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Outcomes and processes of care related to preoperative medical consultation.

https://arctichealth.org/en/permalink/ahliterature141659
Source
Arch Intern Med. 2010 Aug 9;170(15):1365-74
Publication Type
Article
Date
Aug-9-2010
Author
Duminda N Wijeysundera
Peter C Austin
W Scott Beattie
Janet E Hux
Andreas Laupacis
Author Affiliation
Institute for Clinical Evaluative Sciences, Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Anesthesia, Toronto General Hospital and University of Toronto, EN 3-450, 200 Elizabeth St, Toronto, ON M5G 2C4, Canada. d.wijeysundera@utoronto.ca
Source
Arch Intern Med. 2010 Aug 9;170(15):1365-74
Date
Aug-9-2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Case-Control Studies
Chronic Disease
Comorbidity
Confidence Intervals
Confounding Factors (Epidemiology)
Female
Humans
Internal Medicine
Length of Stay - statistics & numerical data
Male
Middle Aged
Odds Ratio
Ontario - epidemiology
Outcome and Process Assessment (Health Care)
Preoperative Care - methods - standards - statistics & numerical data
Referral and Consultation - statistics & numerical data
Retrospective Studies
Risk assessment
Sensitivity and specificity
Surgical Procedures, Operative - mortality
Abstract
Preoperative consultations by internal medicine physicians facilitate documentation of comorbid disease, optimization of medical conditions, risk stratification, and initiation of interventions intended to reduce risk. Nonetheless, the impact of these consultations, which may be performed by general internists or specialists, on outcomes is unclear.
We used population-based administrative databases to conduct a cohort study of patients 40 years or older who underwent major elective noncardiac surgery in Ontario, Canada, between 1994 and 2004. Propensity scores were used to assemble a matched-pairs cohort that reduced differences between patients who did and did not undergo preoperative consultation by general internists or specialists. The association of consultation with mortality and hospital stay was determined within this matched cohort. As a sensitivity analysis, we evaluated the association of consultation with an outcome for which no difference would be expected: postoperative wound infection.
Of 269,866 patients in the cohort, 38.8% (n=104,695) underwent consultation. Within the matched cohort (n=191,852), consultation was associated with increased 30-day mortality (relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.25; number needed to harm, 516), 1-year mortality (1.08; 1.04-1.12; number needed to harm, 227), mean hospital stay (difference, 0.67 days; 0.59-0.76), preoperative testing, and preoperative pharmacologic interventions. Notably, consultation was not associated with any difference in postoperative wound infections (RR, 0.98; 95% CI, 0.95-1.02). These findings were stable across subgroups as well as sensitivity analyses that tested for unmeasured confounding.
Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing. These findings highlight the need to better understand mechanisms by which consultation influences outcomes and to identify efficacious interventions to decrease perioperative risk.
Notes
Comment In: Arch Intern Med. 2011 Feb 28;171(4):368; author reply 368-921357818
Comment In: Arch Intern Med. 2011 Feb 28;171(4):367-8; author reply 368-921357817
PubMed ID
20696963 View in PubMed
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Variation in the practice of preoperative medical consultation for major elective noncardiac surgery: a population-based study.

https://arctichealth.org/en/permalink/ahliterature128601
Source
Anesthesiology. 2012 Jan;116(1):25-34
Publication Type
Article
Date
Jan-2012
Author
Duminda N Wijeysundera
Peter C Austin
W Scott Beattie
Janet E Hux
Andreas Laupacis
Author Affiliation
Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada. d.wijeysundera@utoronto.ca
Source
Anesthesiology. 2012 Jan;116(1):25-34
Date
Jan-2012
Language
English
Publication Type
Article
Keywords
Adult
Age Factors
Aged
Cohort Studies
Comorbidity
Female
Hospital Mortality
Hospitals - classification - statistics & numerical data
Humans
Male
Middle Aged
Odds Ratio
Ontario
Preoperative Care - statistics & numerical data
Referral and Consultation - statistics & numerical data
Registries
Sex Factors
Socioeconomic Factors
Surgical Procedures, Elective - mortality - statistics & numerical data
Surgical Procedures, Operative - mortality - statistics & numerical data
Treatment Outcome
Abstract
Patients scheduled for major elective noncardiac surgery frequently undergo preoperative medical consultations. However, the factors that determine whether individuals undergo consultation and the extent of interhospital variation remain unclear.
The authors used population-based administrative databases to conduct a cohort study of patients, aged 40 yr or older, who underwent major elective noncardiac surgery in Ontario, Canada, between April 2004 and February 2009. Multilevel logistic regression models were used to identify patient- and hospital-level predictors of consultation.
Within the cohort of 204,819 patients who underwent surgery at 79 hospitals, 38% (n = 77,965) underwent preoperative medical consultation. Although patient- and surgery-level factors did predict consultation use, they explained only 5.9% of variation in consultation rates. Differences in rates across hospitals were large (range, 10-897 per 1,000 procedures), were not explained by surgical procedure volume or hospital teaching status, and persisted after adjustment for patient- and surgery-level factors. The median odds of undergoing consultation were 3.51 times higher if the same patient had surgery at one randomly selected hospital as opposed to another.
One-third of surgical patients undergo preoperative medical consultation. Although patient- and surgery-level factors are weak predictors of consultation use, the individual hospital is the major determinant of whether patients undergo consultation. Additional research is needed to better understand the basis for this substantial interhospital variation and to determine which patients benefit most from preoperative consultation.
Notes
Comment In: Anesthesiology. 2012 Aug;117(2):425-6; author reply 426-722828423
Comment In: Anesthesiology. 2012 Jan;116(1):3-522185870
PubMed ID
22185874 View in PubMed
Less detail