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Vernooij JEM, Boerlage RM, Doggen CJM, Preckel B, Dirksen CD, van Leeuwen BL, Spruit RJ, Festen S, van der Wal-Huisman H, van Basten JP, Kalkman CJ, Koning NJ. Is a preoperative multidisciplinary team meeting (cost)effective to improve outcome for high-risk adult patients undergoing noncardiac surgery: the PREPARATION study-a multicenter stepped-wedge cluster randomized trial. Trials 2023; 24:660. [PMID: 37821994 PMCID: PMC10568883 DOI: 10.1186/s13063-023-07685-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND As a result of increased life expectancy and improved care for patients suffering from chronic disease, the number of patients with multimorbidity requiring surgical intervention is increasing. For complex surgical patients, it is essential to balance the potential benefits of surgical treatment against the risk of permanent loss of functional capacity and quality of life due to complications. European and US guidelines on perioperative care recommend preoperative multidisciplinary team (MDT) discussions for high-risk noncardiac surgical patients. However, the evidence underlying benefits from preoperative MDT meetings with all relevant perioperative specialties present is limited. The current study aims to investigate the effect of implementation of preoperative MDT discussions for high-risk patients undergoing noncardiac surgery on serious adverse events. METHODS/DESIGN PREPARATION is a stepped-wedge cluster randomized trial in 14 Dutch hospitals without currently established preoperative MDT meeting. The intervention, preoperative MDT meetings, will be implemented sequentially with seven blocks of 2 hospitals switching from control (preoperative screening as usual) to the intervention every 3 months. Each hospital will be randomized to one of seven blocks. We aim to include 1200 patients. The primary outcome is the incidence of serious adverse events at 6 months. Secondary outcomes include (cost)effectiveness, functional outcome, and quality of life for up to 12 months. DISCUSSION PREPARATION is the first study to assess the effectiveness of a preoperative MDT meeting for high-risk noncardiac surgical patients in the presence of an anesthesiologist. If the results suggest that preoperative MDT discussions for high-risk patients are (cost)-effective, the current study facilitates implementation of preoperative MDT meetings in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT05703230. Registered on 11/09/2022.
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Affiliation(s)
- Jacqueline E M Vernooij
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands.
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Romijn M Boerlage
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschedé, The Netherlands
- Clinical Research Center, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam Public Health, Quality of Care, Amsterdam Cardiovascular Science, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Carine J M Doggen
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschedé, The Netherlands
- Clinical Research Center, Rijnstate Hospital, Arnhem, The Netherlands
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam Public Health, Quality of Care, Amsterdam Cardiovascular Science, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Carmen D Dirksen
- Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rutger J Spruit
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Suzanne Festen
- University Center for Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Hanneke van der Wal-Huisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jean P van Basten
- Department of Urology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Cor J Kalkman
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Nick J Koning
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
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Vernooij JEM, Koning NJ, Geurts JW, Holewijn S, Preckel B, Kalkman CJ, Vernooij LM. Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review. Anaesthesia 2023; 78:607-619. [PMID: 36823388 DOI: 10.1111/anae.15988] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 02/25/2023]
Abstract
Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.
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Affiliation(s)
- J E M Vernooij
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - N J Koning
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - J W Geurts
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - S Holewijn
- Department of Vascular Surgery, Rijnstate Hospital, the Netherlands
| | - B Preckel
- Department of Anaesthesia, Amsterdam UMC, Amsterdam, the Netherlands
| | - C J Kalkman
- University Medical Centre, Utrecht, the Netherlands
| | - L M Vernooij
- Department of Anaesthesia, University Medical Centre Utrecht, the Netherlands
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Jonker G, Booij E, Vernooij JEM, Kalkman CJ, ten Cate O, Hoff RG. In pursuit of a better transition to selected residencies: a quasi-experimental evaluation of a final year of medical school dedicated to the acute care domain. BMC Med Educ 2022; 22:807. [PMID: 36419057 PMCID: PMC9684806 DOI: 10.1186/s12909-022-03871-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Medical schools seek the best curricular designs for the transition to postgraduate education, such as the Dutch elective-based final, 'transitional' year. Most Dutch graduates work a mean of three years as a physician-not-in-training (PNIT) before entering residency training. To ease the transition to selected specialties and to decrease the duration of the PNIT period, UMC Utrecht introduced an optional, thematic variant of the usual transitional year, that enables the development of theme-specific competencies, in addition to physicians' general competencies. METHODS We introduced an optional transitional year for interested students around the theme of acute care, called the Acute Care Transitional Year (ACTY). This study aimed to evaluate the ACTY by judging whether graduates meet postgraduate acute care expectations, indicating enhanced learning and preparation for practice. In a comprehensive assessment of acute care knowledge, clinical reasoning, skills, and performance in simulations, we collected data from ACTY students, non-ACTY students interested in acute care, and PNITs with approximately six months of acute care experience. RESULTS ACTY graduates outperformed non-ACTY graduates on skills and simulations, and had higher odds of coming up to the expectations faculty have of a PNIT, as determined by global ratings. PNITs did better on simulations than ACTY graduates. DISCUSSION ACTY graduates show better resemblance to PNITs than non-ACTY graduates, suggesting better preparation for postgraduate acute care challenges. CONCLUSION Transitional years, offering multidisciplinary perspectives on a certain theme, can enhance learning and preparedness for entering residency.
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Affiliation(s)
- Gersten Jonker
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Eveline Booij
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | | | - Cor J. Kalkman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Olle ten Cate
- Center for Research and Development of Education, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Reinier G. Hoff
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, the Netherlands
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Vernooij JEM, Smulders PSH, Geurts JW, Kalkman CJ, Koning NJ. Preoperative multidisciplinary team decisions for high-risk patients scheduled for noncardiac surgery-a retrospective observational study. Can J Anaesth 2021; 68:1769-1778. [PMID: 34553305 DOI: 10.1007/s12630-021-02114-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Preoperative multidisciplinary team (MDT) meetings are recommended for patients at high risk for perioperative complications and mortality, although the underlying evidence is scarce. We aimed to investigate the effect of MDT decisions on patient management and patient outcome. METHODS We conducted a single-centre retrospective cohort study including all noncardiac surgical patients selected for discussion at preoperative MDT meetings from January 2017 to December 2019 (N = 120). We abstracted preoperative data, MDT decisions, and patient outcomes from the electronic health records for analysis. RESULTS Of the 120 patients registered for an MDT meeting, 43% did not undergo their initially planned surgery. Only 27% of patients received perioperative management as planned before the MDT meeting. Most surgery cancellations were the MDT's decision (22%) or the patient's decision before or after the MDT discussion (10%). Postoperative complications occurred in 28% of operated patients, and postoperative mortality was 4% at 30 days and 10% at three months, most of which was attributable to postoperative complications. Non-operated patients had a 7% mortality rate at 30 days and 9% at three months. Alterations of perioperative management following MDT discussion were associated with fewer cases of extended length of hospital stay (> ten days). CONCLUSION This study shows that preoperative MDT meetings for high-risk noncardiac surgical patients altered the management of most patients. Management alterations were associated with fewer hospital admissions of long duration. These results should be interpreted with appropriate caution given the methodological limitations inherent to this small study.
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Affiliation(s)
- Jacqueline E M Vernooij
- Department of Anesthesiology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.
| | - Pascal S H Smulders
- Department of Anesthesiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - José W Geurts
- Department of Anesthesiology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Cor J Kalkman
- Department of Anesthesiology, University Medical Centre, Utrecht, The Netherlands
| | - Nick J Koning
- Department of Anesthesiology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
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