Preoperative risk prediction and multidisciplinary team discussions: Tools for improving perioperative management for high-risk noncardiac surgical patients

People are becoming older and are suffering from more chronic diseases, partly because technical innovations have improved surgical safety. Since it is known that patients with multiple comorbidities suffer from more adverse events in the perioperative period, it is important to exactly identify those patients who might need extra attention from their multidisciplinary team (all the consultants and other health care workers involved in their perioperative care). According to a joint guideline from The Netherlands Societies of Anaesthesiology (NVA) and Surgery (NVVH) from 2010 these preoperative multidisciplinary team (MDT) meetings should be organized in every hospital in the Netherlands. This thesis is concerned with the identification of high-risk noncardiac surgical patients through the use of perioperative mortality risk calculators, with the state of execution of preoperative MDT meetings in the Netherlands, with the characteristics of the MDT meetings, with the outcome of the MDT meetings and patients. The thesis also started research to investigate more qualitative questions such as: what is the (cost) effectiveness of preoperative MDTs?, the quality of life after preoperative MDTs?, the state of disability after MDTs and the extent of disability free survival after an MDT and decision regret. This study received a grant from ZONMW (the Netherlands Organization for Health Research and Development)
This thesis found that existing preoperative 30-day mortality risk calculators are not reliable enough for identification of high-risk patients at the preoperative screening clinics yet. A few models may be used after external validation of the calculator and maybe updating of the calculator as well. This thesis also found that only 50% of hospitals in The Netherlands have preoperative MDTs for noncardiac high-risk patients installed. Most patients were identified because of doubt regarding the harm-benefit ratio of the planned surgery and preoperative mortality risk calculators were calculated but never used for identification. Variation exists in execution of MDT discussions in The Netherlands. The anaesthesiologist is almost always present during the MDT discussions and the surgeon for more than 70%. During the MDTs for many patients an modification was suggested to the original treatment plan (73-81%) and discussed during multidisciplinary decision-making with the patient and their family after the MDT meeting. One third of the discussed patients did not have surgery after the MDT and 5-10% of the patients refrained from surgery after becoming aware of the higher stakes of their surgery. The treatment that was decided after shared-decision making was almost always executed according to plan. Adverse events were more frequent for the nonsurgical treatment group and more high-risk patients who had no surgical treatment died within 30 days. Variation was present between nine hospitals
Guidelines are needed to implement and improve shared-decision making for high-risk noncardiac surgical patients in the Netherlands to be able to improve perioperative care for high-risk noncardiac surgical patients in all hospitals in The Netherlands.