A Mixed-Methods Study of the Variation in Routine Preoperative Clinic Utilization

Preoperative evaluation is considered essential for surgical optimization, encompassing risk assessment, patient education, and completion of presurgical requirements. However, there are no standardized approaches for preoperative clinic utilization based on patient and procedural risk. We aimed to characterize preoperative clinic utilization among healthy patients undergoing low-risk ambulatory surgery to identify practice- and surgeon-level sources of variation and identify targets for improved quality and value.

We used multiple methods to conduct a retrospective cohort study of low-risk adult patients (American Society of Anesthesiologists classes I and II) undergoing low-risk ambulatory surgery (Operative Stress Score [OSS] 1-2) at a single academic health system between May and December 2024. Preoperative clinic visits within 30 d of surgery were identified. Mixed-effects logistic regression was used to estimate variance attributable to surgeons and procedures, adjusting for patient and procedural factors. A 12-question survey regarding preoperative clinic utilization was distributed to advanced practice providers working in the preoperative clinic and surgeons. Semistructured interviews were conducted with purposively sampled clinicians to capture perspectives on clinic purpose and referral decision-making.

Among 3469 eligible cases, 1788 (52%) included a preoperative clinic visit. Utilization varied across surgical services (22%-88%). In adjusted models, 45% of the variance in preoperative clinic utilization was attributable to the operating surgeon and 11% to procedure type. A total of 106 clinicians (93 surgeons and 13 advanced practice providers) completed the survey (41% response rate). Referral frequency varied widely, and most respondents endorsed medication management (94%) and risk optimization (92%) as primary indications. Interviews (n = 21) described heterogeneity in perceived clinic purpose, referral criteria, and ownership of perioperative tasks.

Preoperative clinic utilization among low-risk ambulatory surgery patients varies significantly and is driven by surgeon-level factors. The heterogeneity in referral practices and perceived clinic roles highlights an opportunity to align preoperative evaluation with patient risk and potentially improve value by avoiding unnecessary visits.