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October 21, 2019

Perioperative Risk Calculators and the Art of Medicine

Author Affiliations
  • 1Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
JAMA Intern Med. 2019;179(12):1619-1620. doi:10.1001/jamainternmed.2019.4914

“The revised cardiac risk index score1 is 0, so the patient can go to the operating room, right?” While patient histories and physical examinations have continued value in most other fields of medicine, perioperative risk assessment may sometimes be condensed to such a singular thought process. But are risk calculators enough by themselves?

The field of perioperative medicine has seen the development of multiple risk calculators for cardiac risk assessment (Box).1-6 These calculators have been valuable in identifying the risk factors for major cardiovascular outcomes. They are easy to use by surgeons or advanced practice clinicians, anesthesiologists, and internists. Patients who are deemed to be at low or very high risk based on these calculators may not need stress testing, leading to a judicious use of resources. Some calculators, such as the American College of Surgeons’ National Surgical Quality Improvement Program universal surgical risk calculator (ACS NSQIP), calculate the risk of multiple complications beyond just cardiac.2 These calculators may help engage patients in shared decision-making before undergoing surgery, especially the high-risk patients who may otherwise underestimate their risk. These decision aids may help motivate patients toward risk-reduction strategies before undergoing surgery.

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    3 Comments for this article
    Pre op Stress testing
    Michael Plunkett, MD | Hospital
    The author still advises stress testing before surgery. The CARP study showed the failure of such an approach. And the recent Canadian Heart guidelines eschewed pre op stress testing.
    Some newer reflections on risk-calculators
    Neelesh Gupta, MD | University of South Alabama
    I perused with interest the Perspective.
    I agree the preoperative assessment is an important issue. The risk-calculators are helpful, but not fool-proof. Many times patients calculated as having much higher risk escape injury while other patients
    calculated as having lower-risk suffer serious post-operative events.
    The problem gets compounded with the use of more than 1 risk calculator or observing the differences in the guidelines.
    The followings are my inputs:
    1. Risk-calculators are often inaccurate, as the data recorded in electronic health records (EHR) are often inaccurate.
    2. Many important impactful variables like cardiorespiratory fitness, and lifestyle are not captured in
    the EHR.
    3. Artificial intelligence (AI) is expected to make a huge difference in the risk-scores, as AI will take into consideration many more variables than any risk-calculator or scoring system have considered so far, plus it will take into account  all high-risk patients, who did not develop any adverse events and all low-risk patients who developed the events.
    4. Thus said, an astute clinical assessment is no substitute for any available risk-calculator. Some patients may experience an adverse outcomes, despite being calculated as low-risk preoperatively.
    Manage the whole individual, and not just a heart in a petri dish
    Umbrine Fatima, MD, FACP | Kenmore Mercy Hospital, Buffalo, NY
    Very well said.

    Increasingly, studies are focusing on cardiac outcomes, which is too narrow in scope. As an Internist who takes care of a whole individual and not just a heart in a petri dish, it irks me when safer cardiac outcomes are glorified at the the expense of some other poor outcomes. It almost appears to have become a marketing gimmick by the pharmaceutical companies, spinning the words (and outcome) to show positive, or at minimum, neutral output, rather than highlight the harms that may be caused to other organs.

    A limit of risk
    calculators is that they are just an aid. If it was as simple as punching some data elements into the calculator to churn out risk, then physicians could all retire.

    I use such tools as only one of many steps of my assessment. Tools can inform me on one fact. They do not make a decision for my patients. Having these tools included in guidelines or heavily relied upon increases liability when we choose to override them since it is hard to satisfy a non-physician jury on the reasons why a physician made a certain decision against the advice of a calculator.