Abstract 15340: Reducing Unnecessary Preoperative Cardiology Referral and Cost in Patients Undergoing Bariatric Surgery

Abstract

Introduction: Candidates for bariatric surgery are at increased risk for cardiovascular disease, which may increase surgical risk. Currently, there are no society guidelines indicating which patients are appropriate for preoperative cardiovascular evaluation and risk stratification. Hypothesis: We hypothesized that applying a standardized surgical risk calculator with a novel multidisciplinary internal referral algorithm to stratify patients for preoperative cardiovascular evaluation would decrease unnecessary referrals and cost. Methods: All patients undergoing bariatric surgery at our institution between 2014-2018 were identified. After assessing baseline patient characteristics, referral patterns to cardiology, prevalence of cardiac testing ordered, and surgical outcomes were measured. The Revised Cardiac Risk Index (RCRI) score was retrospectively calculated for each patient and grouped as low versus increased risk (RCRI score of 0 versus ≥ 1). Imputing a post hoc referral algorithm requiring an RCRI ≥ 1, age ≥ 65, METS ≤ 4, and/or ever smoking history for cardiology referral, we calculated how referral pattern would be affected and the resultant change in referral costs. Results: A total of 797 patients underwent bariatric surgery during the study period, of which 68% (n=540) were referred to cardiology preoperatively. Those referred had more hypertension, hyperlipidemia, diabetes, smoking history, and were more likely to have BMI >50 kg/m 2 . Of those referred, 81% (n=438), 15% (n=81), 3% (n=17), and 1% (n=4) had RCRI scores of 0, 1, 2, and ≥ 3, respectively. Of those patients with an RCRI score of 0, 53% (n=234) underwent further cardiac testing. Strictly applying our standardized internal referral algorithm, of the 540 patients referred to cardiology, only 45% (n=199) were appropriately referred. Based on Medicare reimbursement for Level 4 outpatient consults, this would have resulted in a savings of approximately $86,000. Conclusions: Among candidates for bariatric surgery, a novel referral algorithm based on RCRI and other cardiovascular risk factors may reduce unnecessary preoperative cardiology referrals, with resultant reduction in resource utilization and overall cost savings.