The preoperative cardiology consultation: goal settings and great expectations

Association of Preoperative Medical Consultation With Reduction in Adverse Postoperative Outcomes and Use of Processes of Care Among Residents of Ontario, Canada

Importance

It is uncertain whether preoperative medical consultation reduces adverse postoperative clinical outcomes.

Objective

To investigate the association of preoperative medical consultation with reduction in adverse postoperative outcomes and use of processes of care.

Design, Setting, and Participants

This was a retrospective cohort study using linked administrative databases from an independent research institute housing routinely collected health data for Ontario's 14 million residents, including sociodemographic features, physician characteristics and services, and receipt of inpatient and outpatient care. The study sample included Ontario residents aged 40 years or older who underwent their first qualifying intermediate- to high-risk noncardiac operation. Propensity score matching was used to adjust for differences between patients who did and did not undergo preoperative medical consultation with discharge dates between April 1, 2005, and March 31, 2018. The data were analyzed from December 20, 2021, to May 15, 2022.

Exposures

Receipt of preoperative medical consultation in the 4 months preceding the index surgery.

Main Outcomes and Measures

The primary outcome was 30-day all-cause postoperative mortality. Secondary outcomes included 1-year mortality, inpatient myocardial infarction and stroke, in-hospital mechanical ventilation, length of stay, and 30-day health system costs.

Results

Of the total 530 473 individuals (mean [SD] age, 67.1 [10.6] years; 278 903 [52.6%] female) included in the study, 186 299 (35.1%) received preoperative medical consultation. Propensity score matching resulted in 179 809 well-matched pairs (67.8% of the full cohort). The 30-day mortality rate was 0.9% (n = 1534) in the consultation group and 0.7% (n = 1299) in the control group (odds ratio [OR], 1.19; 95% CI, 1.11-1.29). The ORs for 1 year mortality (OR, 1.15; 95% CI, 1.11-1.19), inpatient stroke (OR, 1.21; 95% CI, 1.06-1.37), in-hospital mechanical ventilation (OR, 1.38; 95% CI, 1.31-1.45), and 30-day emergency department visits (OR, 1.07; 95% CI, 1.05-1.09) were higher in the consultation group; however, the rates of inpatient myocardial infarction did not differ. The lengths of stay in acute care were a mean (SD) 6.0 (9.3) days in the consultation group and 5.6 (10.0) days in the control group (difference, 0.4 [95% CI, 0.3-0.5] days), and the median (IQR) total 30-day health system cost was CAD $317 ($229-$959) (US $235 [$170-$711]) higher in the consultation group. Preoperative medical consultation was associated with increased use of preoperative echocardiography (OR, 2.64; 95% CI, 2.59-2.69) and cardiac stress tests (OR, 2.50; 95% CI, 2.43-2.56) and higher odds of receiving a new prescription for β-blockers (OR, 2.96; 95% CI, 2.82-3.12).

Conclusions and Relevance

In this cohort study, preoperative medical consultation was not associated with a reduction but rather with an increase in adverse postoperative outcomes, suggesting a need for further refinement of target populations, processes, and interventions related to preoperative medical consultation. These findings highlight the need for further research and suggest that referral for preoperative medical consultation and subsequent testing should be carefully guided by individual-level consideration of risks and benefits.

Preoperative cardiology referral practices at a tertiary care centre: A retrospective observational study

Background Preoperative consultations and testing add to healthcare costs. Unnecessary consultations lead to further testing and delay in surgery. Guidelines help us in clinical practice but are seldom followed. We studied the appropriateness of our preoperative cardiology referrals according to the guidelines and functional utility of the consultations. Methods We reviewed the records of patients who underwent elective non-cardiac surgery to identify those who had a preoperative cardiology consult. Appropriateness of the referral was assessed by comparing with the 2014 American College of Cardiology/American Heart Association guidelines. Any recommendations made, major adverse cardiac events and perioperative outcome were also noted. Results Only 71 (15.5%) referrals were appropriate according to the guidelines. A majority of them were for preoperative clearance. The most common recommendation was to withhold antiplatelet medications. None of the consultations made any change in the anaesthetic or surgical plan. Six patients had major perioperative adverse cardiac events. Conclusion The majority of consultations were by surgeons and were not indicated according to the guidelines and did not have any impact on patient outcome. A large proportion of these patients had low cardiac risk index. As anaesthesiologists, we are best equipped to quantify risk and optimize a patient and should be the leaders of the perioperative period.

Impact of preoperative cardiology consultation prior to intermediate-risk surgical procedures

BACKGROUND

Patients undergoing noncardiac, nonvascular surgery (NCNVS) are at risk of perioperative cardiovascular events. However, benefits of cardiology consultation (CC) in patients with known or suspected cardiac disease undergoing intermediate-risk NCNVS is unknown.

METHODS

The study group included 700 consecutive patients referred for CC before intermediate-risk NCNVS in a tertiary-care teaching hospital. The control group included 1200 age-matched and sex-matched consecutive patients proceeded to the intermediate-risk surgery without preoperative CC during the same period. Patients older than 18 years who underwent an elective, NCNVS were enrolled. Requests for consultation were made either by surgeon or an attending anaesthesiologist. All patients underwent a complete preoperative clinical evaluation.

RESULTS

Of the 700 patients who were referred for CC in the study group, 530 patients (75.7%) had no additional recommendations, and 170 patients (24.3%) underwent additional preoperative tests or had a change in preoperative therapy. Only 20 (2.8%) patients' NCNVS were delayed based on the cardiologists' recommendation and 680 patients eventually had their surgeries. Major cardiovascular and noncardiovascular complication rates were similar in the study and in the control groups (12.9% vs 13.6%, P = 0.273 and 25.2% vs 26%, P = 0.432 respectively).

CONCLUSIONS

Preoperative CC in patients who underwent intermediate-risk NCNVS does not affect either perioperative management or outcome of surgery.

Role of telehealth in perioperative medicine for regional and rural patients in Queensland

BACKGROUND

Australians living in regional, rural and remote areas face a myriad of complexities resulting in a trend to poorer health outcomes. Telehealth is being utilised as an alternative mode of service delivery to overcome such barriers. However, there is limited published information concerning the use of telehealth in perioperative medicine.

AIMS

To review the performance of the telehealth preoperative assessment service at Mater Hospital Brisbane to determine last-minute cancellation rates secondary to medical reasons.

METHODS

A retrospective chart audit of all patients referred to perioperative medicine telehealth consultation services was provided at Mater Hospital Brisbane.

RESULTS

During a 1-year period, 229 patients across eight surgical subspecialties were referred for telehealth assessment (85 females, 144 males) with a median age of 67 years. Patients lived a median distance of 1597 km from Brisbane. Of the 229 patients included in the study, 7 (3.1%) experienced last-minute cancellations. From these data, the last-minute cancellation rate due to medical reasons was 1.3%, which is consistent with the international average.

CONCLUSION

The Mater Hospital Perioperative Medicine Telehealth Programme is a means of providing comprehensive perioperative assessment to regional, rural and remote patients that result in reduced last-minute surgical cancellations and surgery within or below the national recommended guidelines.

The preoperative cardiology consultation: indications and risk modification

Background

The cardiologist is regularly consulted preoperatively by anaesthesiologists. However, insights into the efficiency and usefulness of these consultations are unclear.

Methods

This is a retrospective study of 24,174 preoperatively screened patients ≥18 years scheduled for elective non-cardiac surgery, which resulted in 273 (1%) referrals to the cardiologist for further preoperative evaluation. Medical charts were reviewed for patient characteristics, main reason for referring, requested diagnostic tests, interventions, adjustment in medical therapy, 30-day mortality and major adverse cardiac events.

Results

The most common reason for consultation was the evaluation of a cardiac murmur (95 patients, 35%). In 167 (61%) patients, no change in therapy was initiated by the cardiologist. Six consultations (2%) led to invasive interventions (electrical cardioversion, percutaneous coronary intervention or coronary artery bypass surgery). On average, consultation delayed clearance for surgery by two weeks.

Conclusion

In most patients referred to the cardiologist after being screened at an outpatient anaesthesiology clinic, echocardiography is performed for ruling out specific conditions and to be sure that no further improvement can be made in the patient’s health. In the majority, no change in therapy was initiated by the cardiologist. A more careful consideration about the potential benefits of consulting must be made for every patient.