The Preoperative Process

The evidence supporting the implementation of preoperative testing clinics is largely derived from retrospective studies. Historical data suggest that the introduction of a system for preoperative testing is associated with increased patient satisfaction, as well as reductions in unnecessary laboratory testing and outside consultations. Previous data also support a reduction in day-of-surgery cancellations and OR delays and reaffirm the cost savings gained through reductions in unnecessary laboratory testing. From these studies, it is apparent that local factors such as OR volume and type, patient mix, and even geographic considerations will strongly influence the decision to have or use a preoperative clinic. Evidence in areas of benefit that have been attributed to preoperative clinics will be considered individually ( Table 3-1 ).

Very few randomized controlled trials (RCTs) have addressed the cost of having versus not having a clinic. Schiff and colleagues randomly assigned 207 patients to be seen either in an anesthesia preoperative evaluation clinic (APEC) or in the inpatient ward setting. After exclusions and patient refusal, data were available for analysis on 94 patients seen in the APEC and on 78 patients interviewed in the ward. The total time for the consultation was shorter for the APEC 18.3 ± 5.6 versus 26.7 ± 8.4 minutes for the ward visits ( p < 0.001). The type of anesthesia, complexity of the surgery, and preanesthetic visit location significantly influenced the length of the preoperative visit. They calculated that, on the basis of the cost of the anesthetist, the APEC could result in a calculated savings of 6.4 Euro per patient. All patients answered a questionnaire addressing how much they understood after the preanesthetic interview. The authors found that more information was passed on to the patients seen in the APEC compared with those seen in the ward visits ( p < 0.01). On analysis they found that younger, more educated patients seen in the APEC had the highest information gain scores. They did not study day-of-surgery admissions or outpatient surgery patients, and all patients were scheduled for surgery requiring a general endotracheal anesthesia, thus limiting the broad applicability of their findings.

The most recent American College of Cardiology/American Heart Association (ACC/AHA) perioperative guidelines provide recommendations for the preoperative workup in patients with significant cardiac risk factors undergoing noncardiac surgery. The European Society of Anesthesiology recently published similar guidelines. These guidelines help identify and design perioperative strategies that aim to reduce perioperative risk of morbidity and mortality. In general, patients with known coronary disease should receive a careful cardiac baseline assessment; this includes a review of current testing results and new tests as warranted by the history and physical examination. When older than 50 years, even asymptomatic patients may require careful cardiac evaluation if there are associated cardiac risk factors. The advantage of the preoperative testing clinic is the ability of the anesthesiologist to oversee the appropriate testing and consultations. When used appropriately, these types of guidelines can lead to a standardized preoperative approach that can be undertaken in several different settings, including inpatient and outpatient settings. It remains to be shown whether this can lead to perioperative cost savings.

Laboratory Testing

Inappropriate laboratory testing is costly. Large-scale preoperative laboratory testing in healthy individuals leads to an increase in false-positive results and inappropriate workups (see Chapter 2 ). Several studies in healthy patients have demonstrated that screening laboratory testing rarely provides new information that would not otherwise have been obtained from a thorough history and physical examination. When compared with outside referral physicians, anesthesiologists order fewer preoperative laboratory tests, and this may be associated with financial benefit. Starsnic and colleagues examined testing patterns in two groups of patients. Each group had approximately 1500 patients; laboratory tests were ordered by either their surgeon (group S) or by an anesthesiologist seeing them in the preoperative clinic (group A), although in group A surgeons were still allowed to order additional tests if required. Except for concurrence on the complete blood count, anesthesiologists consistently ordered fewer tests compared with surgeons, which resulted in a 28.6% reduction in testing and an estimated cost savings of $20.89 per patient. In a similar study, Vogt and Henson found that 72% of tests ordered by surgeons were “not indicated” according to anesthesiologists, and the net cost of unindicated preoperative tests was $15.75 per patient. Fischer compared a 6-month period before and after the introduction of a clinic directed by anesthesiologists and observed a 59.3% reduction in laboratory testing, or $112.09 per patient. Power and Thackray reported a 38% reduction in preoperative laboratory testing, leading to an estimated saving of $25.44 per patient in 201 elective ear, nose, and throat (ENT) patients after the introduction of testing guidelines that included a review by an anesthesiologist. More recently, Finegan and colleagues performed a prospective double-cohort study. In group 1, testing followed usual practice according to pre-established surgery-specific clinical pathway guidelines. In contrast, testing for group 2 was instituted only through the anesthesiologist attending or resident’s recommendation. Group 1 included 507 patients with a mean preoperative laboratory cost of $124 compared with only $95 for the 431 patients in group 2 ( p < 0.05). When a subgroup analysis was performed, the average cost of residents’ ordering was $110, similar to group 1, whereas attending physicians’ cost averaged $74, approximately $36 less than residents ( p < 0.05). Although group 2 had slightly more complications, these were not related to the preoperative tests. This study supports a reduction in unnecessary laboratory testing when directed by anesthesiologists and demonstrates that education and experience may also contribute to laboratory savings.

Despite these positive results, reductions in laboratory testing cannot all be attributed to preoperative clinics because laboratory testing can be reduced even without a preoperative clinic visit. In one of the few RCTs available on preoperative testing, Schein and colleagues looked at preoperative testing patterns in cataract surgery patients. They randomly assigned 18,189 patients scheduled for cataract surgery into two groups; all patients had a history and physical examination by a health care provider. The “testing” group received additional routine laboratory tests and an electrocardiogram (ECG). In comparison, the “no-testing” group only had tests ordered if indicated by the history and physical examination. They found no difference in outcome of patients with or without testing, and both groups had a similar rate of 31 adverse events per 1000 surgeries.

Thus, despite the dearth of RCTs, the current evidence supports anesthesiology-directed preoperative laboratory testing. This practice can result in substantial cost saving and benefit to the patient. The positive evidence does not mean that a preoperative testing clinic is always cost-effective because it may be possible to influence testing patterns in the absence of a clinic visit. Savings in preoperative laboratory screening may be achieved by improved education of other physicians and the development of clinical pathways by anesthesiologists for surgical patients.

Consultations

Cardiology consultations are a frequent source of frustration in preoperative testing and often do not result in significant alterations in management; instead, they may lead to delays, additional cost, and inconvenience to the patient and hospital. Fischer 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 < 0.0001), despite an increase in patient acuity over the 6-year study period. They also found that after the introduction of an ECG educational program, they were able to reduce consultations for ECG abnormalities from 43.6% to 28.5% ( p < 0.0001).

These groups were able to demonstrate that consultations, cancellations, and delays in surgical bookings could be reduced through the use of preoperative testing clinics. In addition, their data support the development of guidelines for preoperative assessment and education for those involved in preoperative assessment.

Defining the “role of the consultant” is important in the preoperative setting. Unfortunately, many consultations are vague and do not lead to substantial requirements for additional testing or provide new recommendations for perioperative care. 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.

Same-Day Cancellations

OR cancellations are associated with high cost, and every effort is made to decrease these. One major purported benefit of the preoperative screening clinic is a reduction in day-of-surgery delays because the clinic can ensure that patients are medically ready for surgery. Preliminary research suggests that evaluation of ASA physical status III and IV patients in a preoperative evaluation clinic (PEC) is associated with the largest net benefit in terms of reductions in day-of-surgery delays and cancellations.

There are several reports from individual institutions describing reduction of OR cancellations after the introduction of a preoperative testing clinic, although no randomized trials on preadmission screening clinics have been conducted. Correll and colleagues collected data on more than 5000 patients seen in their preoperative clinic over a 14-month period. In that time, 680 medical issues were identified that required further investigation before surgery; 115 of these issues were new medical problems. New problems had a greater possibility of delay (10.7%) or cancellation (6.8%) compared with existing problems: 0.76% and 1.8%, respectively. In a similar study, Ferschl and colleagues compared preoperative testing status between patients assigned to same-day surgery and general ORs. Over a 6-month period, 6524 patient charts were reviewed. They found that 8.4% (98 of 1164) of same-day surgery patients’ appointments were cancelled if seen in the clinic versus 16.5% (366 of 2252) of those of patients not seen in the clinic ( p < 0.001). This was even more dramatic for the general OR patients; they found a cancellation rate of 5.3% for those using the clinic (87 of 1631) compared with 13.0% (192 of 1477) in those not using the preoperative clinic ( p < 0.001). In addition, the preoperative clinic patients were more likely to go to the OR earlier or on time compared with those in the non–preoperative clinic group. These data support the findings reported by Fischer, who was able to demonstrate an 87.9% reduction in OR cancellations from 1.96% (132 of 6722) to 0.21% (16 of 7485) after the formation of the preoperative clinic. Earlier studies have also supported reductions in both cancellations and length of stay after the introduction of a preoperative testing clinic. However, these data were collected at the same time that institutions were changing from an inpatient to an ambulatory surgery model, so the impact of the clinic per se is questionable.

More recently, a survey addressing the impact of PECs on perceived prevalence of day-of-surgery delays was distributed to attendees at the 2005 ASA annual meeting. Twenty-three percent (1857) of attendees completed the survey; of these, 69% worked at institutions using a PEC. For patients evaluated in a PEC, respondents reported that the incidence of “perceived delays over 10%” was 23% of patients compared with 57% of patients not using a PEC, who were instead first evaluated by an anesthesiologist on the day of surgery ( p < 0.001). Sixteen percent of respondents reported that they had a system to evaluate patients before surgery, but not through a PEC; in this group of patients the incidence of perceived delays over 10% was 22%, which was similar to the PEC group. In institutions where PEC was available, the perceived prevalence of day-of-surgery delays due to missing information was higher at 63% versus 42% of respondents at institutions without a PEC ( p < 0.001). Overall, these data suggest that assessment before the day of surgery reduces, but does not eliminate, delays on the day of surgery. There are several reasons why a PEC might not eliminate delays totally. These include different criteria by anesthesiologists in the PEC versus on the day of surgery, incomplete recommended workups or pending results, and the patients in institutions with PECs may have more complex conditions compared with those in facilities without any PEC mechanism. It is important to note that in this study an anesthesiology evaluation, not the PEC per se, led to similar delay rates. Similar results were described by Ferschl et al, who found that an anesthesiologist-directed preoperative interview reduced day-of-surgery cancellations and delays for outpatients. In this study, however, among same-day surgical admissions, preoperative evaluation only reduced cancellations, not delays on the day of surgery.

The studies by Holt et al and Ferschl et al suggest that the preoperative evaluation can account for some of the cancellations or delays encountered in the OR; however, there are other factors to be considered. Fischer found that 90% of cancellations occurred just before the patient entered the OR. Fischer evaluated the impact of cancellations over a 2-year period and found that, on average, a cancellation resulted in 97 minutes of OR downtime; this was in addition to the usual 30 minutes of turnover time between cases. Frequent causes of cancellations identified were alterations in the surgeon’s schedule, patient’s preference, and OR scheduling limitations (i.e., cases running overtime and emergency add-ons). These issues will not be influenced by the presence of a preoperative screening clinic. It is conceivable that the preoperative screening clinic could provide a “bank” of available patients for call-up at short notice in the event of a gap in the OR schedule, but there are no data documenting the success of this approach.

Preoperative Clinic Structure

The implementation of educational programs and the development of clear guidelines and protocols can result in improved efficiency in the clinic, as well as improved communication and patient satisfaction. Recent studies have shown that development of proactive, cooperative comanagement models for perioperative management of high-risk patients undergoing complex surgery improves both quality and efficiency. The staffing models of preoperative clinics may be diverse, and clinics staffed by anesthesiology attendings, residents, dedicated nurse practitioners, and nurses have been described. The structure of a preoperative clinic may present significant opportunities for cost savings. Cantlay and colleagues described improved outcomes after introducing a clinic with consultant anesthesiologists to evaluate complex vascular patients. Varughese and colleagues reported significant financial benefit with the creation of a nurse practitioner–assisted PEC. At this hospital, they substituted nurse practitioners for two anesthesiology attending staff in the preoperative clinic; one attending remained assigned to the clinic for consultations. The nurse practitioners received training in preoperative assessment. After the introduction of the nurse practitioners into the clinic, the incidence of complications, preoperative patient time, and patient satisfaction were monitored at three intervals during a 1-year period. There was no change in patient satisfaction, complication rates, or time spent in the preoperative clinic. After the substitution of the nurse practitioners in the clinic, the group was able to provide two more anesthesiologists to the OR. The increase in anesthesiologist availability resulted in a significant increases in margin for the hospital and the group by increasing billable hours for the physicians, and the addition of two new ORs led to increased case numbers. Clearly, the opportunity at this institution was unique; however, it provides an example of redistribution of resources resulting in a more effective preoperative clinic.

Very few studies have evaluated the consequences of the organization of patient flow of a preoperative assessment clinic on its performance. One such study by Edward et al evaluated the performance of clinics at two Dutch university hospitals that were designed differently. This was done by measuring patient flow time, various procedure times, and total waiting time. They found a significant difference in patient flow time between the two clinics. The patient flow time was longer when ECGs and venipuncture were performed at the general outpatient laboratory than when they were done at the preoperative assessment clinics because of longer waiting times. Also, more tests were requested when they were performed at the preoperative assessment clinic. Based on analysis of patient flow and clinic operations, alterations were made in clinic processes at a tertiary hospital preoperative clinic. These led to increased patient satisfaction and a reduction in waiting time with minimal economic impact.

The Patient

On one hand, anesthetic assessment in an outpatient clinic reduces preoperative patient anxiety and improves costs. On the other hand, it is possible that the savings of the outpatient preoperative clinic may, in fact, represent cost shifted to the patient. For instance, a visit to the preoperative screening clinic may require additional time off work for the patient or the caregiver. Similarly, geographic constraints in rural areas of the country can make the preoperative clinic visit a scheduling challenge. Seidel and colleagues examined geographic barriers to visiting the preoperative clinic and found that, for patients having surgery at an urban tertiary care center, the likelihood of attending preoperative clinic visits was diminished if the patient lived farther away from the hospital.

Unexpected Area of Benefit

One value of the preoperative clinic that is underappreciated is the opportunity for compliance with various regulations. Since the institution of the Patient Self-Determination Act in 1991, all health care facilities receiving Medicare and Medicaid funding need to recognize advance directives such as a living will and durable power of attorney. Most often, this involves providing patients with a written information sheet and inquiring if they have completed the forms. The preoperative clinic visit provides an unusual opportunity for discussion, at a time when families are frequently already involved and the patient is not yet hospitalized. Grimaldo and colleagues randomly assigned elderly patients attending a PEC into “standard” and “intervention” groups. The intervention group attended a session addressing the importance of discussing end-of-life issues and preferences with their families. They found that 87% of patients in the intervention group had discussions with proxies versus 66% in the control group ( p = 0.001). This is an unexpected benefit of the preoperative clinic. For assessment of the impact on cost, it would be useful to compare the preoperative screening clinic cost with the cost of compliance in a nonclinic setting in terms of hospital personnel, time, and space. Additionally, in any instance in which the preoperative screening clinic may improve compliance with hospital or government regulations, the cost of the clinic may be considered a wise investment if the risk of noncompliance is substantial and carries significant consequences.