IMPLEMENTING ACCURACY AND EFFICIENCY IN PREOPERATIVE EVALUATION

The ability of preoperative evaluation of even healthy patients (ASA physical status I or II) to detect important symptoms and medical history makes its benefit greater than its risk. Furthermore, preoperative evaluation done in advance is ultimately cost-efficient, as it minimizes expensive delays on the day of surgery. ( Table 25-19 shows the laboratory tests recommended for asymptomatic patients by various investigators and institutions.) In addition, such assessment can be used to limit the amount of testing to only that warranted by symptoms or risk-grouping ( Table 25-20 ). The protocol described in Table 25-20 (and the algorithms derived from it [see Fig. 25-7 , Fig. 25-8 , Fig. 25-9 , Fig. 25-10 , Fig. 25-11 , Fig. 25-12 , and Fig. 25-13 ]) do have certain requirements if the patient's preoperative condition is to be optimized. A careful history and physical

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Two possible objections by the assessor immediately come to mind:

1. Why can't the primary care physician do the evaluation and send it to me?
2. It's a time-consuming process for which I get no compensation.

In their simplest forms, the answers to these objections are:

1. The primary care physician is not specifically trained in preoperative assessment.
2. Ultimately, preoperative evaluation is very cost-effective for the institution, the health care payors, and the patients. It is justifiable to compensate the anesthesiologist for preoperative assessment at the same rate as for OR time.

First Objection

Although the primary care physician can render a patient's condition optimal for daily living, he or she does not have the anesthesiologist's depth of understanding of the physiologic changes caused by surgery or the requirements that must be met to facilitate class B and C surgical procedures and to optimize perioperative outcome. An example of this is the induction by the primary care physician of some degree of prerenal azotemia for the patient with congestive heart failure. Even though prerenal azotemia may make the patient more comfortable for the conditions of daily living, it predisposes the patient to hypovolemic disaster during surgery. Unfortunately, careful attention to optimizing the perioperative condition is highly desirable but is not compatible with the current state of knowledge and functioning of primary care physicians. Such knowledge is more available and of better quality than in prior decades,^{[263] [264] [265]} and many reports have highlighted the importance of this aspect of care.^{[9] [266] [267] [268]} Nevertheless, the training, knowledge, and ability of primary care physicians are still very deficient in this aspect of consultation.

In addition, the preoperative meeting of anesthesiologist and patient should serve other important functions:

• Informing the patient about treatment options

• Educating the patient about anesthesia, perioperative care, and pain treatment in the hope of reducing anxiety and facilitating recovery^[5]

• Motivating (by using the perioperative experience) the patient to achieving more optimal health and thereby improve perioperative and/or long-term outcome.

At this time, none of these functions is performed adequately by most primary care physicians, and there is no one better trained to do so than the anesthesiologist.

Second Objection

It is cost-efficient for both the institution and the health care provider to have the anesthesiologist perform preoperative assessments, provided a system is set up to make the process cost-efficient. In the OR, the anesthesia service earns revenue only when a patient is undergoing surgery. Thus, the goals of the hospital in producing a cost-efficient OR environment and the goals of the anesthesia department are closely aligned. Long turnover times, unused OR time, and delays in the OR schedule have many disadvantages. They waste the resources of the anesthesia department, reduce the cost-efficiency of hospitals, impede teaching, frustrate surgeons, and decrease harmonious teamwork among health care providers. Such inefficiencies make the hospital, surgical center, and office-based operatory less competitive when fees are determined on the basis of "capitated-care" (payment of fixed fees), a diagnosis-related group (DRG), or an ambulatory care group (ACG).

Because many countries, and especially the United States, are undergoing multiple transitions in the way care is paid for, it is important to note that in all systems efficiency in OR utilization and transition to functional recovery postoperatively or post-procedurally is valuable for all systems. Therefore, it is optimal to facilitate smooth transfer of the patient into the OR. In addition, if preoperative assessment by an anesthesiologist were supplemented by informatics systems linking primary care provider, surgeon, OR, and perioperative care site, more cost-efficiencies could be obtained. For example, a history would not be obtained by the internist, surgeon, surgical resident, anesthesiologist, anesthesia resident, and three teams of nurses—all with imperfect information transfer between them, much duplication of laboratory services, and many delays. Thus, even though the rules for payment have changed, those who live in a capitated care environment will find it cost-efficient to have a system that facilitates preoperative assessment sufficiently early to minimize OR delays, reduce unwarranted testing, facilitate relief of patient anxiety, and speed recovery. Part of the job of the anesthesiologist and of anesthesia societies is to ensure that the value of these services is remunerated appropriately.

For the anesthesiologist, several effective systems could be instituted. Supported by consultation 1 week or more before surgery, or by some other second-opinion mechanisms encouraged by appropriate CPT codes and fee schedules, such systems could pay for themselves ( Fig. 25-14 ). Initiating such a system is not easy, but failure to do so will make the anesthesiologist and his or her practice site less efficient and more costly, less marketable and desirable to patients; and a continuing source of frustration to surgeons, OR administrators, and anesthesiologists.

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Figure 25-7 Evaluating cardiovascular risk for patients undergoing noncardiac surgery: the procedure for determining which cardiovascular laboratory tests are necessary. The history is used to segregate patients into groups for testing and/or invasive monitoring. ECG, electrocardiogram; ICU, intensive care unit; PTCA, percutaneous transluminal coronary angioplasty.

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Figure 25-8 Procedure for determining when pulmonary function tests are warranted.

Figure 25-9 Procedure for determining when a chest radiograph should be obtained.

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Figure 25-10 Procedure for soliciting the signs and symptoms of significant liver disease that warrant the performance of liver function tests.

Figure 25-11 Procedure for determining when blood urea nitrogen (BUN) or creatinine levels should be obtained.

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Figure 25-12 Procedure for determining when blood glucose levels should be obtained.

Figure 25-13 Procedure for determining when hemoglobin levels or a hematocrit should be obtained.

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Figure 25-14 Billing form used to report preoperative second opinion or consultation activities to payers.