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Surgical Innovation
December 9, 2020

Redesigning the Preoperative Clinic: From Risk Stratification to Risk Modification

Author Affiliations
  • 1Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
  • 2Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
JAMA Surg. Published online December 9, 2020. doi:10.1001/jamasurg.2020.5550

The preoperative clinic was introduced to assess the medical conditions of high-risk patients and provide information to anesthesiologists and surgeons to reduce last-minute cancellations. Poor physical fitness, malnutrition, sarcopenia, obesity, anxiety, depression, and harmful lifestyle habits (eg, smoking) are recognized as significant patient risk factors contributing to poor postoperative outcome but are not often assessed in standard preoperative clinics, let alone modified. Prehabilitation is a strategic intervention to improve functional reserve before major surgery. Prehabilitation entails a multidisciplinary, multimodal approach based on knowledge in exercise science and nutrition, beginning with an assessment of cardiopulmonary fitness, body composition, and psychological status and followed by a series of structured, personalized interventions that focus on optimizing aerobic fitness and muscle strength, enhancing lean body mass, and supporting emotional resilience.1

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    2 Comments for this article
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    Redesigning the preoperative clinic A tremendous chance for patient empowerment and digitalization.
    Andreas Schnitzbauer, Professor of Surgery, MD | Frankfurt University Hospital, Goethe-University Frankfurt/Main, Department for General, Visceral and Transplant Surgery, Frankfurt/Main, Germany
    Carli et al. identified one of the most underutilized areas in modern medical treatment and painted a potential future scenario that has to be one of the major targets in research, safety & quality, as well as healthcare economics in the nearer future. Doctors focus on the correct indication bypassing some essential signals that patients send. Frailty and lack of failure to rescue after surgical interventions can be present in up to 30% of the patients older than 55 years old. The average age of cancer diagnosis is approximately 65 years and especially this age group requires major surgical procedures or chemotherapy. Therefore, it is necessary to find a perfect mix of identifying modifiable risks before starting the therapies by weighing all arguments for improving the patients´ tolerance towards potential complications against the delay of the therapy. Literally spoken, none of us would run a marathon without adequate preparation, so we should try to prepare our patients as well as possible for their personal marathon of life. The Covid-19 pandemic in this context might be the accelerator for remote approaches, such as interactive app-based programs that empower the patient to home-based but supervised exercising and prehabilitation programs. Such devices should be cleared by competent bodies in accordance with the regulatory requirements for medicinal products (FDA, BfArM, etc.) to discard the impression of pure lifestyle or fitness apps, which they should and must not be.
    Importantly, the decision-making process should be based upon a structured and standardized protocol of risk assessment of well-established evidence-based tools as outlined by the authors. The exercising results should help to estimate the improvement made during a prehab endurance training. The final decision to step forward and operate should not be based solely on the results of the program but will have the potential to avoid major harm in a significant group of patients by identifying them as significantly improved and capable to tolerate potential complications (reduce failure to rescue). The perfect composition of testing and exercising may be variable and interesting to compare once such solutions are available. To overcome barriers of a new preoperative workflow it must be simple, intuitive, feasible without binding too many valuable resources, helpful for both the patient (patient empowerment) and the doctor (reduce waste) and it should improve outcomes and reduce the cost for the healthcare system on any level.

    References:
    1. Carli F, Baldini G, Feldman LS. Redesigning the Preoperative Clinic: From Risk Stratification to Risk Modification. JAMA Surg. Published online December 9, 2020. doi:10.1001/jamasurg.2020.5550
    2. Shah R, Attwood K, Arya S, et al. Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery. JAMA Surg. 2018;153(5):e180214. doi:10.1001/jamasurg.2018.0214
    3. Hall DE, Arya S, Schmid KK, et al. Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations. JAMA Surg. 2017;152(2):175-182. doi:10.1001/jamasurg.2016.4202
    4. Bechstein WO, Schnitzbauer AA. Operative Procedures: New Ways of Managing Frailty. Dtsch Arzteblatt Int. 2019;116(5):61-62. doi:10.3238/arztebl.2019.0061
    5. Barberan-Garcia A, Ubre M, Pascual-Argente N, et al. Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial. Br J Anaesth. 2019;123(4):450-456. doi:
    CONFLICT OF INTEREST: None Reported
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    Opportunity Cost for TJA Optimization - Timing is Crucial
    Thomas Myers, MD, MPT | University of Rochester, Assistant Professor, Department of Orthopaedic Surgery
    I read with great interest Carli et. al’s piece on risk modification. As a practicing total joint arthroplasty (TJA) surgeon I can speak to the necessity of this concept to the sustainability of TJA to Americans. TJA is a highly successful and desired “elective” surgery but revisions are costly and rising.1 Optimization of modifiable risk factors prior to TJA has proven benefits in a value-based healthcare enviornment.2,3

    Kee et. al have shown that 42% of patients undergoing early (< 2 years from index procedure) revision TJA have at least one modifiable risk factor and
    17% have more than one risk factor.4 Bernstein et al. in a retrospective cohort study evaluated a preoperative optimization protocol focused on nineteen potentially modifiable risk factors.3 In this cohort 74% of patients had at least 1 potentially modifiable risk factor although it’s worth noting that 20% of the entire cohort did not follow through with the recommended optimization efforts before surgery. The post-intervention cohort had a significantly shorter average length of hospital stay (LOS) and lower average total direct variable costs excluding implants. Similarly, Dlott et. al showed a decrease in LOS, 30- and 90-day emergency department visits, and discharge to home in a retrospective analysis of a sixteen point optimization program.2

    Optimization efforts can take months to years to achieve in instances such as smoking, uncontrolled diabetes, or weight loss. However, conservative treatment may only provide sufficient symptomatic relief for a year or two. The period of conservative management should be viewed as the best optimization opportunity. Few things are more frustrating to the patient and the provider than when a patient has exhausted what was once effective physical therapy, anti-inflammatory, and injection treatment for joint pain but is still smoking or has uncontrolled lymphedema. If the TJA surgeon chooses to delay surgery in favor of optimization the angry patient may choose to find a TJA surgeon who will perform the surgery.

    The patient will never be more motivated to make lifestyle modifications than in the moment when they realize they may never escape the pain and limitations of their dysfunctional joint unless they make better medical decisions. Failure to capitalize on this moment has opportunity cost that should leave all medical practitioners questioning how we can best position the patient for sustainable lifestyle changes. This is a rare galvanizing opportunity for real collaborative efforts across medical and surgical disciplines resulting in a win-win for the patients and providers. Ideally third-party payers reward accountable care organizations and others who embrace population health and risk modification measures which are promptly identified and triaged starting with the first clinical encounter.

    1. Bozic KJ, et al. Comparative Epidemiology of Revision Arthroplasty: Failed THA Poses Greater Clinical and Economic Burdens Than Failed TKA. Clin ortho & rel res. 2015;473(6):2131-38.
    2. Dlott CC, et al. Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients. Jl of arthroplasty. 2020;35(6):1508-15.
    3. Bernstein DN, et al. Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients. Jl of arthroplasty. 2018;33(12):3642-48.
    4. Kee JR, et al. Modifiable Risk Factors Are Common in Early Revision Hip and Knee Arthroplasty. Jl of arthroplasty. 2017;32(12):3689-92
    CONFLICT OF INTEREST: None Reported
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