Reducing Overutilization of Preoperative Medical Referrals Among Patients Undergoing Radical Cystectomy Using an...

To evaluate the frequency with which preoperative medical evaluations lead to changes in perioperative management of patients undergoing radical cystectomy and to examine the impact of an evidence-based algorithm on referral utilization.

A retrospective review of 176 patients undergoing radical cystectomy in 2013-2014 was conducted. Patients referred for additional preoperative medical or cardiology evaluation were identified and the incidence of diagnostic testing or management changes resulting from such evaluations were determined. The impact of an evidence-based algorithm on referral utilization and identification of patients undergoing changes in perioperative management was examined.

Of 176 patients, 111 underwent additional preoperative medical evaluation, with 2.7% undergoing additional diagnostic testing and 8.1% experiencing resultant changes in medical management. Perioperative management changes were minor in scope, with the majority (65%) involving management of hypertension or hypokalemia. Perioperative outcomes were similar between patients undergoing urologic evaluation alone and patients referred for additional preoperative medical evaluation. Applying a referral algorithm incorporating the American College of Cardiology guidelines would have avoided 72% of all medical referrals and reduced direct hospital costs of preoperative evaluations by 74%, while still capturing 94% of all patients who underwent perioperative management changes and all patients with diagnostic findings necessitating surgical delay.

Preoperative medical evaluation of patients undergoing radical cystectomy infrequently yields perioperative management changes. The algorithm presented would significantly reduce overutilization and direct hospital costs while capturing patients most likely to benefit from additional medical evaluation.