To the Editor—
Ferschl et al. 1recently reported that preoperative preparation at an anesthesia preoperative medicine clinic (APMC) can reduce both case cancellations and case delays. Their study showed that the median time to start a case in the operating room decreased significantly (by 2–3 min) in patients who were evaluated at the APMC. This time gain as a result of the APMC has not been shown previously. Furthermore, the authors demonstrated a significant decrease in day-of-surgery cancellations (64% for same-day cases and 63% for admitted surgical patients). Although this latter benefit of an APMC has been reported previously,2,3the authors still can be commended for their contribution to the increasing evidence of the positive effects of an APMC on the cost effectiveness of the perioperative process.
However, we do have some important questions regarding this study. First, it is not clear who was responsible for the ultimate decision to cancel a case: the anesthesiologist or the surgeon? Second, the authors report a very high rate of cancellations compared with the rates reported in previous studies (11% in the current study vs. 2% cancellations for medical reasons in previous studies).2,3In the article, no explanation is given for this high cancellation rate. Therefore, although this was a retrospective study, it would have been interesting to have at a minimum some indication of the reasons for these cancellations. For example, if cancellations were caused by incomplete laboratory test results, a similar reduction in cancellations would possibly have been obtained by reeducation using a protocol for preoperative additional testing. Furthermore, cancellations for nonmedical reasons (e.g. , surgery no longer indicated, patient “bumped” from the room, emergency patient instead of the planned surgery) can hardly be influenced by an APMC. In a large cohort study (n = 21,553), we described the effects of a gradual introduction of an APMC for all surgical patients in a university hospital.3This study also documented the reasons for cancellations within 24 h before the planned surgery. After adjustment for age and sex, we found a significant decrease with 30% for cancellations due to medical reasons (e.g. , unstable cardiovascular disease or insufficient diagnostic workup) but a decrease of only 10% for cancellations for nonmedical reasons. Third, at the authors’ institution, the decision as to whether a patient is seen in the APMC is made by the referring surgeon. This resulted in a referral to the APMC of only 43% of the 6,524 surgical patients included in the study. However, as the authors acknowledge, the effect of the APMC on the rate of day-of-surgery case cancellations would likely have been greater when the decision to refer patients to the APMC was not made by the surgeons. We therefore wonder why the authors do not recommend an APMC visit for every patient scheduled for surgery. Do they believe that it will not further enhance patient safety and the utilization of hospital resources?3,4Of course, it may be difficult to compel surgeons to refer all of their patients to the APMC. However, by using the accumulating evidence demonstrating that an APMC yields fewer cancellations on the day of surgery, precious operation room time can be saved. The APMC also guarantees that truly necessary preoperative tests will be ordered timely.2,3Finally, an APMC for all surgical patients reduces the responsibilities and workloads of the surgeons.
Therefore, combining the available evidence, we may conclude that when the APMC is used as an integral component of perioperative care for all surgical patients, the number of unnecessary cancellations due to medical reasons will decrease considerably. Furthermore, patient safety can be expected to increase by a more timely preoperative evaluation and the possibility to discover and treat clinically relevant comorbidity (e.g. , starting a β blocker in patients at high risk for perioperative myocardial ischemia).
*University Medical Center Utrecht, Utrecht, The Netherlands. email@example.com