We thank Tsai and Black for their insightful comments. As previously stated,1we agree that our data sources did not describe several important clinical details, which may have further explained the substantial interhospital variation in rates of preoperative medical consultation. Given that the only previous characterization of preoperative evaluation practices in Ontario occurred in 1997,2our future research plans include an updated cross-sectional survey to better understand contemporary practices in the province.

We further agree that decreasing the current variability in preoperative consultation practice is an important goal for perioperative care. However, the initial emphasis should be on better understanding which specific patients benefit from preoperative medical consultations. Previous research has demonstrated that some perioperative interventions (e.g. , β-blockers)3and tests (e.g. , cardiac stress tests)4are beneficial when applied to some individuals, yet potentially harmful when applied to others. A similar pattern is likely to apply to preoperative medical consultation. Consequently, initiatives that narrowly focus on reducing overall consultation rates may not improve clinical outcomes if the result is a reduced use of consultations among patients who most need them. The goal should instead be to improve the appropriateness of preoperative medical consultations; hence, reducing unnecessary consultations among low-risk patients while potentially increasing consultations among high-risk individuals.

Notably, the existing variability in preoperative consultation practice may actually be helpful in designing initiatives to improve the appropriateness of preoperative medical consultations. Specifically, in characterizing preoperative consultation practices at centers with superior postoperative outcomes, we may be able to identify specific practices that can be implemented more widely at other centers. As suggested in the accompanying editorial,5improved prospective databases will be critical for any such effort to use existing practice variation for identifying “optimal” perioperative practices. Once there is better understanding of which patients should be appropriately referred for preoperative medical consultation, anesthesiologists must take a leadership role in developing preoperative evaluation processes that better target appropriate patients for such specialized preoperative care. The goal for these improved processes should be to simultaneously improve clinical outcomes and patient satisfaction, while reducing healthcare system costs and practice variability.

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Bond DM: Pre-anesthetic assessment clinics in Ontario. Can J Anaesth 1999; 46:382–7
Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM: Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005; 353:349–61
Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A: Non-invasive cardiac stress testing before elective major non-cardiac surgery: Population based cohort study. BMJ 2010; 340:b5526
Kheterpal S: Random clinical decisions: Identifying variation in perioperative care. ANESTHESIOLOGY 2012; 116:3–5