A new study that looked at more than 300,000 patients is suggesting that when it comes to medical outcomes, it might not be necessary to have an appointment with a specialist prior to a surgery that is considered routine.
The study, published Monday in the peer-reviewed journal JAMA Internal Medicine, found that having a preoperative consultation wasn’t associated with a better outcome after surgery.
The idea behind a preoperative consultation with a medical specialist — such as a cardiologist, endocrinologist, or nephrologist, among others — is to go over health issues that could lead to complications during surgery. Surgeons in Canada refer more than 40,000 patients a year for these consultations to prepare for a surgery, but debate has been stirring over whether they are fully necessary or not.
“As a specialist who sees patients for preoperative medical consultations, I’m not convinced these visits are always helpful,” Dr. Weiwei Beckerleg, a general internist at the Ottawa Hospital and assistant professor at the University of Ottawa, as well as lead author of the research, said in a press release. “Most patients I see have already covered the same ground with their anesthesiologist. I’ve had patients ask me ‘Why am I here?’”
In this new study, researchers looked at patient data from 2005 to 2018 in Ontario, focusing on their surgical outcomes and whether they had a preoperative medical consultation.
If these consultations led to an improvement in surgical outcomes, it would be an argument for their benefit. But researchers actually found that in general, outcomes were slightly worse.
Data from around 359,000 patients in the study showed that while 0.7 per cent patients who had no consultation died within 30 days of their surgery, 0.9 per cent of those who had a preoperative medical consultation died within the month after surgery.
To get the broadest picture, researchers started out with a sample of around 530,000 patients.
All patients included were 40 years and older who had intermediate to high-risk surgeries that did not involve the cardiac system, including hip or knee replacements, surgery of the digestive tract, or surgery to remove cancer or part of an organ.
Around 35 per cent of these patients had received a preoperative medical consultation within four months of their surgery. Researchers then matched these 186,000 patients with a set of 179,000 patients who had similar health conditions, age, sex and surgery types, who did not have a preoperative medical consultation.
When these two groups were compared, there was a slightly higher change of death within 30 days after surgery for those who got a consultation.
The rates of inpatient stroke, in-hospital mechanical ventilation and emergency department visits within 30 days after the surgery were also slightly higher in the consultation group. The consultation group also was more likely to be prescribed beta blockers, something researchers flagged as concerning because while these drugs are usually very beneficial, some research has linked a new prescription for patients right before surgery to higher chances of stroke and death.
It’s unclear why preoperative consultations were correlated with a slightly higher mortality rate, but it could be a matter of timing, researchers said.
“The goal of a preoperative medical consultation is to help patients get healthy enough for surgery while not delaying an urgent surgery. It could be that some time-sensitive surgeries were delayed by ordering unnecessary tests,” Dr. Daniel McIsaac, scientist and anesthesiologist at the Ottawa Hospital, chair in Innovative Perioperative Care at the University of Ottawa and senior author of the research, said in the release.
Researchers noted that although the difference in mortality rate was statistically significant, the absolute difference was small. The more important detail is the fact that they observed no clear benefit in having a preoperative consultation in terms of surgical outcomes, something researchers say suggests that guidelines and policies around these may need adjustment.
In Canada currently, between 10 and 40 per cent of elective surgery patients will have a preoperative medical consultation, according to the release.
The biggest predictor for whether a patient was referred for a preoperative consultation was not the type of surgery or their overall health — it was which hospital they were seen in.
Large hospitals affiliated with medical schools were more likely to offer preoperative consultations, in part because they have more staff and tend to perform high-risk surgeries.
The study was run by researchers from the Ottawa Hospital, where consultations are not done to clear a patient for surgery, but only to address a specific problem, according to the release.
Going forward, researchers recommend that older patients be prioritized for preoperative consultations that include expert assessment from a geriatrician, as these specific consultations have shown to improve survival in previous studies.
In the future, they hope further research is able to pinpoint when a preoperative consultation is truly necessary, as well as integrate more data on how patient-led decision making, as well as patient satisfaction in results, factor into the consultation question.
“We’re not saying that preoperative medical consultations should be abolished,” Beckerleg said. “But based on the way they’re run now, we’re not convinced they always make a difference. More research is needed to find which patients benefit most from these consultations. In the meantime, we hope our findings inspire health-care organizations to optimize preoperative care.”
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