Is a preoperative multidisciplinary team meeting (cost)effective to improve outcome for high-risk adult patients undergoing noncardiac surgery: the PREPARATION study-a multicenter stepped-wedge cluster randomized trial.

BACKGROUND: As a result of increased life expectancy and improved care for patients suffering from chronic disease, the number of patients with multimorbidity requiring surgical intervention is increasing. For complex surgical patients, it is essential to balance the potential benefits of surgical treatment against the risk of permanent loss of functional capacity and quality of life due to complications. European and US guidelines on perioperative care recommend preoperative multidisciplinary team (MDT) discussions for high-risk noncardiac surgical patients. However, the evidence underlying benefits from preoperative MDT meetings with all relevant perioperative specialties present is limited. The current study aims to investigate the effect of implementation of preoperative MDT discussions for high-risk patients undergoing noncardiac surgery on serious adverse events. METHODS/DESIGN: PREPARATION is a stepped-wedge cluster randomized trial in 14 Dutch hospitals without currently established preoperative MDT meeting. The intervention, preoperative MDT meetings, will be implemented sequentially with seven blocks of 2 hospitals switching from control (preoperative screening as usual) to the intervention every 3 months. Each hospital will be randomized to one of seven blocks. We aim to include 1200 patients. The primary outcome is the incidence of serious adverse events at 6 months. Secondary outcomes include (cost)effectiveness, functional outcome, and quality of life for up to 12 months. DISCUSSION: PREPARATION is the first study to assess the effectiveness of a preoperative MDT meeting for high-risk noncardiac surgical patients in the presence of an anesthesiologist. If the results suggest that preoperative MDT discussions for high-risk patients are (cost)-effective, the current study facilitates implementation of preoperative MDT meetings in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT05703230. Registered on 11/09/2022.

In pursuit of a better transition to selected residencies: a quasi-experimental evaluation of a final year of medical school dedicated to the acute care domain.

BACKGROUND: Medical schools seek the best curricular designs for the transition to postgraduate education, such as the Dutch elective-based final, 'transitional' year. Most Dutch graduates work a mean of three years as a physician-not-in-training (PNIT) before entering residency training. To ease the transition to selected specialties and to decrease the duration of the PNIT period, UMC Utrecht introduced an optional, thematic variant of the usual transitional year, that enables the development of theme-specific competencies, in addition to physicians' general competencies. METHODS: We introduced an optional transitional year for interested students around the theme of acute care, called the Acute Care Transitional Year (ACTY). This study aimed to evaluate the ACTY by judging whether graduates meet postgraduate acute care expectations, indicating enhanced learning and preparation for practice. In a comprehensive assessment of acute care knowledge, clinical reasoning, skills, and performance in simulations, we collected data from ACTY students, non-ACTY students interested in acute care, and PNITs with approximately six months of acute care experience. RESULTS: ACTY graduates outperformed non-ACTY graduates on skills and simulations, and had higher odds of coming up to the expectations faculty have of a PNIT, as determined by global ratings. PNITs did better on simulations than ACTY graduates. DISCUSSION: ACTY graduates show better resemblance to PNITs than non-ACTY graduates, suggesting better preparation for postgraduate acute care challenges. CONCLUSION: Transitional years, offering multidisciplinary perspectives on a certain theme, can enhance learning and preparedness for entering residency.

Preoperative multidisciplinary team decisions for high-risk patients scheduled for noncardiac surgery-a retrospective observational study.

PURPOSE: Preoperative multidisciplinary team (MDT) meetings are recommended for patients at high risk for perioperative complications and mortality, although the underlying evidence is scarce. We aimed to investigate the effect of MDT decisions on patient management and patient outcome. METHODS: We conducted a single-centre retrospective cohort study including all noncardiac surgical patients selected for discussion at preoperative MDT meetings from January 2017 to December 2019 (N = 120). We abstracted preoperative data, MDT decisions, and patient outcomes from the electronic health records for analysis. RESULTS: Of the 120 patients registered for an MDT meeting, 43% did not undergo their initially planned surgery. Only 27% of patients received perioperative management as planned before the MDT meeting. Most surgery cancellations were the MDT's decision (22%) or the patient's decision before or after the MDT discussion (10%). Postoperative complications occurred in 28% of operated patients, and postoperative mortality was 4% at 30 days and 10% at three months, most of which was attributable to postoperative complications. Non-operated patients had a 7% mortality rate at 30 days and 9% at three months. Alterations of perioperative management following MDT discussion were associated with fewer cases of extended length of hospital stay (> ten days). CONCLUSION: This study shows that preoperative MDT meetings for high-risk noncardiac surgical patients altered the management of most patients. Management alterations were associated with fewer hospital admissions of long duration. These results should be interpreted with appropriate caution given the methodological limitations inherent to this small study.

RéSUMé: OBJECTIF: Les réunions préopératoires d'une équipe multidisciplinaire (EMD) sont recommandées pour les patients présentant un risque élevé de complications périopératoires et mortalité, bien que les données probantes sous-jacentes soient rares. Notre objectif était d'étudier l'effet des décisions d'une EMD sur la prise en charge et les issues des patients. MéTHODE: Nous avons mené une étude de cohorte rétrospective monocentrique incluant tous les patients chirurgicaux non cardiaques retenus pour discussion lors des réunions préopératoires de l'EMD de janvier 2017 à décembre 2019 (N = 120). Pour notre analyse, nous avons extrait les données préopératoires, les décisions de l'EMD et les issues des patients des dossiers de santé électroniques. RéSULTATS: Sur les 120 patients inscrits pour discussion dans une réunion de l'EMD, 43 % n'ont pas subi la chirurgie initialement prévue. Seulement 27 % des patients ont bénéficié de la prise en charge périopératoire prévue avant la réunion de l'EMD. La plupart des annulations de chirurgie étaient dues à la décision de l'EMD (22 %) ou à la décision du patient avant ou après la discussion de l'EMD (10 %). Des complications postopératoires sont survenues chez 28 % des patients opérés, et la mortalité postopératoire était de 4 % à 30 jours et de 10 % à trois mois, en majorité attribuable à des complications postopératoires. Les patients non opérés avaient un taux de mortalité de 7 % à 30 jours et de 9 % à trois mois. Les modifications de prise en charge périopératoire à la suite des discussions de l'EMD ont été associées à une réduction des cas de prolongation du séjour à l'hôpital (> dix jours). CONCLUSION: Cette étude montre que les réunions préopératoires de l'EMD pour les patients chirurgicaux non cardiaques à haut risque ont modifié la prise en charge de la plupart des patients. Les modifications apportées à la prise en charge ont été associées à une diminution du nombre d'admissions à l'hôpital pour une longue durée. Ces résultats doivent toutefois être interprétés avec prudence compte tenu des limites méthodologiques inhérentes à cette petite étude.