Patterns of preoperative consultation and surgical specialty in an integrated healthcare system

Abstract

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.

Fig. 1

Frequency distribution of preoperative consultations in the 42 days preceding the index surgery, showing a bimodal distribution with peaks on preoperative days 7 and 14.

Fig. 2

Forest plot displaying the adjusted odds ratios and 95% CIs for predictors of referral for preoperative consultation. The adjusted model included all of the variables displayed. The referent category for surgical specialty was general surgery. Revised cardiac risk index (RCRI): patients with 0, 1, 2, or 3 or more factors were assigned to classes I, II, III, or IV, respectively; referent category was class I. The Deyo comorbidity index was used as a categorical variable, scores of 0, 1, 2, and ≥3 are represented by categories 0, 1, 2, and 3. The referent category was 0. The estimate for age is for 10-yr difference. ACE-I = angiotensin converting enzyme inhibitors; Ca channel blockers = calcium channel blockers; Deyo = Deyo comorbidity index; Nonasp antiplt agents = nonaspirin antiplatelet agents; Other anti-htn = other antihypertensive medications.