Describing the value of preoperative assessment resembles the fable of six blind men trying to describe an elephant: Each comes across different parts and creates his own version of reality from that limited experience and perspective. Therefore, a clear definition of both value and preoperative assessment is necessary to inform the following discussion.
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.
Ensuring appropriateness of procedure and high-quality shared decision-making
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
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
Completion of regulatory requirements
Completion and review of testing deemed necessary to ensure proper assessment and optimization
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)
Patient and family education
Ensuring High-Quality Shared Decision-Making and Appropriateness of Care
Beyond outcomes, appropriateness also encompasses considerations of cost/risk. A high-value procedure offers a favorable outcome at a cost considered to be worthwhile based on the degree of likely benefit. Existing methods of ensuring the appropriateness of surgical care have attempted to maximize benefit and minimize harm by incorporating clinical evidence, surgeon qualifications, and hospital certification. Notably absent from these approaches is attention to whether the procedure is consistent with the patient’s overall preferences and values ( Fig. 4.1 ). Ensuring high-quality shared decision-making as a part of preoperative assessment also assumes appropriate discussion of additional risk attributable to comorbidities, reviewing advance care directives and assignment of health-care proxy, and discussion of special requests such as DNR/DNI statements and refusal of blood products. These discussions are critical to complete effectively as part of the preoperative assessment process.
At what point during the preoperative assessment period should shared decision-making discussions be held? Is this the responsibility of the referring physician, surgeon, proceduralist, or anesthesiologist? The patient should be making the final decision on the basis of the results of these discussions. As Fig. 4.1 suggests, high-quality shared decision-making may be best performed as a multistep process. The surgeon has the expertise to make the clinical decision regarding which operation is best for the patient’s diagnosis and can speak best to risks/benefits in this area. However, the impact of the patient’s comorbidities on the likelihood of achieving beneficial outcomes may be best addressed by anesthesiologists with expertise in perioperative medicine. The discussion incorporating specific patient goals and values should be done in this holistic context. All too often, the presence of a signed surgical consent obviates further discussion on whether a truly informed decision has been made or whether issues such as those noted earlier have been discussed preoperatively. Consent for anesthesia may be similarly uninformed. Regardless of opinion regarding where this responsibility lies, there is good evidence that the quality of current practice falls short in the domains of patient understanding, incorporation of patient values, and advance care planning, despite the presence of signed surgical consent at the time of the preoperative assessment. In a study of over 1000 preoperative patients, 8% could not identify their diagnosis, 10% could not identify their procedure, and 7% reported that they did not know the risks and benefits of different options. Half of those in this study scheduled for postoperative intensive care unit recovery were unaware of this need for the intensive care unit.
In the absence of high-quality shared decision-making in the preoperative period, patients fail to develop a clear sense of which risks and benefits are most important to them, and some remain unsure of which option is therefore best. Such deficits in decision-making may help account for intensity and cost of care at the end of life; nearly one-third of elderly Americans undergo surgery in the last year of life, most within the last month of life.
The data describing advance care planning during preoperative assessment are similarly discouraging. One study indicated that medical patients were 22 times more likely than surgical patients to have notes relating to end-of-life care. Another study of advance care planning before elective surgery found that nearly two-thirds of patients seen in the preoperative clinic after the surgical office visit had not completed an advance directive, and even among the patients who had completed one, nearly one-third were missing from the chart. Roughly one-half had a health-care proxy on file, and almost one-third reported a desire to talk further about advance care planning. Surgeons performing high-risk operations rarely discuss the potential need for prolonged mechanical ventilation/intensive care or elicit patient preferences about postoperative treatments ; having a patient sign anesthesia consent without these discussions preoperatively is problematic. This current pattern is at odds with the American Society of Anesthesiology and American College of Surgeons guidelines recommending preoperative discussion regarding implications of advance directives on intraoperative and postoperative care.
Although clinicians and our professional societies may agree with the importance of preoperative assessment incorporating discussions to address these issues and ensure high-quality shared decision-making, these lofty goals are difficult to achieve routinely. These deficits reflect several factors.
First, surgical and anesthesia training is generally lacking in these skills; a minority of residents express feeling comfortable performing key tasks such as conducting these preoperative discussions regarding advance care directives, patient goals and values, and perioperative code status. There are also cultural issues that may have narrowed discussion of anesthesia and surgical practice. For example, “Even with 4 years of medical school education and 4 years of residency training, most anesthesiologists are not (nor want to be) trained to deal with issues outside the immediate perioperative area.”
Second, the time it takes to incorporate these high-value discussions into preoperative assessment programs takes clinical resources. Hospital administrators may fail to realize the impact of allowing time to ensure high-quality decision-making on improving value by reducing inappropriate care that is not aligned with patient goals and values. In addition, ensuring an adequate discussion of risk/benefit may result in better patient selection for high-risk procedures, hopefully resulting in fewer patients likely to have complications that result in increased long-term health-care costs. As newer payment models such as bundled payments and accountable care organizations become more prevalent, there will be increasing emphasis on ensuring appropriate care and good patient selection to improve outcomes and reduce overall health-care costs. Until recognition of the importance of these discussions on value is widespread, it may be difficult to get the educational and clinical resources necessary to ensure these discussions occur routinely as a critical part of preoperative assessment.
Third, and finally, it is difficult to ensure that high-quality shared decision-making has occurred during preoperative assessment because there are currently no widely accepted metrics. There are, of course, standards for informed consent, as described by Joint Commission and Centers for Medicare and Medicaid Services (CMS) guidelines, which focus on description of the surgery and anesthesia, clinical risks and benefits, and treatment alternatives. However, metrics currently do not exist to ensure that these minimal standards, as well as incorporation of patient goals and values, are met. As demonstrated, signed consent does not equal high-quality shared surgical decision-making. Developing measures of decisional quality during preoperative assessment is an essential task for several reasons. First, measurement is necessary to evaluate the effectiveness of innovations intended to enhance shared decision-making. Second, it can facilitate use of payment incentives to drive implementation of evidence-based strategies. Finally, measurement tools will be necessary to identify populations at risk of experiencing low-quality decision-making processes and their negative sequelae. Despite its importance in guiding innovation, the process of developing and validating tools for measurement of preoperative decision quality is in its infancy.
Preoperative Assessment Should Ensure Appropriate Risk Assessment and Optimization
Completion of surgical, anesthesia, and nursing preoperative assessments should ensure proper risk assessment and optimization. This includes optimization of old issues and diagnosis of new issues that could impact outcomes. Appropriate risk assessment and optimization are necessary for optimal throughput and use of the operating room and procedural areas to occur.
The evolution of preoperative assessment systems shows increasing benefits from risk assessment and optimization. Outpatient preoperative assessment clinics initially were constructed to replace preoperative inpatient admission days when payment systems changed to eliminate additional revenue for increasing length of stay. Additional benefits became apparent over the ensuing years, as recently summarized in an article describing well-known landmarks in preoperative clinic achievements. Computerized preoperative clinic evaluations were shown to identify patients with increasing risk. Preoperative clinic assessment was associated with reductions in unnecessary laboratory testing and reduced cancelations and delays on the day of the procedure, as well as reduced length of stay. These benefits have resulted in significant cost savings. In addition to optimizing known comorbidities, preoperative clinic assessment has been shown to diagnose and manage a significant number of new medical issues that could have significant impact on patient outcome and day-of-surgery efficiency. Most recently, in matched cohorts, in-person preoperative clinic evaluations have been shown to significantly decrease postoperative inpatient mortality.
To achieve the benefits described requires multidisciplinary coordinated development of preoperative systems best suited for institutions. To be successful, overall medical direction by a clinician with expertise in perioperative medicine as well as operations management is essential. Developing a value-based business plan supported by evidence-based clinical protocols is needed. Sufficient resources should be provided to diagnose and manage comorbidities, involving outside consultants as needed. The return on investment in terms of ensuring high-value care should be documented and metrics established for review by collaborative multidisciplinary administrative leadership. Cost of preoperative services is not an outcome metric; value of preoperative services is. Routine preoperative assessment done by surgery and anesthesia clinicians, as well as routine preoperative care provided by the hospital, is already bundled into the payments received by clinicians and the hospital. Additional billing therefore cannot be done for routine preoperative services because that would be considered double billing. Administrators who say that preoperative services do not generate revenue may be uninformed about the current state of payment for these tasks. Institutions are, in fact, being paid for these services. Routine pre- and postoperative care services are part of the payment already received in the payments sent to the hospital, surgeon, and anesthesiologist performing the procedure. Additional consultative and management services that go beyond routine care can be billed for, but they require a referral for a specific reason. Routine history and physical examinations cannot be billed for separately, whether done by a surgeon, an anesthesiologist, a hospitalist, or a primary care specialist. Institutions need to learn how to provide the elements needed efficiently for routine services and not to eliminate them because they cannot bill for them separately. There are many elements required for routine care that cannot be billed for separately, such as maintenance of an electronic medical record and salaries of administrators who do not generate clinical billing. Institutions accept that these are necessary cost centers for overall success; preoperative services need to be considered in a similar manner. Of course, management of more complex patients can generate separate billing, and the details of the business case for preoperative services are covered in a separate chapter.
Risk assessment and optimization require transfer of all important documentation so that downstream providers receive high-quality handoffs. Good preoperative assessment systems can ensure this by coordinating information that may be fragmented across different providers and domains. This provides information that is critical to effective use of the operating rooms as well as patient safety.
Specifically, in the perioperative setting, authors of a review of surgical malpractice claims related to communication breakdowns reported that 43% involved handoffs and 38% of these occurred preoperatively. Chow et al showed that standardized communication to downstream providers after preoperative assessment improves multiple domains, including medical optimization, provider communication, patient satisfaction, clinical planning, postoperative care, operating room efficiency, and patient safety. Fig. 4.2 lists some elements impacted by preoperative clinic handoffs with specific examples. It is very likely that robust preoperative risk assessment prevents many near misses, as review of Chow et al.’s publication reveals. The role of preoperative assessment in communication across the perioperative continuum can be critical, and perioperative leadership should develop and monitor standardized communication processes.