Sunday, August 29, 2010

Preoperative Medical Consultation May Increase Risk

Attention readers: Unlike my previous post on the reasons medical students do not choose primary care careers, this post is serious. I feel I have to explain because when my blog on primary care appeared as a guest post on the blog KevinMD, someone commented that I should have said up front that it was satire. I found that hard to believe.

Similarly hard to believe, but appearing in the current issue (August 9/23, 2010) of Archives of Internal Medicine is an article that has the following conclusions: “Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing.”

The study was a retrospective cohort study of 269,000 patients who underwent intermediate and high-risk noncardiac surgery in Ontario, Canada. Over 90% of the more than 104,000 patients who underwent preoperative medical consultation were matched to similar patients who did not have a consult. While the increases in mortality rates and length of stay are small, they are real. In addition to the increased 30-day and one-year mortality rates and length of stay, patients receiving consults had more preoperative testing such as unnecessary echocardiograms and were given more drugs including beta-blockers. The beta-blockers were probably not indicated and were associated with increased rates of postoperative stroke in abdominal and thoracic surgery patients. Interestingly, consults with specialists such as cardiologists led to higher mortality rates.

In fairness, the authors mentioned several limitations of the study including the fact that they used an administrative database which did not include certain complications and that it was a retrospective study. But evidence is evidence, and a prospective study on this topic would be impossible due to ethical considerations. Reminder: This is factual information from an internal medicine journal. I leave you to ponder the implications of this study.

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