Are Ambulatory Surgical Patients as Healthy as We Think? Using a Self-Reported Health Status Questionnaire to Identify Unsuspected Medical Comorbidities
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- Mackenzie, C.R., Mandl, L.A., Reyes, C. et al. HSS Jrnl (2006) 2: 121. doi:10.1007/s11420-006-9011-6
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Over the last 30 years, there has been a strong trend toward the performance of surgery in the ambulatory, outpatient setting. In 1982, of all operations performed in the United States, 20% were performed as outpatient procedures; by 1995, this figure had increased to 60% . This trend has been particularly evident in the field of orthopedic surgery. For example, at Hospital for Special Surgery, which focuses exclusively on musculoskeletal disease, there were over 7,000 ambulatory surgeries (AMS) performed in 2004. This is in contrast to ∼4,700 outpatient procedures performed in 1996.
Although economically advantageous, AMS challenges the system of care in a variety of ways, perhaps most significantly in the arena of preoperative medical evaluation. Medical consultations on these patients are usually ordered at the discretion of the attending surgeon. In general, patients undergoing AMS are younger and healthier than those being admitted for inpatient procedures. However, given that an increasing proportion of surgery is being performed on an AMS basis, it is likely that older and potentially less healthy patients are being offered this option. Therefore, this study was undertaken to determine if a simple self-reported health status questionnaire could be an effective tool to capture medical comorbidities that might impact perioperative care.
rank his or her health as excellent, good, fair, or poor
list all medications taken
note any problem with prior surgery
complete a brief review of systems, including cardiac, respiratory, gastrointestinal, neurological, endocrine, etc.
note any symptoms of sleep apnea
note use of alcohol or “recreational” drugs
Seventy-seven questionnaires were reviewed by the study internists. The mean age of the patients was 41 years, with a range from 14 to 80 years, and 51% were female. Of the 77 patients whose questionnaires were reviewed, 40 were approved for surgery on the basis of the questionnaire alone. Although all patients had been booked for surgery by their surgeon without requesting an internal medicine consultation, it was not clear that the remaining 48% (37/77) of patients could be considered suitable surgical candidates (without further evaluation) based on the patient's answers to the questionnaire. Seven patients, in fact, were referred for immediate medical consultation. The remaining 30 patients were contacted by telephone to determine whether further medical work-up was indicated. Of the 30 patients called, 20 were approved for surgery after the telephone conversation, 1 required immediate medical consultation, 8 needed further interventions, whereas 1 patient was lost to follow-up. Interventions included stopping anticoagulants, stopping nutraceuticals or supplements, changing diabetic medication dose, ordering an electrocardiogram (EKG), ordering antibiotics, or reviewing patient medical records.
Improved surgical techniques, anesthesia and pain management, have resulted in the ability to perform a much broader range of surgical procedures on an ambulatory basis. This results in tremendous cost savings, and is often much more convenient for the patient. Currently, most plastic and cosmetic surgery is performed on an outpatient basis, as is transurethral resection of the bladder and lithotripsy in urology, hernia repair in general surgery, sinus procedures in otolaryngology, and laparoscopy in general and gynecological surgery . As a general practice, AMS has also been successfully adopted by the field of orthopedic surgery, especially procedures that are performed arthroscopically. At our institution, the proportion of surgical cases performed in the ambulatory setting has increased by 25% between the years 1997 and 2004.
Initially, patients whose surgery was performed in the outpatient setting tended to be younger and healthier, and they were often undergoing minor procedures. As might be expected, these patients generally had low complication rates. However, as the indications for AMS have expanded, older and more medically complicated patients are being offered this option. At HSS, the average age of AMS patients has been gradually increasing—from 44 years in 1999 to 46 years in 2004, with a range of 18–92 years. In 2004, 15% of AMS patients were over 65-year old, whereas 4% were over 75-year old. It should, therefore, no longer be assumed that, by definition, AMS patients can be considered a “low-risk” population: a “healthy” 65-year old is simply not the same as a “healthy” 45-year old. Compounding this potential problem is the patients' own belief that their health is “good or excellent,” despite self-reporting serious medical comorbidities, a self-perception that may contribute to the minimization (by the patient and surgeon) of perioperative risk. As such, there will be an increasing need to improve our methods for preoperative assessment to ensure patient safety and optimize postoperative outcomes. Apropos of these considerations, this article describes our early experience with a screening methodology that demonstrates promise in the identification of patients who may be a higher risk for surgery in the outpatient setting.
Our data suggest that routine preoperative assessment of AMS patients as currently practiced may result in an underestimation of potentially important medical comorbidities. Serious medical conditions were identified by the questionnaire, which had not been previously noted, and which an experienced internist determined required further assessment before surgery. Adding our questionnaire to the preoperative screening process made a substantial impact: 20% of patients required additional consultation and/or medical intervention before an internist was willing to approve them for surgery.
The utility of the preoperative examination before admission for elective surgery has been demonstrated, at least for inpatient surgery. In a study of 21,553 patients booked for elective inpatient procedures, introducing routine presurgical assessment as an outpatient led to significant decreases in cases canceled for medical reasons, decreases in the length of hospital stay, and a significant increase in the rate of same-day admissions . In addition, the number of preoperative EKGs, chest radiographs, and preoperative laboratory tests also decreased significantly. The number of patients on whom no laboratory tests were performed increased from 17% to 37%. There was no change in postoperative ICU admissions despite the decrease in preoperative testing . Other investigators in different centers have shown similar results [3–6]. Thus, in the inpatient arena of surgical practice, preoperative medical assessment appears to reduce costs and potentially result in improved patient outcomes.
Although much less robust, there are some data that support the observation that the preoperative evaluation of ambulatory surgical patients is also beneficial. For instance, the preoperative evaluation of AMS patients has been shown to be cost saving through a reduction in the number and length of unexpected inpatient admissions . What is not clear is if these relatively healthy adults benefit medically from an evaluation before the day of surgery . It should be noted, however, that much of these data are over a decade old and do not reflect trends toward performing AMS procedures on older, potentially less healthy patients. Nonetheless, the data we present herein at least suggests that patients are at a higher risk than previously thought.
In closing, this study suggests that in our AMS population, potentially serious medical conditions are being underestimated preoperatively, a problem that fortunately can be readily addressed by using a simple and questionnaire-based methodology. Whether such early identification of patients at risk will lead to better outcomes in the AMS patient is unknown and is an important area for further study.