I. L. Leeds1, J. K. Canner1, F. Gani1, P. M. Meyers1, E. R. Haut1, J. E. Efron1, F. M. Johnston1 1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA
Introduction: Preoperative comorbidities can have substantial effects on operative risk and outcomes. The modifiability of these risks remains poorly understood. The purpose of this study was to evaluate the impact of non-surgeon preoperative comorbidity optimization on short-term postoperative outcomes.
Methods: Patients with employer-sponsored commercial insurance undergoing a colectomy (ICD-9 codes: 17.3x, 45.7x, 45.8x, 48.5) were identified in the Truven Health MarketScan database (2010-2014). Patients were included if they could be matched to a preoperative surgical clinic visit within 90 days of an operative intervention by the same surgeon. The time interval between the surgical visit and the colectomy was defined as the “potential preoperative optimization period.” In this time interval, patients were defined as “optimized” if they were seen by an appropriate non-surgeon for at least one of their preexisting comorbidities (e.g., primary care or endocrinology visit for diabetic patient). Propensity score matching with 1:1 nearest-neighbor matching with replacement was performed prior to regression analysis to account for between-group covariate extremes. Bivariate analysis and mult
Results: We identified 16,279 eligible colectomy episodes, of which 3,940 (24.2%) were in patients with at least one clinically significant comorbidity. 64.8% of patients with comorbidities were medically optimized prior to surgery. 2,545 medical optimized patients were matched to 1,388 non-optimized controls. Operative indications included neoplasm (50.5%) and diverticulitis (32.6%). The optimized subgroup was significantly older, more likely to be male, more comorbid at baseline by Charlson score, and more likely to reside in the northeastern United States.
Medically optimized patients had a lower risk of complications (29.9% vs. 33.7%, p=0.014) driven largely by fewer postoperative gastrointestinal, renal, hepatic, wound, and septic complications. Multivariable logistic regression controlling for patient demographics, operative indication, and Charlson Comorbidity Index demonstrated that patients optimized prior to surgery had a 15% lower odds (OR 95% CI = 0.73-0.99, p=0.036) of having a complication compared with non-optimized patients. The median increase in preoperative costs for optimized patients was $1,519 (p<0.001) while the median increased total cost with a complication was $18,941 (p<0.001).
Conclusion: Many surgical patients do not receive focused preoperative care for their medical comorbidities. Patients who receive comorbidity-associated nonsurgical care prior to an operation have better short-term surgical outcomes. The individual costs of medical optimization are much less than the cost of a surgical complication. These findings support further prospective study of whether patients undergoing high-risk surgery can benefit from more intensive preoperative optimization.