Global health implications of preanesthesia medical examination for ophthalmic surgery

Teleconsultation for preoperative evaluation during the coronavirus disease 2019 pandemic: A technical and medical feasibility study

BACKGROUND

During the surge in coronavirus disease 2019 (COVID-19) infections in early 2020, many medical organisations began developing strategies for implementing teleconsultation to maintain medical services during lockdown and to limit physical contact. Therefore, we developed a teleconsultation preoperative evaluation platform to replace on-site preoperative meetings.

OBJECTIVE

This study assessed the feasibility of a teleconsultation for preoperative evaluation and procedure-associated adverse events.

DESIGN

Implementation study.

SETTING

A tertiary care university hospital in Germany from April 2020 to October 2020.

PATIENTS

One hundred and eleven patients scheduled for elective surgery.

INTERVENTION

Patients were assigned to receive teleconsultation for preoperative evaluation and to complete a subsequent survey.

MAIN OUTCOME MEASURES

Primary endpoints were medical and technical feasibility, user satisfaction and time savings.

RESULTS

For 100 out of 111 patients, telepreoperative consultations allowed for adequate perioperative risk assessment, patient education and also for effective collection of legal signatures. For six patients (5.4%), consultations could not be started because of technical issues, whereas for five patients (4.8%), clearance for surgery could not be granted because of medical reasons. A clear majority of anaesthetists (93.7%) rated the telepreoperative evaluations as equivalent to on-site meetings. The majority of the patients considered teleconsultation for preoperative evaluation as convenient as an on-site meeting (98.2%) and would choose a teleconsultation again (97.9%). Median travel time saved by patients was 60 min (Q1 40, Q3 80). We registered one adverse event: we detected atrial fibrillation in one patient only immediately prior to surgery.

CONCLUSION

Telepreoperative evaluations are medically and technically feasible, yielding high satisfaction rates on both sides. However, regarding patient safety, not every patient is equally well suited. Overall, implementation of teleconsultation for preoperative evaluation into clinical routine could help maintain medical care during the COVID-19 pandemic.

TRIAL REGISTRATION

NCT04518514, ClinicalTrials.gov.

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

IMPORTANCE

Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.

OBJECTIVE

To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.

EXPOSURES

Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.

MAIN OUTCOMES AND MEASURES

Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.

RESULTS

Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.

CONCLUSIONS AND RELEVANCE

Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.

[Validity time of normal results of preoperative tests for surgical reintervention and the impact on postoperative outcomes]

BACKGROUND AND OBJECTIVE

There are few data defining the period of time in which preoperative tests can be considered valid. The purpose of this study was to determine the likelihood of changes in the results of preoperative tests previously normal in relation to time, and the impact of these changes on postoperative outcomes.

METHODS

A total of 970 patients with normal preoperative tests before the first surgery and who required a new intervention were included. The preoperative tests performed for the first procedure were compared with those performed for the second procedure. The following variables were assessed regarding their potential to induce changes in test results: sex, age, surgical risk, previous chemotherapy or radiotherapy, and presence of comorbidities. In-hospital outcomes were analyzed.

RESULTS

The median time between procedures was 27 months (6-84). The probability of change in at least one of the preoperative exams was 1.7% (95% CI: 0.5-2.9), 3.6% (95% CI: 1.8-5.4), and 6.4% (95% CI: 3.9-8.9) during the 12, 24, and 36-month intervals, respectively, for patients aged <50 years and 2.1% (95% CI: 0.7-3.5), 9.2% (95% CI: 5.9-12.5), and 13.4% (95% CI: 9.3-17.5), respectively, for patients ≥ 50 years of age. Age (p=0.009), surgical risk (p <0.001), chemotherapy (p=0.001), radiotherapy (p=0.012), and comorbidities (p <0.001) were associated with the likelihood of changes in test results. Test changes were not significantly associated with in-hospital adverse outcomes (p=0.426).

CONCLUSION

For patients undergoing a second surgical procedure, the probability of change in previously normal preoperative tests is low during the first years after the first surgical intervention, and when changes occurred, they did not adversely affect the in-hospital postoperative outcomes.

Validity time of normal results of preoperative tests for surgical reintervention and the impact on postoperative outcomes

Background and objective

There are few data defining the period of time in which preoperative tests can be considered valid. The purpose of this study was to determine the likelihood of changes in the results of preoperative tests previously normal in relation to time, and the impact of these changes on postoperative outcomes.

Methods

A total of 970 patients with normal preoperative tests before the first surgery and who required a new intervention were included. The preoperative tests performed for the first procedure were compared with those performed for the second procedure. The following variables were assessed regarding their potential to induce changes in test results: sex, age, surgical risk, previous chemotherapy or radiotherapy, and presence of comorbidities. In-hospital outcomes were analyzed.

Results

The median time between procedures was 27 months (6–84). The probability of change in at least one of the preoperative exams was 1.7% (95% CI: 0.5–2.9), 3.6% (95% CI: 1.8–5.4), and 6.4% (95% CI: 3.9–8.9) during the 12, 24, and 36-month intervals, respectively, for patients aged <50 years and 2.1% (95% CI: 0.7–3.5), 9.2% (95% CI: 5.9–12.5), and 13.4% (95% CI: 9.3–17.5), respectively, for patients ≥50 years of age. Age (p = 0.009), surgical risk (p < 0.001), chemotherapy (p = 0.001), radiotherapy (p = 0.012), and comorbidities (p < 0.001) were associated with the likelihood of changes in test results. Test changes were not significantly associated with in-hospital adverse outcomes (p = 0.426).

Conclusion

For patients undergoing a second surgical procedure, the probability of change in previously normal preoperative tests is low during the first years after the first surgical intervention, and when changes occurred, they did not adversely affect the in-hospital postoperative outcomes.

The Clinical Impact of Cardiology Consultation Prior to Major Vascular Surgery

OBJECTIVE

To understand statewide variation in preoperative cardiology consultation prior to major vascular surgery and to determine whether consultation was associated with differences in perioperative myocardial infarction (poMI).

SUMMARY BACKGROUND DATA

Medical consultation prior to major vascular surgery is obtained to reduce perioperative risk. Despite perceived benefit of preoperative consultation, evidence is lacking specifically for major vascular surgery on the effect of preoperative cardiac consultation.

METHODS

Patient and clinical data were obtained from a statewide vascular surgery registry between January 2012 and December 2014. Patients were risk stratified by revised cardiac risk index category and compared poMI between patients who did or did not receive a preoperative cardiology consultation. We then used logistic regression analysis to compare the rate of poMI across hospitals grouped into quartiles by rate of preoperative cardiology consultation.

RESULTS

Our study population comprised 5191 patients undergoing open peripheral arterial bypass (n = 3037), open abdominal aortic aneurysm repair (n = 332), or endovascular aneurysm repair (n = 1822) at 29 hospitals. At the patient level, after risk-stratification by revised cardiac risk index category, there was no association between cardiac consultation and poMI. At the hospital level, preoperative cardiac consultation varied substantially between hospitals (6.9%-87.5%, P <0.001). High preoperative consulting hospitals (rate >66%) had a reduction in poMI (OR, 0.52; confidence interval: 0.28-0.98; P <0.05) compared with all other hospitals. These hospitals also had a statistically greater consultation rate with a variety of medical specialties.

CONCLUSIONS

Preoperative cardiology consultation for vascular surgery varies greatly between institutions, and does not appear to impact poMI at the patient level. However, reduction of poMI was noted at the hospitals with the highest rate of preoperative cardiology consultation as well as a variety of medical services, suggesting that other hospital culture effects play a role.

The impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery: a cohort study

PurposeAmbulatory surgery is a major area of surgical and anesthetic practice, and preoperative clinics are being increasingly used for low-risk surgical procedures. This study investigated the impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery.MethodsThis was a retrospective cohort study of 968 consecutive patients undergoing cataract surgery. Details of medical conditions, surgical, anesthetic, and postoperative information were collected from medical records. A logistic regression model was developed using propensity score adjustment for baseline characteristics.ResultsOut 968 patients included, 240 (24.7%) underwent outpatient preoperative evaluation. There were no perioperative major cardiovascular events. Hypertension occurred in 319 (33%) patients, accounting for 79.7% of all adverse events. Preoperative evaluation resulted in a lower hypertension rate after adjustment for propensity score (OR=0.6; 95% CI 0.41-0.93); no effects were observed on posterior capsule rupture and emergency visits/hospitalization within 7 days of surgery. Eighty-nine patients (9.3%) had an initial systolic pressure ≥180 mm Hg, which was not associated with higher risk of posterior capsule rupture (P=0.158) or postoperative adverse events (P=0.902). Median waiting time to surgery was 6 and 2 months for evaluated and non-evaluated patients, respectively (P<0.001).ConclusionsIn the context of low-risk surgery and no major perioperative and postoperative outcomes, it appears that outpatient preoperative evaluation has no role in reducing adverse events in cataract surgery candidates. Despite fewer hypertensive episodes observed in evaluated patients, these episodes were not associated with any medical or surgical outcomes.

Preoperative Consultations

Preoperative consultation is an important intervention that likely has most benefits for intermediate-risk to high-risk patients undergoing major surgery. Consultation rates are likely increasing and there is significant practice variation in the use of consultation. Consultations should be available within a well-organized and coordinated process of preoperative assessment. Preoperative consults should be accessible to anesthesia and surgical teams involved in the procedure and to the providers involved in postoperative care. The role of preoperative consultation should evolve as a rational approach and emerge as a value-based service. New payment methodologies are likely to facilitate appropriate use of this important resource.

Value of interactive scanning for improving the outcome of new-learners in transcontinental tele-echocardiography (VISION-in-Tele-Echo) study

BACKGROUND

Point-of-care (POC) echocardiography may be helpful for mass triage, but such a strategy requires adequately trained sonographers at the remote site. The aim of this study was to test the feasibility of using a novel POC echocardiography training program for improving physicians' imaging skills during preanesthetic cardiac evaluations performed in a community camp organized for treating cataract blindness.

METHODS

Seventeen physicians were provided 6 hours of training in the use of POC echocardiography; nine were taught on site and eight were taught online through a transcontinental tele-echocardiography system. The trained physicians subsequently scanned elderly patients undergoing cataract surgery. The quality of images was graded, and agreement between local physicians' interpretations and Web-based interpretations by worldwide experts was compared.

RESULTS

A total of 968 studies were performed, with 660 used for validating physicians' competence. Major cardiac abnormalities were seen in 136 patients (14.2%), with 32 (3.3%) deemed prohibitive to surgery in unmonitored settings. Although good-quality images were obtained more frequently by physicians trained on site rather than online (P = .03), there were no differences between the two groups in agreement with expert interpretations. The majority of physicians (70.6%) expressed satisfaction with the training (average Likert-type scale score, 4.24 of 5), with no difference seen between the two groups. The training resulted in significant improvements in self-perceived competence in all components of POC echocardiography (P < .001 for all).

CONCLUSIONS

This study establishes the feasibility of using short-duration, one-on-one, personalized transcontinental tele-echocardiography education for wider dissemination of echocardiographic skills to local physicians in remote communities, essential for optimizing global cardiovascular health.

Preanesthesia evaluation for ambulatory surgery: do we make a difference?

PURPOSE OF REVIEW

Ambulatory surgery is considered low risk; however, both surgery-related and patient-related factors combine to determine the overall risk of a procedure. The preanesthesia evaluation is useful to gather information and determine whether additional testing or medical optimization is necessary prior to surgery with the goal to prevent adverse events and improve outcomes.

RECENT FINDINGS

Recent literature focused on the preanesthesia evaluation provides guidelines for patient-centered testing. Routine, protocolized preoperative testing is expensive and has not shown to improve outcomes. The preanesthesia visit is useful for patient evaluation, not specifically testing, but for the synthesis of information, medical optimization, additional targeted testing if indicated, assessment of risk, and plan for perioperative management.

SUMMARY

Current literature supports a preanesthesia visit that focuses on individual patient evaluations and patient-directed effective interventions. This is in contrast to the previous routine, protocolized preoperative preparations. The challenge for anesthesiologists lies in understanding both surgery-specific and patient-specific risk factors, and targeting interventions to optimize the outcomes.

Preoperative risk assessment--from routine tests to individualized investigation

BACKGROUND

Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications.

METHOD

This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies.

RESULTS

The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period.

CONCLUSION

In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.

Preoperative consultations for medicare patients undergoing cataract surgery

IMPORTANCE

Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service.

OBJECTIVE

To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556,637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89,817 individuals who underwent surgery from 2005 to 2006.

MAIN OUTCOMES AND MEASURES

Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery.

RESULTS

The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics.

CONCLUSIONS AND RELEVANCE

Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.