Judicious Use of Preoperative Consultants. Relevant disclosures: None. Preoperative Consultation by Specialists: Overall Impact on Outcome?

Transcription

1 Judicious Use of Preoperative Consultants Changing Practice of Anesthesia Meeting 2014 Relevant disclosures: None Rachel Eshima McKay, MD Professor, Anesthesia and Perioperative Director, UCSF Mount Zion PREPARE Clinic 1 2 Objectives in preoperative evaluation Preoperative Consultation by Specialists: Overall Impact on Outcome? Minimizing case delay and cancellation Decreasing variability and waste Providing accurate risk assessment Improving patient outcomes Improving patient satisfaction Coordinating care through surgical episode Randomized trials lacking Frequently No specific question is asked Consultants misinterpret the question Recommendations are ignored Katz RI et al. Can J Anesth 2005; 52:

2 Which Preoperative Evaluation Strategy Best Achieves these Objectives? For Reducing Day-of-Surgery Case Cancellation and Delay Anesthesiologist on day-of-surgery Internist prior to day-of-surgery Internist/hospitalist in a preoperative assessment clinic (PAC) Anesthesiologist- directed PAC Clinician in PAC with additional referral to a consultant for complex or other matters Anesthesia-directed PAC Ferschl M et al. Anesthesiology 2005; 103: Van Klei WA et al. Anesth Analg 2002; 94: Fischer SP et al. Anesthesiology 1996; 85: PAC Evaluation and Impact on Case Cancellation in a Dutch Teaching Hospital Observational study, before and after anesthesiadirected PAC implementation Standard condition: operative anesthesiologist evaluates patient one day prior to surgery PAC intervention: anesthesiologist evaluates per written protocol average of 3 weeks prior to surgery, provides perioperative instructions >21,500 patients studied over 3-year period van Klei et al. Anesth Analg 2002; 94: Implementation of preoperative clinic: Impact on day-of-surgery cancellations Medical Condition Before PAC, % After PAC, % OR (95% CI) Untreated hypertension ( ) CV/pulmonary instability ( ) Febrile illness ( ) Insufficient work-up ( ) Total medical reasons ( ) Logistical + medical ( ) van Klei et al. Anesth Analg 2002; 94:

3 Stanford University Stanford University: Impact of PAC Referral Cardiology Internal Medicine Pulmonary Before PAC: N = 3576, six-month window Surgeon Anesthesiologist After PAC: N = 4313, six-month window Surgeon Anesthesiologist % reduction in testing 88% reduction in day-of surgery cancellation Establishment of PAC led to 85% reduction in surgeon referral to specialists Fischer SP et al. Anesthesiology 1996; 85: Fischer SP et al. Anesthesiology 1996; 85: Possible Reasons Anesthesia-PAC Reduced Cancellation and Delay? Anesthesia Consultation: Other Benefits? Earlier patient evaluation Standardization of protocols, less testing Better understanding of the planned surgery and anesthesia Direct communication with surgeon and anesthesiologist Lesser likelihood of ordering inappropriate tests Increased patient acceptance of regional anesthesia Reduced patient anxiety Katz RI et al. Anesth Analg 2011; 112: Wijeysundera DN et al. Arch Int Med 2009; 169: Klopfenstein CE et al. Can J Anesth 2000; 47:

4 Preoperative Consultation: 2014 Review by Health Quality Ontario Expert panel assembled Research question: Determine clinical utility of preoperative consultations by internal medicine vs anesthesiologists at assessment clinics Three trials met inclusion criteria Findings summarized Limitations cited Utility of an Anesthesia Clinic in a Hong Kong Tertiary Hospital 640 patients in a two-month period undergoing elective non-cardiac surgery PAC visit resulted in shorter postoperative length of stay ( days, P = 0.001) Limitations: Small sample size Inclusion criteria, baseline characteristics poorly defined Chan FW et al. Hong Kong Medical Journal 2011; 17: Anesthesia Consult: Impact on Length of Stay 271,082 patient cohort from Ontario, Intermediate and high-risk non-cardiac surgery 39% underwent anesthesia consult Propensity scoring used to identify matched pairs, minimize confounding, N = 180,254 Anesthesia consult associated with modest but significant decrease in LOS (0.35 days, P < 0.001) Arch Int Med 2009; 169: Anesthesia Consult: No mortality difference Arch Int Med 2009; 169:

5 Internal Medicine Consult: Length of Stay From same patient cohort 38.8% underwent internal medicine consult Matched pairs, N = 191,852 More testing and pharmacologic intervention Increased length of stay (0.65 days, P < 0.001) Internal Medicine Consult: Increased Mortality 30-day mortality (RR = 1.16, P < 0.001) 1-Year mortality (RR = 1.08, P < 0.001) Arch Int Med 2010; 170: Arch Int Med 2010; 170: Ontario Cohort Studies: Limitations and Conclusions Why might medicine consultation increase mortality? Pharmacologic interventions may have caused harm Lesser familiarity with perioperative issues Unmeasured confounders (bias) Arch Int Med 2010; 170: Studies overpowered (statistical versus clinical significance) No stratification of intermediate versus high-risk surgery as related to outcome LOS not categorized as pre versus postop Underlying mechanism for outcome difference not explained Patients whose surgery cancelled on basis of consultation not considered Reasons for allocation to consultation type not clear Experts cited insufficient data on which to draw a conclusion Future studies needed Preoperative Consultations: Rapid Review. March 2014:

6 Role of Consultant: Is Value Added? Do we have a specific question? Does a clinical condition need optimization? Will the consultant play a role in postoperative and future management? Are findings from large observational trials generalizable to my institution? Role of Preoperative Evaluation and Testing: How often do abnormal findings and tests change perioperative management? How often are these changes in management beneficial to the patient? Are there better risk assessment tools than the ones we currently use? Where Should We Prioritize Efforts? Who is at Risk of Death or Disability? Annually, millions of patients die worldwide within 30 days after elective surgery Example- POISE-1 cohort, 30-day outcomes: MI 5.7% (fatal in 11.6%) All-cause mortality 3.1% Stroke 0.5% Who were these patients? Pearse RM et al. Lancet 2012; 380: Devereaux PJ et al. Lancet 2008; 371: Who is at Highest Risk for Adverse CV Events? Revised Cardiac Risk Index Adjusted OR, Derivation Cohort Adjusted OR, Validation Cohort High-risk surgery 2.8 ( ) 2.6 ( ) Ischemic heart disease 2.4 ( ) 3.8 ( ) History of CHF 1.9 ( ) 4.3 ( ) H/O cerebrovascular disease 3.2 ( ) 3.0 ( ) Insulin therapy for diabetes 3.0 ( ) 1.0 ( ) Preoperative serum Cr > ( ) 0.9 ( ) Number of Risk Factors Based on logistic models containing these variables RCRI Class 0 I 1 II 2 III 3 IV Lee TH et al. Circulation 1999; 100: POISE-I cohort

7 Higher RCRI Class Statistically Predicted Adverse Cardiovascular Events Assessment of Cardiovascular Risk: A New Tool with Better Sensitivity? Percent of patients with post-op MACE ROC = Lee TH et al. Circulation 1999; 100: Regression model from >200,000 non-cardiac surgery patients in 2007 from NSQIP Incorporates procedural and patient comorbidity data C-statistic = versus for RCRI alone for prediction of postoperative MACE Gupta PK et al. Circulation 2011; 124: Surgical Risk Calculator: Cardiac Events Risk Calculator: Respiratory Gupta H et al. Failure Chest 2011; 140:

8 Does Preoperative Myocardial Perfusion Testing Predict Events in High-Risk Stable Patients? Recent retrospective analysis of prospective series suggests no 373 patients underwent open and endovascular AAA repair between in Korea All evaluated with P-thal prior to surgery, troponins post-op 18% of patients had abnormal studies 11/373 patients had met criteria for postoperative MI 8 with negative studies 2 with reversible defects 1 with fixed defects Perfusion deficits UNPREDICTIVE of MI in logistic model that identified CHF, nitrate use and elevated BMI as predictors PPV 29% and NPV 78% indicates that P-thal is not useful in predicting postoperative events in this population Shin S et al. World Journal of Surgery: DOI /s , epub 31 Aug 2013 Distinguishing Features of Perioperative MI Perioperative Acute Coronary Syndrome (ACS) is driven by the neurohumeral response to surgery Catecholamine release raises myocardial O2 demand Mobilization of metabolic substrates leads to fluid retention and hyperglycemia Activation of inflammatory mediators leads to vasospasm, platelet activation and fibrinolysis Rupture of atherosclerotic plaque results from activation of sympathetic + inflammatory responses to the wounding and healing process Plaque rupture risk with critical flow limitation bears little relationship to plaque size Monahan TS et al. J Vasc Surg 2005; 41: Muller J et al. Circulation 1997; 96: Cardiovascular Assessment Tools: Biomarkers Natriuretic peptide measurements Preoperative elevation within thresholds independently predict 30-day MACE in vascular and non-cardiac surgery patients Values improve predictive performance of RCRI Postoperative elevation adds predictive of 30 and 180 day events Postoperative troponin values Elevation (TnT 0.04 ng/ml) within first 3 days of noncardiac surgery strongly predictive of 30-day mortality (9.8 vs 1.1%) AHR = 3.87 ( ), population attributable risk = 34% Only 16% of patients with MINS had symptoms of ischemia Only 42% had diagnostic EKG changes Clinical use after high-risk surgery may identify patients needing referral, closer monitoring Rodseth RN et al. JACC 2014; 63: Botto F et al. Anesthesiology 2014; 120: Who gets sent to the consultant before low-risk surgery?

9 Cataract Surgery: Trend By Calendar Year: Cataract Surgery Very low risk of postoperative adverse events No difference in outcome on the basis of routine testing (EKG, CBC, electrolytes) Estimated cost of routine testing prior to cataract surgery > 150 million USD annually Have we been paying attention? Adjusted Probability of Preoperative Consultation (%) Schein O et al. NEJM 2000; 342: Thilen, S et al. JAMA Intern Med. 2014;174(3): Unadjusted Proportion Undergoing Consultation, (%) Consultation for Cataract Surgery, By Referral Region: 0-68% Thilen, S et al. JAMA Intern Med. 2014;174(3): Prioritizing Quality Improvement Efforts: Broadly Defined Outcome All patients from ACS-NSQIP undergoing GS procedures identified (N = 129,233) 36 procedures were categorized by CPT code Each procedure examined for contribution to Overall adverse event and mortality burden Overall excessive length of stay Few procedures had disproportionate contribution to morbidity and excess LOS 306 Hospital Referral Regions, Schilling PL et al. J Am Coll Surg 2008; 207:

10 Where Is Most Room for Improvement? Procedure N (%) AA rate XS LOS/AA (days) Colectomy 12,767 (9.9) 28.9 (24.3%) 9.8 Bariatric surgery 6167 (4.8) 8.3 (3.4%) 3.7 Mastectomy 4313 (3.3) 5.6 (1.6%) 0.9 IHR (outpatient) 9509 (7.4) 1.1 (0.7%) 0.2 Which Processes of Might Lead to Improvements in Outcome? Schilling PL et al. J Am Coll Surg 2008; 207: Standardization of Approach: The ERAS Example Preoperative counseling Optimization of nutrition Standardization of analgesics Standardization of anesthetic plans Early mobilization Cochrane Review, 237 colorectal surgery subjects ERAS: RR = 0.50 ( ) for all complications ERAS: LOS reduced 2.94 ( ) days No difference in readmission rates or mortality Spanjersberg JR et al. Cochrane Collaboration 2011 Possible Long Term Impact: Prehabilitation Requires implementation 30 days prior (not feasible if need for surgery is urgent) Rigorous physical training programs showed low compliance and 30% had deterioration in function Improvement in performance increased probability of full recovery at 9 weeks Trimodal approach (nutritional counseling, moderate exercise, anxiety reduction) has shown initial promise Mayo NE et al. Surgery 2011; 150: Li C et al. Surg Endosc 2013; 27:

11 Prehabilitation: Impact of Trimodal Intervention Performance, 6MWT (meters) Intervention Group: - Presurgical improvement - Baseline or better 8 weeks post-op Control Group: -Performance < baseline at 8 weeks Preoperative Evaluation: Looking Ahead Elimination of testing prior to low-risk surgery Selective referral for consultation with specific questions Close communication with surgeon, anesthesia team Standardized clinical assessment and management plans Adoption of care pathways where appropriate Patient education and optimization Better risk assessment tools Long-term outcome assessment into post-discharge phase of care with emphasis on return to full function Li C et al. Surg Endosc 2013; 27: