Evaluation of electronic screening in the preoperative process.

STUDY OBJECTIVE: Rising patient numbers, with increasing complexity, challenge the sustainability of the current preoperative process. We evaluated whether an electronic screening application can distinguish patients that need a preoperative consultation from low-risk patients that can be first seen on the day of surgery. DESIGN: Prospective cohort study. SETTING: Preoperative clinic of a tertiary academic hospital. PATIENTS: 1395 adult patients scheduled for surgery or procedural sedation. INTERVENTIONS: We assessed a novel electronic preoperative screening application which consists of a questionnaire with a maximum of 185 questions regarding the patient's medical history and current state of health. The application provides an extensive health report, including an American Society of Anesthesiologists physical status (ASA-PS) classification and a recommendation for either consultation by an anesthesiologist at the preoperative clinic or approval for screening on the day of surgery. MEASUREMENTS: The recommendation of the electronic screening system was compared with the regular preoperative assessment using measures of diagnostic accuracy and agreement. Secondary outcomes included ASA-PS classification, patient satisfaction, and the anesthesiologists' opinion on the completeness and quality of the screening report. RESULTS: Sensitivity to detect patients who needed additional consultation was 97.5% (95%CI 91.2-99.7) and the negative likelihood ratio was 0.08 (95%CI 0.02-0.32). 407 (29.2%) patients were approved for surgery by both electronic screening and anesthesiologist. In 909 (65.2%) cases, the electronic screening system recommended further consultation while the anesthesiologist approved the patient (specificity 30.9% (95%CI 28.4-33.5); poor level of agreement (ĸ = 0.04)). Agreement regarding ASA-PS classification scores was weak (ĸ = 0.48). The majority of patients (78.0%) felt positive about electronic screening replacing the regular preoperative assessment. CONCLUSIONS: Electronic screening can reliably identify patients who can have their first contact with an anesthesiologist on the day of surgery, potentially allowing a major proportion of patients to safely bypass the preoperative clinic.

Pedunculated Morphology of T1 Colorectal Tumors Associates With Reduced Risk of Adverse Outcome.

BACKGROUND & AIMS: Risk stratification for adverse events, such as metastasis to lymph nodes, is based only on histologic features of tumors. We aimed to compare adverse outcomes of pedunculated vs nonpedunculated T1 colorectal cancers (CRC). METHODS: We performed a retrospective study of 1656 patients diagnosed with T1CRC from 2000 through 2014 at 14 hospitals in The Netherlands. The median follow-up time of patients was 42.5 months (interquartile range, 18.5-77.5 mo). We evaluated the association between tumor morphology and the primary composite end point, adverse outcome, adjusted for clinical variables, histologic variables, resection margins, and treatment approach. Adverse outcome was defined as metastasis to lymph nodes, distant metastases, local recurrence, or residual tissue. Secondary end points were tumor metastasis, recurrence, and incomplete resection. RESULTS: Adverse outcome occurred in 67 of 723 patients (9.3%) with pedunculated T1CRCs vs 155 of 933 patients (16.6%) with nonpedunculated T1CRCs. Pedunculated morphology was independently associated with decreased risk of adverse outcome (adjusted odds ratio [OR], 0.59; 95% CI, 0.42-0.83; P = .003). Metastasis, incomplete resection, and recurrence were observed in 5.8%, 4.6%, and 3.9% of pedunculated T1CRCs vs 10.6%, 8.0%, and 6.6% of nonpedunculated T1CRCs, respectively. Pedunculated morphology was independently associated with a reduced risk of metastasis (adjusted OR, 0.62; 95% CI, 0.41-0.94; P = .03), incomplete resection (adjusted OR, 0.57; 95% CI, 0.36-0.91; P = .02), and recurrence (adjusted hazard ratio, 0.52; 95% CI, 0.32-0.85; P = .009). Metastasis, incomplete resection, and recurrence did not differ significantly between low-risk pedunculated vs nonpedunculated T1CRCs (0.8% vs 2.9%, P = .38; 1.5% vs 0%, P = .99; 1.5% vs 0%; P = .99). However, incomplete resection and recurrence were significantly lower for high-risk pedunculated vs nonpedunculated T1CRCs (6.5% vs 12.5%; P = .007; 4.4% vs 8.6%; P = .03). CONCLUSIONS: In a retrospective study of patients with T1CRC, we found pedunculated morphology to be associated independently with a decreased risk of adverse outcome in a T1CRC population at high risk of adverse outcome. Incorporating morphologic features of tumors in risk assessment could help predict outcomes of patients with T1CRC and help identify the best candidates for surgery.