Effectiveness of preoperative medical consultations by internal medicine physicians: a systematic review

Abstract

Objective: Clinics have been established to provide preoperative medical consultations, and enable the anaesthetist and surgeon to deliver the best surgical outcome for patients. However, there is uncertainty regarding the effect of such clinics on surgical, in-hospital and long-term outcomes. A systematic review of the literature was conducted to determine the effectiveness of preoperative medical consultations by internal medicine physicians for patients listed for elective surgery.

Design: Systematic searches of MEDLINE, EMBASE, CINAHL, PubMed, Current Contents and the NHS Centre for Reviews and Dissemination were conducted up to 30 April 2017.

Setting: Elective surgery.

Study selection: Randomised controlled trials and non-randomised comparative studies conducted in adults.

Outcome measures: Length of hospital stay, perioperative morbidity and mortality, costs and quality of life.

Results: The one randomised trial reported that preadmission preoperative assessment was more effective than the option of an inpatient medical assessment in reducing the frequency of unnecessary admissions with significantly fewer surgical cancellations following admission for surgery. A small reduction in length of stay in patients was also observed. The three non-randomised studies reported increased lengths of stay, costs and postoperative complications in patients who received preoperative assessment. The timing and delivery of the preoperative medical consultation in the intervention group differed across the included studies.

Conclusion: Further research is required to inform the design and implementation of coordinated involvement of physicians and surgeons in the provision of care for high-risk surgical patients. A standardised approach to perioperative decision-making processes should be developed with a clear protocol or guideline for the assessment and management of surgical patients.

Keywords: elective surgery; internal medicine physicians; preoperative medical consult; systematic review.

Figure 1

Summary of search results and study selection.

Figure 2

The timing of the preoperative medical consultation in each included study. *Macpherson and Lofgren compared preadmission medical consultations (outpatient clinic) to postadmission preoperative medical consultations (inpatient) and Auerbach et al compared a medical consultation on the day before, day of or day after surgery with a medical or other specialty consultation on days other than the intervention (ie, two or more days before surgery).