Pre-surgery exam rates vary widely among hospitals

Hospitals vary greatly in the number of patients who see an internal medicine specialist before major non-cardiac surgery, with rates ranging from five per cent of patients to 90 per cent, new research from the University of Toronto and St. Michael's Hospital has found.

The findings are important because they suggest there are no commonly agreed upon standards for which patients should have such consultations, said Dr. Duminda Wijeysundera, a U of T professor of anesthesia, a scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences (ICES).

As a result, some patients may be getting expensive tests and exams they don’t need, while others who do need them are not getting them, said  Wijeysundera, who is also an anesthesiologist at Toronto General Hospital-University Health Network.

Wijeysundera studied the records of 205,000 patients who underwent major elective non-cardiac surgery in 79 hospitals in Ontario from 2004 to 2009. His results were published today in the journal Anesthesiology.

All patients scheduled for elective surgery in Ontario must undergo a preoperative medical history and physical, which are typically done by the patient’s family physician or surgeon. Referrals to an internal medicine specialist are usually made at the discretion of the surgeon or anesthesiologist.

One-third of the patients studied underwent a pre-operative medical consultation. Not surprisingly, most were older, were patients at teaching hospitals or hospitals with high volumes of surgery, or had other, pre-existing medical conditions such as diabetes or heart disease.

However, the rates varied widely from hospital to hospital, and could not be explained based on the surgical procedure, the volume of surgeries conducted at the hospital or whether it was a teaching hospital.

“That suggests the forces driving this have little to do with how sick the patient is,” Wijeysundera said. “Further research is needed to better understand the basis for this inter-hospital variation and to determine which patients benefit most from pre-operative consultation.”

More research is also needed to determine whether the difference may be explained by individual surgeon’s preferences, he said.

Wijeysundera said pre-operative consultations may be helpful for patients with other medical issues, because it’s an opportunity to document and/or treat those pre-existing conditions and take steps to lower their risks for surgery, or even cancel the procedure.

But previous studies have found no clear evidence that these consultations improve patient outcomes. In fact, the studies have suggested the tests and examinations may be associated with longer hospital stays, more post-operative complications and even a slightly higher death rate.

“When performed in patients who are unlikely to benefit from them, these consultations can increase healthcare costs, while exposing some individuals to unnecessary and potentially harmful tests or interventions,” he said.