Evaluation of Services for the Preoperative Assessment and Management of High-Risk Surgical Patients

Abstract

Outpatient preoperative assessment clinics, such as the physician-led high-risk clinic in a large metropolitan public hospital in South Australia, have been established to assess and manage surgical patients at high risk of morbidity and mortality due to their medical co-morbidities. To date, the design and implementation of preoperative medical assessment and management has been heterogeneous, with minimal detail on the actual services provided as part of the intervention. Further, there have been no published studies evaluating the costs and outcomes of physician-led preoperative assessment for patients with modifiable medical co-morbidities prior to elective surgery. Five distinct projects contributed to the main aims of this research: to evaluate the preoperative assessment and management services provided by the physician-led high-risk clinic, and provide recommendations for improvement using an explanatory sequential mixed methods approach. This research represents the first comprehensive evaluation of services for the preoperative assessment and management of high-risk surgical patients. Multiple regression analyses identified nine potentially modifiable medical co-morbidities to be associated with increased length of stay and postoperative complications, supporting the rationale that optimisation of poorly controlled medical co-morbidities prior to surgery could improve postoperative outcomes. The costs and effects of physician-led preoperative assessment and management were evaluated using a propensity score-based approach with retrospective and prospective data. It was found that the clinic reduced the frequency of unnecessary admissions and cancellations but significant uncertainty remained around the effect of the clinic on length of hospital stay, postoperative complications, hospital costs and post-discharge mortality. Supplemental data on a prospective cohort of patients identified preoperative health-related quality of life as a potential unmeasured confounder in the evaluation, with high-risk clinic patients reporting lower mean index scores. Semi-structured interviews with surgeons found that the factors influencing their decision to refer a patient to the high-risk clinic appear to be driven by the aim to manage the uncertainty and risk to the patient regarding surgery and it was seen as a strategy for managing difficult and complex cases. Additionally, the integration of the services provided by the clinic in this study appear to offer additional value in supporting the surgical decision-making process for the surgical team and patient beyond the clinical outcomes, such as managing the patient’s expectations regarding care and assistance after discharge from hospital. Further perspectives from patients and other medical professionals collaborating with the clinic should be explored and would provide further insight into the aspects of care that provide additional value. This evaluation provides a guide to the identification of elective surgical patients who are likely to benefit most from preoperative physician-led medical optimisation and provides clarity on the collaborative care provided by the high-risk clinic and surgical teams in managing complex patients, to inform the assessment of such clinics in Australia. Such models of care involving the management of high-risk patients are increasingly likely as the public hospital system is subjected to increasing demands from an ageing population. This research has demonstrated the need to plan for the robust evaluation of new health service initiatives, which may be facilitated through better co-ordinated planning and evaluation across Australian hospitals.