Internal medicine consultation for high-risk surgical patients: reflection on hospital mortality and readmission rates in a low-income country

Rosa, Paulo Ricardo Mottin; Spagnól, Marcio Fernando; Rothlisberger, Leonardo; Gelain, Marco Antônio Smiderle; Brida, Mathias Silvestre de; Teixeira, Cassiano

doi:10.1590/1806-9282.20230468

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Revista da Associação Médica Brasileira

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Original Article • Rev. Assoc. Med. Bras. 69 (11) • 2023 • https://doi.org/10.1590/1806-9282.20230468 copy

Internal medicine consultation for high-risk surgical patients: reflection on hospital mortality and readmission rates in a low-income country

Authorship SCIMAGO INSTITUTIONS RANKINGS

SUMMARY

OBJECTIVE:

The objective of this study was to assess the impact of internal medicine consultation on mortality, 30-day readmission, and length of stay in surgical patients.

METHODS:

This is a retrospective descriptive study developed in a public Brazilian teaching hospital with 850 beds.

RESULTS:

A total of 70,245 patients were admitted from 2010 to 2018 to the surgery departments. The main outcomes measured were patients’ mortality, 30-day readmission, and length of stay. Mortality of high-risk patients was lower when followed by internal medicine consultation: patients with ASA≥3 (RR 0.89 [95% confidence interval (95%CI) 0.80–0.99], p=0.02), patients with ASA≥3 plus≥65 years (RR 0.88 [95%CI 0.78–0.99], p=0.04), patients with ASA≥3 plus high-risk surgery (RR 0.86 [95%CI 0.77–0.97], p=0.01), and patients with ASA≥4 plus age ≥65 years (RR 0.83 [95%CI 0.72–0.96], p=0.01). The 30-day readmission of high-risk patients was lower when followed by internal medicine consultation: patients with ≥65 years (RR 0.57 [95%CI 0.37–0.89], p=0.01) and patients with high-risk surgery (RR 0.63 [95%CI 0.46–0.57], p=0.005). The Poisson multivariate regression with adjustment in variances showed that all the variables (namely, age, ASA, morbidity index, surgery risk, and internal medicine consultation) were associated with higher mortality of patients; however, internal medicine consultation was associated with a reduction of mortality in high-risk patients (RR 0.72 [95%CI 0.65–0.84], p=0.02) and an increase of mortality in low-risk patients (RR 1.55 [95%CI 1.31–1.67], p=0.01).

CONCLUSION:

High-risk surgical patients may benefit from perioperative internal medicine consultations, which probably decrease hospital mortality and 30-day hospital readmission.

KEYWORDS:
Hospital medicine; Internal medicine; Perioperative care; Hospital surgery department

		Control group	Internal medicine consultation group		p-value^* * Differences between the control and internal medicine consultation groups. No statistical differences were found between patients with consultation and patients with co-management.
		Control group	Patients with consultation	Patients with co-management
Number of patients		65,145	3,507	2,040	–
Age, median		51 [27.2]	64 [18.6]	66 [17.6]	<0.01 ^Ⱡ Ⱡ P-value of the Kruskal-Wallis test.
	≥65 years	22.5%	48.5%	55.4%	<0.01 ^ⱡ ⱡ P-value of the chi-square test.
Male gender		42.4%	51.2%	54.7%	<0.01 ^ⱡ ⱡ P-value of the chi-square test.
Charlson comorbidity index		3 [2–4]	4 [2–5]	4 [3–5]	<0.01 ^Ⱡ Ⱡ P-value of the Kruskal-Wallis test.
Patient risk
	ASA ≥3	19.3%	38.6%	65.1%	<0.01 ^ⱡ ⱡ P-value of the chi-square test.
	ASA ≥4	1.9%	5.0%	15.0%	<0.01 ^ⱡ ⱡ P-value of the chi-square test.
Surgery risk					<0.01 ^ⱡ ⱡ P-value of the chi-square test.
	Low risk	64.0%	38.4%	30.0%
	Intermediate risk	19.4%	24.7%	16.0%
	High risk	16.6%	39.6%	54.0%
Surgery department					ns
	General surgery	22,849 (94.6%)	733 (3.0%)	565 (2.3%)
	Digestive surgery	786 (66.4%)	357 (30.2%)	41 (3.5%)
	Thoracic surgery	3,036 (89.4%)	248 (7.3%)	111 (3.3%)
	Vascular surgery	8,995 (91.5%)	174 (1.8%)	662 (6.7%)
	Bariatric surgery	550 (96.5%)	7 (1.2%)	13 (2.3%)
	Gynecology	14,797 (96.6%)	390 (2.5%)	125 (0.8%)
	Oncologic surgery	2,992 (93.9%)	51 (1.6%)	142 (4.5%)
	Proctology	2,841 (83.3%)	428 (12.6%)	122 (3.6%)
	Urology	8,299 (85.8%)	1,119 (11.6%)	259 (2.7%)
Hospital length of stay (days)		4.0 [1.0–11.0]	20.0 [12.0–34.0]	22.0 [13.0–37.0]	<0.01 ^Ⱡ Ⱡ P-value of the Kruskal-Wallis test.
ICU admission need		5.7%	20.1%	40.0%	<0.01 ^ⱡ ⱡ P-value of the chi-square test.
Hospital mortality		2.4%	6.9%	18.1%	<0.01 ^ⱡ ⱡ P-value of the chi-square test.

	Hospital mortality		Hospital length of stay		30-day readmission
	IMC vs. CG (p-value)	RR (95%CI)	IMC vs. CG	p-value	IMC vs. CG (p-value)	RR (95%CI)
≥65 years	33.3 vs. 37.2% (p=0.06)	0.90 (0.80–1.01)	31 [18–49] vs. 20.5 [11–35]	<0.001	4.5 vs. 8.0% (p=0.01)	0.57 (0.37–0.89)
ASA ≥3	35.0 vs. 39.4% (p=0.02)	0.89 (0.80–0.99)	37 [23–60] vs. 23 [13–38]	<0.001	6.3 vs. 8.8% (p=0.06)	0.7 (0.49–1.03)
ASA ≥4	47.0 vs. 50.5% (p=0.27)	0.93 (0.82–1.96)	35 [22–39] vs. 2 [6–22]	<0.001	8.1 vs. 6.8% (p=0.55)	1.19 (0.67–2.11)
High-risk surgery	29.2 vs. 28.5% (p=0.70)	1.02 (0.91–1.15)	36 [23–56] vs. 22 [12–36]	<0.001	6.1 vs. 9.7% (p=0.005)	0.63 (0.46–0.57)
ASA ≥3 + ≥65 years	41.5 vs. 47.2% (p=0.04)	0.88 (0.78–0.99)	35 [20–55] vs. 21 [12–38]	<0.001	4.2 vs. 7.5% (p=0.07)	0.56 (0.30–1.06)
ASA ≥3 + high-risk surgery	26.6 vs. 19.6% (p<0.001)	1.36 (1.21–1.52)	32 [19–52] vs. 17 [9–28]	<0.001	7.0 vs. 9.0% (p=0.07)	0.78 (0.59–1.02)
ASA ≥4 + >65 years	50.5 vs. 58.3% (p=0.06)	0.87 (0.74–1.01)	33 [18–53] vs. 14 [8–27]	<0.001	5.7 vs. 8.3% (p=0.39)	0.68 (0.28–1.66)
ASA ≥4 + high-risk surgery	51.1 vs. 60.5% (p=0.01)	0.85 (0.74–0.96)	43 [21–63] vs. 20 [10–34]	<0.001	8.5 vs. 5.5% (p=0.26)	1.53 (0.73–3.25)

Variable		Relative risk (95%CI)	p-value
Age (years)		1.03 (1.02–1.03)	<0.001
ASA
	ASA 1	1.00	–
	ASA 2	2.11 (1.43–3.15)	<0.001
	ASA 3	8.75 (5.83–13.12)	<0.001
	ASA 4	22.35 (14.8–33.8)	<0.001
	ASA 5	30.91 (19.81–48.17)	<0.001
Charlson comorbidities index
	Charlson comorbidities index <2	1.00	–
	Charlson comorbidities index ≥2	6.75 (4.82–10.01)	<0.001
Surgical risk
	Low-risk surgery	1.00
	Intermediate-risk surgery	1.42 (1.22–1.71)	<0.001
	High-risk surgery	2.21 (1.93–2.54)	<0.001
Internal medicine consultation		1.11 (1.01–1.21)	0.01
	Internal medicine consultation in low-risk patients	1.55 (1.31–1.67)	0.01
	Internal medicine consultation in high-risk patients^* * High-risk surgical patients were considered: patients with ASA ≥3, patients aged over 65 years, patients submitted to a high-risk surgery, and any combination of these three variables.	0.72 (0.65–0.84)	0.02

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[1] *Corresponding author: paulo.mottin.rosa@gmail.com