Medical School, University of Michigan, Ann Arbor.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.
JAMA Netw Open. 2021 Nov 1;4(11):e2130016. doi: 10.1001/jamanetworkopen.2021.30016.
Preoperative optimization is an important clinical strategy for reducing morbidity; however, nearly 25% of persons undergoing elective abdominal hernia repairs are not optimized with respect to weight or substance use. Although the preoperative period represents a unique opportunity to motivate patient health behavior changes, fear of emergent presentation and financial concerns are often cited as clinician barriers to optimization.
To evaluate the feasibility of evidence-based patient optimization before surgery by implementing a low-cost preoperative optimization clinic.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study was conducted 1 year after a preoperative optimization clinic was implemented for high-risk patients seeking elective hernia repair. The median (range) follow-up was 197 (39-378) days. A weekly preoperative optimization clinic was implemented in 2019 at a single academic center. Referral occurred for persons seeking elective hernia repair with a body mass index greater than or equal to 40, age 75 years or older, or active tobacco use. Data analysis was performed from February to July 2020.
Enrolled patients were provided health resources and longitudinal multidisciplinary care.
The primary outcomes were safety and eligibility for surgery after participating in the optimization clinic. The hypothesis was that the optimization clinic could preoperatively mitigate patient risk factors, without increasing patient risk. Safety was defined as the occurrence of complications during participation in the optimization clinic. The secondary outcome metric centered on the financial impact of implementing the preoperative optimization program.
Of the 165 patients enrolled in the optimization clinic, most were women (90 patients [54.5%]) and White (145 patients [87.9%]). The mean (SD) age was 59.4 (15.8) years. Patients' eligibility for the clinic was distributed across high-risk criteria: 37.0% (61 patients) for weight, 26.1% (43 patients) for tobacco use, and 23.6% (39 patients) for age. Overall, 9.1% of persons (15 patients) were successfully optimized for surgery, and tobacco cessation was achieved in 13.8% of smokers (8 patients). The rate of hernia incarceration requiring emergent surgery was 3.0% (5 patients). Economic evaluation found increased operative yield from surgical clinics, with a 58% increase in hernia-attributed relative value units without altering surgeon workflow.
In this quality improvement study, a hernia optimization clinic safely improved management of high-risk patients and increased operative yield for the institution. This represents an opportunity to create sustainable and scalable models that provide longitudinal care and optimize patients to improve outcomes of hernia repair.
术前优化是减少发病率的重要临床策略；然而，近 25%接受择期腹部疝修补术的患者在体重或药物使用方面并未得到优化。尽管术前阶段是促进患者健康行为改变的独特机会，但临床医生往往因担心紧急就诊和经济问题而不愿进行优化。
通过实施低成本的术前优化诊所，评估在手术前进行基于证据的患者优化的可行性。
设计、设置和参与者：这项质量改进研究是在为接受择期疝修补术的高危患者实施术前优化诊所 1 年后进行的。中位（范围）随访时间为 197（39-378）天。2019 年，在一家学术中心每周开设一次术前优化诊所。该诊所针对的是接受择期疝修补术的患者，其体重指数大于或等于 40、年龄 75 岁或以上或有吸烟史。数据分析于 2020 年 2 月至 7 月进行。
入组患者接受健康资源和纵向多学科护理。
主要结局是参与优化诊所后手术的安全性和适宜性。假设是优化诊所可以在术前减轻患者的风险因素，而不会增加患者的风险。安全性定义为参与优化诊所期间发生的并发症。次要结果指标集中在实施术前优化计划的经济影响上。
在优化诊所登记的 165 名患者中，大多数为女性（90 名[54.5%]）和白人（145 名[87.9%]）。平均（SD）年龄为 59.4（15.8）岁。患者入组的标准分布在高危标准中：体重占 37.0%（61 名患者），吸烟占 26.1%（43 名患者），年龄占 23.6%（39 名患者）。总体而言，9.1%的患者（15 名）成功接受了手术优化，13.8%的吸烟者（8 名）成功戒烟。需要紧急手术治疗的疝嵌顿发生率为 3.0%（5 名患者）。经济评估发现手术科室的手术量增加，疝归因的相对价值单位增加了 58%，而不改变外科医生的工作流程。
在这项质量改进研究中，疝优化诊所安全地改善了高危患者的管理，并提高了机构的手术效果。这为创建提供纵向护理和优化患者以改善疝修补术结果的可持续和可扩展模型提供了机会。
