Abstract
BackgroundSurgical patients are sometimes referred for preoperative evaluations by consultants in other medical specialties, although consultations are unnecessary for many patients, particularly for healthy patients undergoing low-risk surgeries. Surgical specialty has been shown to predict usage of preoperative consultations. However, evidence is generally limited regarding factors associated with preoperative consultations. This study evaluates surgical specialty and other predictors of preoperative consultations.MethodsThis retrospective cohort study analyzed surgery claims of 7400 privately insured patients in Washington, United States, from eight surgical specialties. We estimated log-Poisson generalized estimating equation models that regress whether a patient received a consultation on surgical specialty and covariates accounting for the data’s hierarchical structure with patients nesting within surgeons, and surgeons nesting within provider organizations. Covariates include age, gender, Deyo comorbidity index, surgical risk, and geographic factors.ResultsOverall, 485 (6.6%) patients had a preoperative consultation. The incidence of preoperative consultation varied significantly by surgical specialty. Orthopedics, neurosurgery, and ophthalmology had 3.9 (95% CI 2.4, 6.5), 2.3 (95% CI 1.1, 4.5), and 2.3 (95% CI 1.1, 4.6) times greater adjusted likelihoods of preoperative consultation than general surgery, respectively. The adjusted likelihoods of consultation for gynecology, urology, otolaryngology, and vascular surgery were not statistically different from general surgery. The following covariates were associated with greater likelihood of preoperative consultation: greater age, higher surgical risk, having one or more comorbidities vs. none, and small rural towns vs. urban areas. More than 75% of all consultations were provided to patients with a Deyo comorbidity index of 0 or 1. Low surgical risk patients had 0.3 (95% CI 0.3, 0.5) times the likelihood of preoperative consultation of intermediate and high-risk patients overall.ConclusionsThe likelihood of preoperative consultation varied fourfold (an absolute 9% points) across surgical specialties. Most consultations were provided to patients with low comorbidity and with low or intermediate surgical risk. To improve usage of preoperative consultations as an evidence-based practice, future research should determine how the health outcomes effects of preoperative consultations vary depending on comorbidity burden and surgical risk.
Highlights
Surgical patients are sometimes referred for preoperative evaluations by consultants in other medical specialties, consultations are unnecessary for many patients, for healthy patients undergoing low-risk surgeries
Consistent with our previous work, which studied patients in an integrated health care system (Thilen et al 2013), we found that ophthalmology and orthopedics were associated with greater usage of preoperative medical consultations relative to general surgery
In summary, in this study using commercial insurance claims, we found that surgical specialty is associated with the usage of preoperative medical consultation
Summary
Surgical patients are sometimes referred for preoperative evaluations by consultants in other medical specialties, consultations are unnecessary for many patients, for healthy patients undergoing low-risk surgeries. Previous studies have reported wide variability in usage of preoperative medical consultation (Fleisher et al 2009; Evaluation ASoATFoP 2002), which is consistent with the absence of clear recommendations from evidence-based practice guidelines directing how to select surgical patients for referral to other specialties (Katz et al n.d.; Clelland et al 1996; Auerbach et al 2007; Wijeysundera et al 2010). Previous studies have suggested that comorbidity burden is an important determinant (Auerbach et al 2007; Wijeysundera et al 2010); an analysis of Medicare claims for patients undergoing cataract surgery found that non-medical factors primarily explained variation in usage of preoperative consultations (Thilen et al 2014)
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