Several randomized and observational trials in the past decade and the more recent ACC/AHA guidelines support the use of preoperative beta‐blockers (PBBs) in selected patients undergoing noncardiac surgery (NCS). The Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center is a referral‐based clinic providing standardized preoperalive evaluation by hospitalists. We sought to determine whether referral to the IMPACT Center increased the likelihood of administration of PBBs in concordance with the guidelines
We performed a retrospective cohort study of 33,009 patients from January 2005 to December 2007 who underwent elective NCS requiring at least an overnight admission to the hospital. Patients were identified from the surgery scheduling system. A nonparsimonious propensity model was developed to predict IMPACT Cenler referral. Patient demographics, clinical laboratory values, comorbidities, type of surgery, surgical risk using a 5‐point scale based on procedural bleed risk, anesthesia risk using a 4‐point scale analogous to the ASA Physical Status classification derived from a computerized questionnaire consisting of 148 interactive questions, prescribed medications, and prior surgical history were included in the model. Multiple logistic regression, stratified by the propensity for IMPACT referral, was used to determine significant predictors of perioperative beta‐blocker use. beta‐blocker eligibility were defined using a standardized assessment and treatment protocol.
Overall. 61.6% of patients were assessed in the IMPACT Center. The propensity model for IMPACT referral demonstrated strong predictive ability (c statistic = 0.858). The unadjusted odds ratio (OR) for IMPACT referral predicting PBB was 1.24 (P < 0.001). The OR for IMPACT referral remained a significant predictor of PBB (1.14, P < 0.001), even after rigorous adjustment for referral bias using propensity score methods and controlling for patient age (OR = 1.02 per year, P < 0.001), beta‐blocker eligibility (yes or no; (OR = 3.14, P < 0.001), anesthesia risk (per unit on 4‐point scale; OR = 1.31, P < 0.001), systolic blood pressure (per unit mmHg; OR = 1.01, P < 0.001), prior acute myocardial infarction (OR = 2.00, P < 0.001), peripheral vascular disease (OR = 1.97, P < 0.001), diabetes (OR = 1.41, P < 0.001), and asthma (OR = 0.80, P = 0.012).
Preoperative patient assessment in the IMPACT center was associated with higher rates of perioperative beta‐blocker prescription, even after accounting for referral bias using propensity stratification. Further research is underway to investigate whether the higher use of PBB translated into improved perioperative cardiac outcomes in this cohort.
A. Rajamanickam, Cleveland Clinic, physician who also evaluates patients in IMPACT; A. Usmani, Cleveland Clinic, physician who also evaluated patients in IMPACT; E. Hixson, none; M. Pecic, none; A. Prabhakaran, Cleveland Clinic, Physician who also evaluates patients in IMPACT; A. Jaffer, Cleveland Clinic, physician who also evaluated patients in IMPACT; B. Harte. Cleveland Clinic, physician who also evaluates patients in IMPACT.
To cite this abstract:Rajamanickam A, Usmani A, Hixson E, Pecic M, Prabhakaran A, Jaffer A, Harte B. Assessment and Optimization of Cardiac Performance for Noncardiac Surgery Patients: The Increase Quality Improvement. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 118. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/assessment-and-optimization-of-cardiac-performance-for-noncardiac-surgery-patients-the-increase-quality-improvement/. Accessed September 19, 2019.