Reducing Unnecessary Preoperative Cardiology Referral and Cost in Patients Undergoing Bariatric Surgery

Candidates for metabolic and bariatric surgery (MBS) are at increased risk for cardiovascular disease (CVD), which may increase surgical risk. Currently, there are no society guidelines indicating which patients are appropriate for preoperative cardiac risk stratification. We hypothesized that applying a standardized surgical risk calculator with a novel referral algorithm to stratify patients for preoperative cardiac risk stratification would decrease unnecessary referrals and cost to patients and the healthcare system. All patients undergoing MBS at our institution between 2014 and 2023 were identified. Baseline patient characteristics, referrals to cardiology, subsequent cardiac testing ordered, and surgical outcomes were measured. Revised Cardiac Risk Index (RCRI) score was retrospectively calculated for each patient and grouped as low versus increased risk (RCRI score of 0 vs ≥1). Deriving a novel scoring system (RCRI score, ever smoker, age ≥65, and/or METS ≤4) and imputing this retrospective referral algorithm using this score to guide cardiology referral, we calculated how the referral pattern would be affected and the resultant change in costs. Postoperative cardiac complications were assessed as defined by myocardial infarctions, cardiac arrests, stroke, or cardiovascular death. A total of 1,528 patients underwent MBS during the study period, of which 56% (n = 852) were referred to cardiology preoperatively. Those referred were older, had more hypertension, hyperlipidemia, and diabetes, were ever smokers, had heart failure and atrial fibrillation, and were more likely to have BMI >50 kg/m². Of those patients with an RCRI score of 0, 45% (n = 435) underwent further cardiac testing. Strictly applying our standardized referral algorithm, of the 852 patients referred to cardiology, 30% (n = 255) were referred despite being low risk. Based on Medicare reimbursement for Level 4 outpatient consults and unnecessary testing, this would have resulted in a savings of approximately $28,000. There were no postoperative cardiac complications. In conclusion, among candidates for bariatric surgery, a novel referral algorithm based on RCRI and other CVD risk factors may reduce unnecessary preoperative cardiology referrals, with resultant reduction in resource utilization and overall cost savings.