Risk reduction before surgery. The role of the primary care provider in preoperative smoking and alcohol cessation

Abstract

Background: Daily smokers and hazardous drinkers are high-risk patients, developing 2-4 times more complications after surgery. Preoperative smoking and alcohol cessation for four to eight weeks prior to surgery halves this complication rate. The patients' preoperative contact with the surgical departments might be too brief for the hospital to initiate these programmes. Therefore, it was relevant to evaluate a new clinical practice which combined the general practitioner's (GP) referral to surgery with a referral to a smoking and alcohol intervention in the surgical pathway.

Methods: The design was an exploratory prospective trial. The outcome measured was the number of patients referred to a preoperative smoking and alcohol cessation programme at the same time as being referred for elective surgery by their GP. The participants consisted of 72 high-risk patients who were referred for elective surgery by 47 local participating GPs. The GPs, nurses, and specialists in internal medicine, prehabilitation and surgery developed new clinical practice guidelines based on the literature and interviews with 11 local GPs about the specific barriers for implementing a smoking and alcohol cessation programme. The role of the GP was to be the gatekeeper: identifying daily smokers and hazardous drinkers when referring them to surgery; handing out information on risk reduction; and referring those patients identified to a preoperative smoking and alcohol cessation programme. The role of the hospital was to contact these patients to initiate smoking and alcohol cessation at the hospital out-patient clinic for life-style intervention.

Results: The GPs increased their referral to the smoking and alcohol cessation programme from 0% to 10% (7/72 patients) in the study period.

Conclusion: The effect of the study was limited in integrating the efforts of primary care providers and hospital surgical departments in increasing the up-take of preoperative smoking and alcohol cessation programmes aimed at smokers and harmful drinkers referred for surgery. New strategies for cooperation between GPs and surgical departments are urgently needed.

Trial registration: J.nr. 2005-54-1781 in Danish Data Protection Agency. J.nr. 07 268136 in Scientific Ethical Committee for Copenhagen and Frederiksberg Municipalities.

Figure 1

Integrated preoperative guidelines for lifestyle intervention prior to surgery (the boxes above the arrow concern the pathway from GP to surgery, and the boxes under the arrow concern the integrated preoperative lifestyle intervention; closed boxes refer to the GPs and striated lines to the hospital activities).

Figure 2

Trial profile. Patients referred by the 47 engaged GPs for elective surgery and preoperative smoking and alcohol intervention.