The Value of Preoperative Assessment Before Noncardiac Surgery in the Era of Value-Based Care
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Over the past several decades, the field of preoperative cardiac evaluation before noncardiac surgery has evolved substantially. Initially, the focus was on identifying high-risk patients who might benefit from additional interventions, but the value of those interventions, such as coronary revascularization, was unknown. Beginning around the time of the publication of the first American College of Cardiology/American Heart Association (ACC/AHA) Guidelines in 1996, the focus has evolved from identification of risk to targeted evaluation and treatment for those in whom it would impact outcome, ie, those in whom there is clearly value.
There are currently 3 major Society Guidelines, the 2014 ACC/AHA Guidelines,1 the 2014 European Society of Cardiology/European Society of Anesthesiology,2 and the 2017 Canadian Cardiovascular Society (CCS),3 that address preoperative assessment. There are clear differences between the first 2 guidelines and the more recent CCS Guidelines, which may, in part, reflect the evolution of new evidence since the publication of earlier guidelines. However, a notable philosophical difference in data interpretation is clear as well.
Until recently, the ACC/AHA Guidelines, and most medical consultations, included the assumption that surgery was not only indicated but would occur. As health care moves from volume to value, shared decision making around the risks and benefits of surgery …