Preoperative Medical Referral Prior to Hepatopancreatic Surgery-Is It Worth it?

Many patients who present for complex surgery have underlying medical comorbidities. While surgeons often refer these patients to medical appointments for preoperative "optimization" or "clearance," the actual impact of these visits remains poorly examined. The objective of the current study was to define the potential benefit of preoperative medical appointments on outcomes and costs associated with hepatopancreatic (HP) surgery.

Patients with modifiable comorbidities undergoing HP surgery were identified in the Medicare claims data. The association of preoperative non-surgical visit and postoperative outcomes and expenditures was assessed using inverse propensity treatment weighting analysis and multivariable logistic regression.

Among the 5574 Medicare beneficiaries who underwent a hepatopancreatic surgery, one in seven patients (n = 830, 14.9%) was "optimized" preoperatively. On multivariable logistic regression analysis, age (OR 1.02; 95% CI 1.01-1.03; p = 0.006) and higher comorbidity burden (OR 1.03; 95% CI 1.01-1.05; p = 0.007) were associated with modest increased odds of being referred in the preoperative period for a non-surgical evaluation; the factor most associated with preoperative non-surgical visit was male patient sex (OR 1.33; 95% CI 1.14-1.56; p < 0.001). After adjustment for competing risk factors and random site effect, patients with an "optimization" visit had 28% lower odds (OR 0.72; 95% CI 0.59-0.86; p < 0.001) of experiencing an operative complication. Additionally, patients who had a non-surgical visit had 13% higher median total expenditures compared with individuals who did not undergo an "optimization" visit (p < 0.05).

In conclusion, roughly one in seven Medicare beneficiaries who underwent HP surgery may have been risk stratified by a non-surgical provider prior to surgery. Preoperative evaluation was associated with modestly lower odds of complications following HP surgery and higher Medicare expenditures. Further research is needed to determine its routine utility as a means to decrease the morbidity surrounding HP surgery.