Effectiveness of preoperative medical consultations by internal medicine physicians: a systematic review

Pham, Clarabelle T.; Gibb, Catherine; Fitridge, Robert; Karnon, Jonathan

doi:10.1136/bmjopen-2017-018632

Cited by 17 publications

(20 citation statements)

References 20 publications

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“…32,40,41 This suggests a role well beyond clinical consultation and may explain why these complex interventions appear to show more promise than preoperative physician consultation as a single strategy. 11 However, this complexity also leads to potential variability within and between services and reliance on good communication and teamwork. 41 Evaluation designs, such as cluster randomization or well-conducted interrupted time series designs, would be appropriate for these complex interventions 42 well as variable descriptors of physician-led interventions, there is a possibility that we missed important studies in our search.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes

2020

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IMPORTANCE Older patients who undergo surgery may benefit from geriatrician comanagement. It is unclear whether other internal medicine (IM) physician involvement improves outcomes for adults who undergo surgery. OBJECTIVE To evaluate the association of IM physician involvement with clinical and health system outcomes compared with usual surgical care among adults who undergo surgery. DATA SOURCES MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for studies published in English from database inception to April 2, 2019. STUDY SELECTION Prospective randomized or nonrandomized clinical studies comparing IM physician consultation or comanagement with usual surgical care were selected by consensus of 2 reviewers. DATA EXTRACTION AND SYNTHESIS Data were extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline by 2 authors independently. Intervention characteristics were described using existing indicators. Risk of bias was assessed using Risk of Bias 2.0 and Risk of Bias in Nonrandomized Studies of Interventions tools. Studies were pooled when appropriate in meta-analysis using random-effects models. Prespecified subgroups included IM physician-only vs multidisciplinary team interventions and patients undergoing elective vs emergency procedures. MAIN OUTCOMES AND MEASURESThe prespecified primary outcome was length of stay; other outcomes included 30-day readmissions, inpatient mortality, medical complications, functional outcomes, and costs. RESULTSOf 6027 records screened, 14 studies (with 1 randomized clinical trial) involving 35 800 patients (13 142 [36.7%] in intervention groups) were eligible for inclusion. Interventions varied substantially among studies and settings; most interventions described comanagement by a hospitalist or internist; 7 (50%) included a multidisciplinary team, and 9 (64%) studied predominantly patients who had elective procedures. Risk of bias in 10 studies (71%) was serious.

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Section: Discussionmentioning

confidence: 99%

Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes

2020

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“…The surgeon and clinic physician relationship has also not been well described in previous studies,4 making it difficult to determine whether the clinic physician provided a stand-alone consultation with no postoperative patient follow-up or an integrated approach to patient care between the surgeon and clinic physician. The clinic physician in this study was considered a member of surgical teams with expertise on the medical management of patients in preparation for surgery.…”

Section: Discussionmentioning

confidence: 99%

“…A set of potentially modifiable comorbidities have been identified to be associated with increased length of hospital stay and postoperative complications 3. Patients with poorly controlled modifiable comorbidities can be referred for medical optimisation prior to elective surgery at the discretion of the surgical consultant, but the factors that influence this referral are not well understood 4. Further, there has been minimal detail published on the actual services provided as part of the medical optimisation of patients and its design and implementation has been heterogeneous to date 4…”

Section: Introductionmentioning

confidence: 99%

Supporting surgeons in patient-centred complex decision-making: a qualitative analysis of the impact of a perioperative physician clinic

et al. 2019

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ObjectivePatients with comorbidities can be referred to a physician-led high-risk clinic for medical optimisation prior to elective surgery at the discretion of the surgical consultant, but the factors that influence this referral are not well understood. The aims of this study were to understand the factors that influence a surgeon’s decision to refer a patient to the clinic, and how the clinic impacts on the management of complex patients.DesignQualitative study using theoretical thematic analysis to analyse transcribed semi-structured interviews.SettingInterviews were held in either the surgical consultant’s private office or a quiet office/room in the hospital ward.ParticipantsSeven surgical consultants who were eligible to refer patients to the clinic.ResultsWhen discussing the factors that influence a referral to the clinic, all participants initially described the optimisation of comorbidities and would then discuss with examples the challenges with managing complex patients and communicating the risks involved with having surgery. When discussing the role of the clinic, two related subthemes were dominant and focused on the management of risk in complex patients. The participants valued the involvement of the clinic in the decision-making and communication of risks to the patient.ConclusionsThe integration of the high-risk clinic in this study appears to offer additional value in supporting the decision-making process for the surgical team and patient beyond the clinical outcomes. The factors that influence a surgeon’s decision to refer a patient to the clinic appear to be driven by the aim to manage the uncertainty and risk to the patient regarding surgery and it was seen as a strategy for managing difficult and complex cases.

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“… 10 Other studies have reported an increased length of stay, costs and post-operative complications in patients who had a PAME. 11 This data may be biased if patients who were referred for a PAME were higher risk or had poorer functional capacity. Regardless, PAMEs continue to be an essential part of surgical care, often due to practice tradition, medico-legal concerns, and to avoid any potential delays.…”

Section: Introductionmentioning

confidence: 99%

Pre-Anesthetic Medical Evaluations: Criteria Considerations for Telemedicine Alternatives to Face to Face Visits

Khera

Blessman

Deyo-Svendsen

et al. 2022

Health Services Research and Managerial Epidemiology

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Background The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study aimed to identify patient-related factors where a face to face (FTF) evaluation is indicated, measured by the need for pre-operative testing. Methods A retrospective chart review was conducted on patients age ≥ 18 years who had a PAME between January 2019–June 2020 at a rural primary care clinic in Southeast Minnesota. Data collected included age, gender, Charlson Comorbidity Index Score, medications, revised cardiac risk index (RCRI), smoking status, exercise capacity, body mass index, and pre-operative testing. Logistical regression modeling for odds ratios of outcomes was performed. Results 254 patients were included, with an average age of 64.1 years; 43.7% were female. Most were obese (mean BMI 31.6), non-smoking (93.7%) with excellent functional capacity (87.8% ≥ 5 METs). 76.8% of the planned surgeries were intermediate or high risk. 35.0% ( n = 89) of visits resulted in medication adjustments and 76.7% ( n = 195) in pre-operative testing. Age ≥ 65 years, ≥7 current medications, and diabetes all significantly increased the odds of requiring pre-operative testing ( P < .05). Conclusions This study was able to identify patient-related factors that increased the likelihood of requiring pre-operative testing. Patients who are age ≥ 65 years, ≥7 current medications, and those with diabetes could be scheduled for a FTF evaluation. Others could be scheduled for a telemedicine visit to minimize health-care exposures.

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Effectiveness of preoperative medical consultations by internal medicine physicians: a systematic review

Cited by 17 publications

References 20 publications

Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes

Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes

Supporting surgeons in patient-centred complex decision-making: a qualitative analysis of the impact of a perioperative physician clinic

Pre-Anesthetic Medical Evaluations: Criteria Considerations for Telemedicine Alternatives to Face to Face Visits

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