Is a Preoperative Screening Clinic Cost-Effective?

Chaper Outline

• Introduction

• Preoperative Assessment Settings

• Consultations

• Collaborative Care

  • Brain Health

  • Frailty

  • Preoperative Anemia

  • Chronic Pain and Surgery

  • Shared Decision Making

• Operating Room Cancellations

• Areas of Uncertainty

INTRODUCTION

Preoperative clinic visits have been shown to improve patient satisfaction, reduce unnecessary testing and consultation, and decrease length of hospital stay and in-hospital mortality postoperatively. Optimization of a patient’s medical condition before surgery has also been shown to decrease operating room (OR) cancellations and delays. Furthermore, preoperative optimization aligns with the overarching goal of the Centers for Medicare and Medicaid Services (CMS) of providing comprehensive value-based care (VBC). Since the introduction of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, CMS has steadily moved toward alternative payment models focusing on value-based payments and measurements and away from more individual fee-for-service payment models. VBC is defined as a health care reimbursement model that is based on positive outcomes for patients relative to the cost. Preoperative clinics and optimization strategies are examples of collaborative, multidisciplinary care pathways that create value. The preanesthetic assessment was initially instituted to improve OR efficiency and focused on strategies to reduce delays and cancellations on the day of surgery. Patients were often seen only a few days before surgery, limiting the ability to intervene on poorly controlled conditions. Since the mid-1990s, the focus of preoperative clinics and consultations has evolved, shifting toward optimization and management of modifiable risk factors and chronic illnesses. This has led to a push for earlier planning of patient perioperative care as soon as there is contemplation of surgery. There is evidence that suggests that up to 20% of patients seen in presurgical preoperative assessment clinics have modifiable risk factors that could reduce postoperative complications. ^, Preoperative consultations and clinics have a valuable role to play in a patient’s surgical experience and outcomes.

PREOPERATIVE ASSESSMENT SETTINGS

The preoperative screening clinic is one example of a preoperative assessment alternative; others include a telephonic interview, an internet health screen, a primary care physician evaluation, and a mail-in health quiz. Frequently, a visit to a preoperative clinic is combined with another tool such as the health survey, and these results are used to identify patients requiring laboratory testing or a consultation with the anesthesiologist. Since the mid-1990s, preoperative testing clinics have gained in popularity. A survey of anesthesiology programs found the presence of a preoperative testing clinic in 88% of university and 70% of community hospitals in 1998. Similar results were obtained after a survey in Ontario, Canada: 63% of 260 hospitals had preoperative clinics. Options for multiple avenues of clinical care have allowed for further accessibility for patients. For example, a study was done evaluating remote preoperative patients in rural areas of Northern Territories in Australia, which showed positive perceptions by patients on technical quality, efficacy, patient experience, and patient preferences. Additionally, the COVID-19 pandemic shifted many (if not all) preoperative assessment clinics to a virtual realm temporarily, and some have remained remote. This allowed institutions to consider once again how to navigate providing effective quality and comprehensive care.

CONSULTATIONS

In a patient with known or suspected cardiac diseases undergoing noncardiac surgery, there is still controversy on the best way to conduct the assessment. Cardiac consultations without a clear question and only “clearance” can be unnecessary and lead to delays, additional cost, and inconvenience to the patient and hospital. Fischer et al. found that the introduction of the preoperative clinic led to a significant reduction in the number of cardiology, pulmonary, and medical consultations. After the introduction of stringent guidelines for consultation, Tsen and colleagues reduced the rate of cardiology consultations in patients undergoing noncardiac surgery from 1.46% (914 patients) to only 0.49% (279 patients; p < .0001), despite an increase in patient acuity over the 6-year study period. They also found that after the introduction of an electrocardiogram (ECG) educational program, they were able to reduce consultations for ECG abnormalities from 43.6% to 28.5% ( p < .0001).

Defining the role of the consultant is important in the preoperative setting. All consultations should provide a careful assessment of risk, and the success of a consultation is improved when the question is specific. An additional role of the consultant should be to advise on future health and additional postoperative strategies to reduce the patient’s future risk, if possible.