relatively healthy patients having low-risk surgery may be a practice with unproven health benefit. Indeed, no current practice guideline recommends that such patients be routinely referred for consultation.…”

mentioning

confidence: 99%

“…7-9,12-16 In these previous reports, frequency of consultations for patients undergoing intermediate- to high-risk surgery (sometimes referred to as major surgery) has ranged from 10 to 40%. Some investigators have also found that whereas increased age and comorbidities did predict referral for preoperative consultation, increased surgical risk did not.…”

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Patterns of Preoperative Consultation and Surgical Specialty in an Integrated Healthcare System

et al. 2013

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Background Many patients scheduled for elective surgery are referred for a preoperative medical consultation. Only limited data are available on factors associated with preoperative consultations. The authors hypothesized that surgical specialty contributes to variation in referrals for preoperative consultations. Methods This is a cohort study using data from Group Health Cooperative, an integrated healthcare system. The authors included 13,673 patients undergoing a variety of common procedures—primarily low-risk surgeries—representing six surgical specialties, in 2005–2006. The authors identified consultations by family physicians, general internists, pulmonologists, or cardiologists in the 42 days preceding surgery. Multivariable logistic regression was used to estimate the association between surgical specialty and consultation, adjusting for potential confounders including the revised cardiac risk index, age, gender, Deyo comorbidity index, number of prescription medications, and 11 medication classes. Results The authors found that 3,063 (22%) of all patients had preoperative consultations, with significant variation by surgical specialty. Patients having ophthalmologic, orthopedic, or urologic surgery were more likely to have consultations compared with those having general surgery—adjusted odds ratios (95% CI) of 3.8 (3.3–4.2), 1.5 (1.3–1.7), and 2.3 (1.8–2.8), respectively. Preoperative consultations were more common in patients with lower revised cardiac risk scores. Conclusion There is substantial practice variation among surgical specialties with regard to the use of preoperative consultations in this integrated healthcare system. Given the large number of consultations provided for patients with low cardiac risk and for patients presenting for low-risk surgeries, their indications, the financial burden, and cost-effectiveness of consultations deserve further study.

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Use of Medical Consultants for Hospitalized Surgical Patients

et al. 2014

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A s the Centers for Medicare & Medicaid Services (CMS) and others move to bundled payments around longitudinal episodes of care, hospitals are facing a greater need to understand practice variation and areas of excess resource use within episodes of care. In the case of inpatient surgery, for example, one recent study suggests that episodebased payments for surgery vary as much as 10% to 40% after adjusting for case mix and price. 1 For some procedures, variation in episode-based payments is driven by multiple factors, including readmissions, use of home health, skilled nursing services, and other components of postdischarge care. 1,2 Another source of variation is the use of professional services, including the use of medical consultants. Internists and medical subspecialists are frequently called on to provide pre-operative assessments of risk and to provide advice on how to reduce these risks. Medical consultants may also be employed for more routine comanagement, caring for surgical patients' chronic medical conditions such as diabetes and hypertension for the duration of the hospital stay. Finally, medical consultants often assist in the care of patients with certain complications after surgery, including acute kidney injury, surgical site infections, and postoperative myocardial infarction.Although prior work suggests a long-term trend toward increased use of medical consultants for comanagement of surgical patients, 3 variation in the use of consultations for hospitalized surgical patients has not been studied carefully. In this context, we used national Medicare data to explore the use of medical consultations around inpatient surgery, factors as-IMPORTANCE Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important.OBJECTIVE To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals. DESIGN, SETTING, AND PARTICIPANTSObservational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. MAIN OUTCOMES AND MEASURES Number of inpatient medical consultations.RESULTS More than half of patients undergoing colectomy (91 684) or THR (339 319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colect...

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Variation in the Practice of Preoperative Medical Consultation for Major Elective Noncardiac Surgery

Abstract: Background: Patients scheduled for major elective noncardiac surgery frequently undergo preoperative medical consultations. However, the factors that determine whether individuals undergo consultation and the extent of interhospital variation remain unclear.

Cited by 65 publications

References 40 publications

Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery

Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery

Patterns of Preoperative Consultation and Surgical Specialty in an Integrated Healthcare System

Use of Medical Consultants for Hospitalized Surgical Patients

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