Preoperative optimization programs (POPs) can improve patients’ readiness for surgery, reduce day-of-surgery cancellations, and produce financial benefits for surgical practices, new research suggests.
In a study from the University of Michigan, high-risk patients who attended a low-cost preoperative optimization clinic in the months before their elective abdominal hernia repair were successfully optimized for surgery and experienced a low rate of unintended health consequences in the lead-up to their operation.
The program also had financial benefits for the clinic, with more patients able to undergo surgery and an increase in hernia-related relative value units (RVUs) for the institution.
In 2018, the University of Michigan launched an optimization program for patients undergoing elective hernia repair. Patients who requested an elective hernia repair and had a body mass index over 40 kg/m2, were smokers, or were older than 75 years of age were directed to the once-weekly, half-day clinic led by an advanced practice provider. In appointments, the provider counseled patients about smoking cessation and nutrition, made referrals to bariatric surgery or weight programs, did weight loss check-ins, and coordinated with other health care providers to improve patients’ comorbidities. Patients could become eligible for surgery if they successfully mitigated controllable risk factors.
Of 176 patients referred to the clinic, 52% were for weight, 34% for tobacco use and 14% for age. Median follow-up was 183 days (range, 39-378 days).
Overall, 10% of referred patients were successfully optimized for surgery. Tobacco cessation was achieved in 12% of active smokers, and 9% of people with obesity elected to pursue bariatric surgery.
The rate of hernia incarceration requiring emergent surgery was 3%.
In its first year, the program increased the rate of referred patients who underwent surgery, leading to a 19% increase in surgical yield, compared with the number of new hernia patients who were immediately eligible for surgery in 2018. Surgeons saw 10% more patients in the surgical clinic, and there was a 27% increase in hernia-attributed RVUs without altering surgeon workflow.
“These results showed a low rate of adverse health events during the time period of surgical delay, suggesting we can safely delay surgery in order to mitigate risk factors for high-risk surgical patients,” said Lia D. Delaney, BS, a medical student and researcher at the University of Michigan Medical School, in Ann Arbor, who presented the findings. “There is no detriment to the institution because we are increasing patient capacity and financial gain.”
Financial concerns, along with fears of emergent presentation, are often cited as barriers to optimization, she said. However, the University of Michigan model is low-cost, scalable and sustainable for other practices.
“Implementation of a similar model only requires a workflow adjustment for the institution, based on triaging patients who request elective surgery,” she said.
In a study from Stamford Hospital in Connecticut, patients who participated in a POP before their elective surgery were less likely to have their operation canceled on the day of their procedure.
Researchers conducted a retrospective data review of all elective surgical procedures with planned same-day inpatient admission at Stamford Hospital between October 2018 and January 2020. Of 5,352 patents scheduled for surgery over this period, 2,934 attended the hospital’s POP.
Among patients who attended the POP, only 0.55% of cases were canceled on the day of surgery—far lower than the 12.4% reported in the group who were not POP participants.
There were 300 patients of 2,418 in the non-POP group who had same-day cancellations. All were due to incomplete workups.
In comparison, 16 of 2,934 patients in the POP group experienced same-day cancellations. Acute changes in status or noncompliance with preoperative instructions were the most significant drivers of cancellations in the POP group.
“Formalized perioperative optimization programs can significantly decrease day-of-surgery cancellation rates, can also decrease hospital costs, and, above all, provide a streamlined perioperative experience for our patients,” said presenting author Nicolle Burgwardt, MD, a surgical resident at Stamford Hospital.
Participation in the POP clinic increased over time as surgeons became more supportive of the program, she said. Nearly 70% of surgical patients are now seen at the clinic, up from 39% in 2018.
This article is from the March 2021 print issue.