UW Shoulder and Elbow Academy: The 4 Ps and Modification of Patient factors prior to surgery

The Ethics of Patient Risk Modification Prior to Elective Joint Replacement Surgery.

We emphasized in prior posts that the outcome of surgery depends in large part on the 4 Ps: the problem being treated, the patient with the problem, the procedure used to treat the problem and the physician providing the treatment.

This article discusses the importance of patient factors and strategies for optimizing them. Their list of potentially modifiable risk factors includes bacterial colonization, diabetes control, body mass index(BMI), smoking status, fall risk, narcotic and/or alcohol dependence, physical conditioning, neurocognitive disorders, nutritional status, cardiovascular status, nongenetic thromboembolic risk, and anemia. This is an important list and gives both patients and their surgeons a lot to think about. How can we best minimize these risk factors in elective surgery?

Here are some of the data they present:

Patients with a BMI > 45 have an 8 times greater risk of complications than average weight patients.

Smokers have a 24% higher risk of postoperative complications, including surgical site infections, pneumonia, stroke and death.

Uncontrolled diabetes (perioperative hyperglycemia) increases the risk of infection.

Staph aureus colonization increase the risk of infection.

Complications, longer lengths of hospital stay, and readmissions increase the risk of penalties or non-payment under current and planned federal programs. Thus on one had there is an incentive for providers to operate on individuals with increased risk to build case volume on one hand and there are incentives for delaying surgery and modifying these risk factors or avoiding elective surgery on individuals at increased risk on the other.

This article provides an interesting discussion of these issues from the standpoint of the surgeon as well as from the standpoint of the patient and 'patient autonomy'. How much of the decision to delay surgery while risk is minimized should be up to the doctor and how much to the patient? How to balance nonmaleficence and beneficence. How to balance the benefit of delay for risk modification with the harm of delay from progression of disease?

This article does not discuss the problems in applying the systems encouraging the reduction of modifiable risk to the situation with unmodifiable risk, such as past medical history, genetics, Medicaid status, race and age. Policies that discourage surgery on high risk patients require complex stratification to distinguish modifiable and unmodifiable risk. Otherwise, Medicaid patients with a history of malignancy and certain ethnicities may be unable to find providers willing to perform the surgeries they need.