The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study

Abstract

Background: Surgical options for patients vary with age and comorbidities, advances in medical technology and patients' wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee.

Methods: In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018.

Results: A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported.

Conclusions: Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

Keywords: Challenging surgical treatment option; Patient safety; Preoperative multidisciplinary conference; Shared decision making.

Fig. 1

Flow chart of the decision-making process for multidisciplinary High-Risk Conferences. All health care professionals involved in patient care can request to convene a conference and attend. The attendees proceed with the conference on the basis of the initiative of the Patient Safety Committee, not that of the surgeon. The Patient Safety Committee is under the direct control of the director of our institution. The committee plays a central role in collecting and analyzing data regarding medical accidents/incidents, education/enlightenment activities related to patient safety and supporting the response to medical malpractice. ICU = intensive care unit

Fig. 2

Breakdown of the clinical departments responsible for cases discussed at High-Risk Conferences. Data are presented as number of cases (%). Cardiovascular surgery, which conducts highly difficult and advanced surgeries for patients with severe comorbidities, had the greatest number of conferences (24%). Urology had 11%, leading in surgical procedures, such as those for huge renal cell carcinoma or retroperitoneal tumors, performed across multiple surgical departments. Conferences for orthopedics were generally focused on the patient’s ability to tolerate the surgery and anesthesia

Fig. 3

Reasons for convening and conclusions determined at High-Risk Conferences. The presence of severe comorbidities and whether patients with could tolerate surgery and anesthesia was the most common reason for convening a conference. After a High-Risk Conference, surgery was conducted as planned for 88% of cases. Changes in treatment plan occurred for 12% (5% surgical procedure modified and 7% surgery cancelled)