Study Evaluates Effectiveness of Medical Pre-Operative Clinics
Anesthesiologists typically initiate an assessment of surgical patients in the immediate preoperative period focused on management of the airway, physiologic parameters, and choice of anesthetic. Given the growing complexity of medical issues in surgical patients, portions of the preoperative assessment may need to be addressed weeks prior to surgery; however, there is limited research on medical preoperative clinics. This study evaluated the impact of the addition of a hospitalist-run preoperative clinic to standard practice in one VAMC. All Veterans seen in the clinic who were scheduled for inpatient or outpatient non-cardiothoracic surgery from 7/03 through 7/05 were included in this study (n=5,223). Veterans were categorized into two groups: those seen from 7/03 to 6/04, when Anesthesia Department staff supervised the preoperative clinic (Period A); and those seen from 7/04 to 6/05, the first year of the new hospitalist-run system (Period B). Using VA data, investigators compared information on patients in the two groups, including: demographics, American Society of Anesthesia (ASA) score (higher number reflects worse score), perioperative beta blocker usage, surgical cancellations on the day of surgery, length of stay (LOS), and mortality.
- The addition of an internal medicine-focused preoperative clinic was associated with improved patient outcomes and reduced hospital LOS for Veterans undergoing surgery. Adjusted LOS was reduced for inpatients with an ASA score of 3 or higher. ASA classifications were similar for Veterans in both Period A and Period B, with more than 60% having an ASA of 3 or higher.
- Inpatient mortality rates were reduced for Veterans seen in Period B in the hospitalist-run preoperative clinic compared to Veterans seen in Period A (0.36% vs. 1.27%). There also was a trend toward a reduction in same day, medically avoidable surgical cancellations (8.5% vs. 4.9%).
- There was a significant increase in the number of Veterans on perioperative beta blockers, with 26% in Period A compared to 33% in Period B.
- Identifying other clearly defined process measures is a study limitation, but quantification would have required extensive chart review and substantial resources which were unavailable.
- Beta-blocker usage data were determined by patients prescribed beta blockers perioperatively, and did not exclude patients on long-term therapy prior to presentation.
- Investigators did not have a breakdown of post-operative hospital stay regarding days in the ICU, monitored, or ward setting, thus a true cost-effectiveness analysis could not be done.
Drs. Vazirani, Lankarani-Fard, and Stelzner are part of the VA Greater Los Angeles Healthcare System. Dr. Asch is part of HSR&D Center for Health Care Evaluation, Palo Alto, CA.
Vazirani S, Lankarani-Fard A, Liang L-J, Stelzner M, and Asch S. Perioperative Processes and Outcomes after Implementation of a Hospitalist-Run Preoperative Clinic. Journal of Hospital Medicine September 7, 2012;Epub ahead of print.