Preoperative Evaluation and Cost Containment R. A. Wiklund, ed. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins, 2002. ISBN 0020-5907. 200 pp., $225.00
In reaction to cost containment pressures and the need to coordinate increasingly complex processes on an ambulatory basis, preoperative evaluation evolved in the 1990s. Other factors such as introduction of information technologies and growth of evidence-based medicine practices also played a role in the maturation of preoperative clinics. While there are significant needs for development of new knowledge, dissemination, and room for practice improvement, Preoperative Evaluation and Cost Containmen t does not go far enough to close those gaps.
Generally, the book promises more than it delivers, especially regarding the topic of cost containment. Highlighting of this important and emerging topic in the book’s title leads one to expect that a systematic approach to cost containment strategies and tactics would be integrated across the range of topics covered. However, only two chapters actually deal with this important issue.
Some topics addressed in terms of intraoperative contexts while the preoperative perspective is lacking (e.g., the chapters on endocarditis prophylaxis and perioperative beta-blockers), a shortcoming of much of the preoperative literature. In addition, in a book of this general scope, it is surprising that traditional and important issues such as hypertension and pulmonary disease are not mentioned at all. Innovative areas such as patient education, decision-support tools, and preoperative planning of postdischarge care where cost analyses are particularly relevant are neglected.
The chapter on endocarditis prophylaxis is important in that it brings this oft-neglected topic to the attention of anesthesiologists. However, the position paper by the American Heart Association on Prevention of Bacterial Endocarditis presents the material in a much clearer and more succinct manner. This chapter falls short in not elucidating the need and methods for improved identification of presurgical patients at risk for endocarditis, given that 47% of cases occur in patients with no previous diagnosis of heart disease. The chapter does not address the dilemma of what to do with the patient who presents for urgent surgery with a murmur of unknown etiology or those having surgery on infected tissue. While the often-overlooked issue of joint prostheses infections is discussed, unfortunately that discussion is buried in the middle of a chapter without a heading and is not included in the index.
Patients are widely using herbal remedies in combinations and doses that are beginning to be appreciated as creating significant new risks perioperatively, yet this topic received only cursory attention. There are a number of inconsistencies and incorrect statements. In the chapter on transfusion medicine, in one of the few references to cost containment analysis, one is confused by the statement, “Autogeneic and directed-donor blood transfusions (approximately $120 per unit) are more costly than volunteer allogeneic blood (approximately $136 per unit)” (p. 164). “Factor VII” is incorrectly substituted for Factor VIII on page 181. On page 188, the American College of Cardiology recommendations for endocarditis prophylaxis are stated incorrectly and are not internally consistent with the recommendations presented in an earlier chapter. Neither of these two statements is referenced to allow confirmation by the reader. One solution would have been to offer more tabular or graphic presentations and cross-references material throughout the book. Indeed, a number of such opportunities are missed, which would have helped the reader easily find and navigate related information.
Although there is an excellent discussion of the pharmacology of beta-blockers and the rationale for using them perioperatively, there is minimal data or advice on how to implement this practice, particularly in the preoperative period. This is an important omission given the documented systemic, cultural, and even behavioral challenges to translating research into practice. This omission is especially important in the case of perioperative beta blockade, where extensive research has validated its efficacy in reducing cardiovascular morbidity and mortality perioperatively. It would also have been useful and appropriate to employ cost-benefit analysis to discuss the utility of pursuing a diagnosis of cardiac disease in high-risk patients versus treatment with beta-blockers and intensive intra- and postoperative care and monitoring.
The chapter on computer and information technology begins to address several of the exciting new frontiers in health care delivery. However, it falls short in neglecting to discuss use of this technology as a powerful tool for quality assurance and linkages to best practices, evidence-based guidelines, and cost containment. In addition, the issues of distributed simultaneous access to critical data, legibility, improvements in patient safety, and education across the continuum of health care participants, including patients, are not presented. A discussion of products other than the single one mentioned to accomplish this task, such as the Vanderbilt Perioperative Information Management System and Preopvisit.com, would have improved this chapter.
The chapter on diabetes mellitus stands out as being particularly thorough and well written, as is the chapter on quality improvement. The authors of the chapters on drugs affecting platelet function and noninvasive cardiac testing are to be commended for presenting refreshingly clear information on topics not readily available in anesthesiology texts. Some thoughtful information on cost containment is presented, albeit sporadically. These few bright spots are overshadowed by a lack of attention to detail in content, design, and accuracy of material and questionable decisions in topic selection.