The Value of Preoperative Assessment

Value

The pursuit of value in health-care is an increasingly important focus of health policy discourse. At a basic level, value is defined as health outcomes that matter to the patient, divided by cost. As Porter wrote, “value” is not a code word for cost reduction. Value depends on results, not just inputs, and cannot be measured by considering only the cost or volume of services delivered. Frequently hospital administrators focus only on increasing procedural volume as a measure of operating room “success”with little attention paid to both the short- and long-term metrics, lasting well beyond day of discharge, that determine the actual value that the procedure provided. Current commonly used measures are also a problem. Although 30-day morbidity and mortality are important, the patient would certainly hope that the results of a procedure are of far more benefit than just avoiding death and complications.

The shift from volume to value is hopefully at a tipping point but will be difficult to achieve if budgets are siloed and the overall impact of a procedure across patients’ health-care trajectories in terms of outcomes achieved for resources expended is not considered. Administrators who remain focused on siloed budgets may cite the “expense” of providing preoperative assessment services that could maximally impact value for the patients undergoing procedures at their institutions. The total expenses for the full cycle of care for each patient’s condition must be included. Preoperative services should be available that will maximize the value of the overall cycle of care, rather than attempting to reduce costs in individual siloed budgets. Lowering costs in siloed budgets could actually increase overall costs of the surgical episode if downstream impact is not considered.

High-value interventions offer the patient benefits more than harm, based on high-quality preoperative risk assessment and shared decision-making. Risk–benefit analysis has never been straightforward, but it has become even more complex with recognition that the appropriateness of care depends on patient-specific preferences and goals. The task of ensuring high-value preoperative assessment is therefore inextricable from the process of developing patient-centered, shared decision-making processes in the preoperative setting. In addition to undermining value, inappropriate care is a threat to the ethical integrity of surgical practice.

Preoperative Assessment Elements

Preoperative assessment is done after the decision to perform a procedure is made; it is defined as a set of multidisciplinary tasks that must be completed prior to beginning any procedure. These steps cannot be eliminated, but they can be done in different ways at different institutions, based on patient acuity and risk of surgery performed. As an example, Table 4.1 lists the clinical and regulatory elements of preoperative assessment and how these are achieved at Brigham and Women’s Hospital. Each institution should evaluate a similar list of preoperative elements and decide where and by whom each is performed, with an eye toward maximizing value throughout the continuum of care. A careful analysis will determine how best to provide preoperative care at individual institutions. For example, at Brigham and Women’s Hospital, most patients having in-person preoperative assessment visits are classified as American Society of Anesthesiologists physical status III and IV, generally having higher-risk procedures. Patients who are deemed healthier by an internal algorithm and who are having lower-risk surgery are screened by phone, with the anesthesia assessment and anesthesia consent done immediately prior to the procedure. Regardless of whether phone or in-person assessment is done, metrics must reflect that completion of all required elements occurs. Shifting some of these elements to the day of the procedure may give a false impression that eliminating preoperative clinic functions saves cost. Unless the cost of the portion of day-of-surgery resources devoted to what could have been done preoperatively is contained separately in the overall operating room budget, however, these costs are not actually being eliminated; they are just hidden within the operating room budget costs. In addition, the cost per minute of clinic time is much less than the cost per minute of operating room time, so any tasks done on the day of the procedure will cost proportionately more. The cost of day-of-surgery delays and cancelations must be considered as well.

For example, institutions without robust preoperative assessment systems usually have nursing resources assigned on the day of surgery just to perform nursing functions that could have been done in the preoperative clinic. Patients may be inconvenienced because these institutions have them arrive hours earlier than they might have needed to otherwise, so that operating rooms can start on time. Anesthesiologists may discover clinical issues and medication errors that result in delays, cancelations, or at worst proceeding with a case that would otherwise not have been done if sufficient time had been available to address these issues. Perhaps thinking about reassigning resources currently used on the day of surgery to perform preoperative assessment functions would shift resources with a positive financial impact. Hospitals with robust preoperative systems can perform all of these functions prior to the day of the procedure; nursing as well as anesthesia and surgical staff can spend much less time per patient on their surgical day.

Goals of Preoperative Assessment

Good preoperative assessment systems include performing surgical population management, ensuring that resources are focused throughout the care cycle to obtain the highest possible value from the procedure. This requires triaging populations preoperatively to perioperative care pathways. An understanding of the intended goals of a well-designed preoperative assessment system is essential. Protocols and pathways need to be evidence based as much as possible, with regular review and modification as evidence evolves. In addition, institutional strategies that result in new surgical or procedural service lines need to be analyzed to determine the impact of additional volume on preoperative resources and the need to modify pathways and protocols. Good preoperative assessment systems are never static or generic.

An understanding of the intended goals of a well-designed preoperative assessment system is essential.

Overall goals are outlined here and will be discussed in detail in the following sections.

• 1.

  Ensuring appropriateness of procedure and high-quality shared decision-making

• 2.

  Completion of surgical, anesthesia, and nursing assessments to ensure proper risk assessment and optimization; need to ensure optimization of old issues and diagnosis of new issues that could impact outcomes

• 3.

  Population management assigning patients in specific groups to appropriate perioperative pathways to ensure high-value care; examples include enhanced recovery after surgery (ERAS), patients at risk for significant pain issues post procedure, and geriatric patients deemed to be frail and/or cognitively impaired

• 4.

  Completion of regulatory requirements

• 5.

  Completion and review of testing deemed necessary to ensure proper assessment and optimization

• 6.

  Documentation and transmission of all important information to downstream providers, including information impacting setup of the operating room (e.g., latex allergy), assignment of the teams (e.g., Jehovah’s Witnesses members, difficult airways), and issues reflecting patient goals and values, (e.g., do not resuscitate/do not intubate [DNR/DNI] statements, advance care directives, health-care proxies)

• 7.

  Patient and family education