Abstract
BACKGROUND
Clinical guidelines support the use of preoperative B-blocker in select patients. Patient safety groups have sought to measure the level of adherence to these recommendations.
OBJECTIVE
This study was performed to compare the utilization of preoperative B-blocker with current guidelines across multiple diverse institutions.
DESIGN
Retrospective chart review was performed of inpatients undergoing noncardiac surgery across 5 hospital centers during 2003 to 2004. The primary outcome of interest was the administration of preoperative B-blocker.
PARTICIPANTS
The study sample included 1,304 randomly selected patients meeting the guideline criteria for preoperative B-blockade.
MEASUREMENTS AND MAIN RESULTS
Among patients meeting recommendations for preoperative B-blocker, only 44% (430/983) received B-blocker before surgery. Patients who had not previously received B-blocker were given B-blocker before surgery in only 14% (85/600) of cases. Target heart rates goals for perioperative B-blockade were achieved in 26% (113/430) of cases. Predictors for initiating preoperative B-blocker included nonelective surgery or a history of hypertension or diabetes. Individual hospitals were independently predictive of preoperative B-blocker administration in multivariable models.
CONCLUSIONS
Preoperative B-blocker was significantly underutilized when compared with the current guideline recommendations. Target heart rate goals were not achieved in clinical practice, and few hospitalized patients had preoperative B-blockade initiated. The lack of adherence to preoperative B-blocker recommendations in practice may be impacted by ongoing clinical questions regarding the appropriate selection of candidates for this therapy. Further efforts toward achieving guideline recommendations for preoperative B-blocker use should be focused on the subset of patients that are uniformly agreed upon to be at high risk for cardiac events.
Keywords: adrenergic β-antagonists, perioperative care, quality indicators, health care, practice guidelines
Clinical guidelines and consensus statements support the use of a preoperative B-blocker to prevent adverse cardiac events among surgical patients at risk for ischemia. 1– 3 These recommendations are based upon the results of observational studies in which reductions in cardiac complications were noted among patients who received B-blocker. 4, 5 Further evidence for this practice is drawn from several small randomized trials of preoperative B-blocker administration. In the first of these trials, Mangano et al. 6 demonstrated that, among patients with risk factors for ischemia, the use of preoperative B-blocker resulted in a reduction in cardiovascular events and a mortality benefit following hospitalization. In a subsequent study, Poldermans et al. demonstrated a reduction in perioperative myocardial infarction (MI) and death with B-blocker use in high-risk patients undergoing vascular surgery. 7 Finally, additional evidence supporting the role of preoperative B-blocker is derived from the extensive literature supporting B-blocker usage in the secondary prevention of MI and extrapolation of these results to the operative setting. 8, 9
Despite these studies and the recommendations of clinical guidelines, however, there has been a call for additional research to examine the applicability of these findings to other patient populations in large multicenter randomized trials. 2 Although these trials are currently underway, in the interim, patient safety groups continue to advocate for the administration of preoperative B-blocker and the measurement of its use as a marker for quality of care. 10– 12 To date, studies examining the current utilization of preoperative B-blocker have been limited to single institution studies and database analysis of pharmacy and administrative data. 13– 15 This study contributes to the literature by examining the use of a preoperative B-blocker through a detailed chart review of patients undergoing noncardiac surgery in multiple, diverse institutions. We sought to determine the actual utilization of B-blocker among patients meeting current recommendations for its use throughout the perioperative period and upon discharge. In addition, we examined predictors for preoperative B-blocker utilization and measured the heart rate response following B-blocker administration as it is used in clinical practice.
DESIGN
Setting
We performed a retrospective chart review of medical records on a random sample of patients undergoing noncardiac surgery among 5 participating hospitals of the New York-Presbyterian Healthcare System. The participating institutions included a large urban academic medical center, 3 community-based teaching hospitals, and a nonteaching community hospital located throughout the greater New York Tri-State Area. The institutional review board of each of the participating sites approved the study protocol before the study initiation. At the time of this study, no participating site had a standardized pathway or protocol in place for preoperative B-blocker use. Before data collection, all of the institutions participated in quality improvement initiatives highlighting current preoperative recommendations and B-blocker utilization. 1 These initiatives included multidisciplinary grand rounds and departmental sessions using a standardized powerpoint presentation. Schematics of the current guidelines were available on the system-wide intranet and distributed to hospitals on pocket cards and posters for provider work areas. In addition, one of the participating institutions, Institution D, developed a preadmission history and physical form that also listed the latest recommendations for preoperative B-blocker use. This form was used in the preadmissions testing unit for patients obtaining laboratory studies and medical clearance before surgery.
Patients
The study charts were selected from a computer-generated random sample of patients with a surgical diagnosis-related group (DRG) code admitted during a 1-year period from January 1, 2003 through December 31, 2004. A distribution of surgical cases was sampled throughout the study period. Included cases were at least 18 years of age and had undergone a noncardiac surgical operation requiring hospital admission. Cases included patients with established coronary artery disease (CAD), patients undergoing high-risk vascular surgery (intrathoracic, intraabdominal, and suprainguinal), and patients with CAD risk factors that would warrant preoperative B-blockade according to the most recent recommendations given by Auerbach and Goldman. 1 This includes patients with any 2 of the following minor clinical criteria (age ≥65 years, hypertension, current smoker, serum cholesterol ≥240 mg/dL, diabetes mellitus [DM] not requiring insulin therapy) or 1 criterion from the Revised Cardiac Risk Index (high-risk surgery as defined previously, ischemic heart disease, cerebrovascular disease defined as a history of transient ischemic attack or a history of cerebrovascular accident, DM requiring insulin therapy, chronic renal insufficiency defined as a baseline creatinine level of at least 2.0 mg/dL). Relative contraindications to B-blocker use were defined as a history of bronchospasm, asthma, chronic obstructive pulmonary disease (COPD), or a history of decompensated congestive heart failure (CHF) due to the potential intolerance of preoperative initiation and titration of B-blocker in these subgroups.
Patients without established CAD or cardiac risk factors do not meet current criteria for preoperative B-blocker and were excluded from further review. Patients who were pregnant or undergoing transplant, ambulatory, or cardiac surgery were excluded due to limited data recommending B-blockade in these subgroups. In addition, all cases with absolute contraindications to B-blockade including hypotension, intolerance to this class of medications, high-grade atrioventricular block, active bronchospasm, admission complicated with decompensated CHF, and bradycardia (heart rate ≤55 bpm) unrelated to medication use were also excluded.
Measurements
Trained nurse chart reviewers abstracted all data variables using a structured electronic data-collection instrument. Demographic and clinical variables including age, gender, race, hospital site, insurance status, cardiovascular risk factors, type of surgery, relative contraindications to B-blocker use, use of a B-blocker before admission, nonelective surgery, and use of other cardiac medications were collected. The use of a B-blocker and mean values for systolic/diastolic blood pressure and heart rate were abstracted for each patient at the time of hospital admission, before surgery, during surgery, immediately following surgery, 48 hours after surgery, and upon discharge. Explicit criteria were used to collect all patient-related variables and clinical diagnoses.
Statistical Analysis
All descriptive statistics were obtained with the use of statistical software (Stata Statistical Software: Release 8. College Station, TX: Stata Corp LP). Univariate measures of association for continuous variables were evaluated using Student's t test (parametric) or the Wilcoxon rank sum test (nonparametric), and categorical variables were evaluated using the χ2 test. Multivariate logistic regression analysis was performed to examine predictors of preoperative B-blocker utilization. Clinical and demographic candidate predictor variables with P < .25 in univariate analysis and variables with clinical relevance to the outcome of interest were included in the multivariate regression model. The standard errors were adjusted to account for potential clustering of patients by hospitals (i.e., nonindependent observations nested within hospital) with the use of generalized estimating equations modeling. Adjusted variable estimates are given as odds ratios (OR) in the final multivariate logistic regression model.
RESULTS
A total of 1,304 cases that met current recommendations for preoperative B-blockade were examined across 5 institutions. 1 Excluding 321 patients with relative contraindications, the final analysis includes 983 total cases. Table 1 shows the clinical characteristics of this population. The mean age was 69 (±14) years, with 40% (397/983) of patients identified as non-Caucasian and 57% (563/983) identified as female. The majority of patients had a diagnosis of hypertension 82% (802/983) with a much smaller proportion having an established diagnosis of CAD 27% (267/983). Less than half of the study population, 39% (384/983), was receiving B-blocker medication as an outpatient.
Table 1.
Clinical Characteristics and Demographics (N = 983)*
| Characteristics | n (%) |
|---|---|
| Age, years (mean±SD) | 69±14 |
| Female sex % | 563 (57) |
| Non-Caucasian race % | 397 (40) |
| CAD | 267 (27) |
| Nonelective surgery | 227 (23) |
| Vascular surgery | 73 (7) |
| Cerebrovascular disease | 130 (13) |
| Hypertension | 802 (82) |
| Diabetes mellitus | 344 (35) |
| Current tobacco | 173 (18) |
| Hypercholesterolemia | 483 (49) |
| Chronic renal insufficiency | 91 (9) |
| Outpatient B-blocker use | 384 (39) |
CAD, established coronary artery disease.
Values are given as number (percentage) of patients or mean ± SD.
Utilization of Preoperative B-blockade
The administration of B-blockade before surgery varied according to risk, with 43% of patients at intermediate risk (413/957) and 65% of patients at high risk (17/26) receiving preoperative B-blockade (P = .02) (Table 2). Of the patients who received preoperative B-blockade, 94% (403/430) had B-blocker continued in the postoperative period and 91% (391/430) were discharged with B-blocker. Among patients who were not receiving B-blocker as an outpatient (61% [599/983]), the initiation of preoperative B-blockade after hospitalization was uncommon and not significantly different among patients with a greater number of risk factors or established disease. Patients who had not previously received outpatient B-blocker were given it in the preoperative period in 14% (83/589) of intermediate-risk patients compared with 20% (2/10) of patients at high risk (P = .60) and 21% (23/112) of patients with established CAD (P = .08).
Table 2.
Preoperative B-blocker Use by Guideline Recommendation*
| Recommendation Categories | Total Use of PBB % (n) | Initiation of PBB†% (n) | Discharge with BB‡% (n) | HR ≤65 bpm % (n) |
|---|---|---|---|---|
| Intermediate risk* | 43 (413/957) | 14 (83/589) | 91 (375/413) | 26 (109/413) |
| High risk* | 65 (17/26) | 20 (2/11) | 94 (16/17) | 24 (4/17) |
| Established CAD | 62 (165/267) | 21 (23/112) | 93 (153/165) | 29 (48/165) |
CAD, established coronary artery disease; HR ≤65 bpm, average heart rate ≤65 bpm during the intraoperative and postoperative period.
Values are given as percentage (number) of patients.
Current recommendations given by Auerbach and Goldman 1 with intermediate-risk patients having 1 major or 2 minor risk factors and high-risk patients having 3 or more major risk factors for perioperative ischemia.
Percentage (number) of patients administered preoperative B-blocker among patients who were not taking B-blocker as an outpatient.
Percentage (number) of patients discharged with B-blocker among patients administered preoperative B-blocker.
Heart Rate Reduction
Overall, few patients who received B-blocker before surgery achieved the target heart rate goals of clinical trials. Patients who received preoperative B-blocker achieved an average heart rate ≤65 bpm from the time of surgery through the first 48 hours of the postoperative period in 26% (113/430) of patients compared with 17% (93/553) of those who did not (P = .0003). No differences were observed in meeting these target goals among subgroups of patients (Table 2).
Characteristics of Patients Receiving Preoperative B-blocker
In univariate analysis, no differences were observed with regard to gender, race, or insurance status between patients who received preoperative B-blocker and those who did not. Clinical differences were apparent between these groups, with patients receiving preoperative B-blocker more likely to have CAD risk factors as well as established disease (Table 3). There was also a significant difference observed according to the surgical procedure that the patients were undergoing. Among candidates for preoperative B-blocker undergoing vascular surgery with ≥2 CAD risk factors, 59% (39/66) received preoperative B-blocker compared with 22% (11/50) of patients with similar risk factors undergoing gynecologic surgery (P = .0001).
Table 3.
Characteristics of Patients Who Did or Did not Receive Preoperative B-blocker*
| Characteristic | BB+ at Admit | BB− at Admit | ||||
|---|---|---|---|---|---|---|
| Received Preop BB (n = 345) n (%) | Did not Receive Preop BB (n = 39) n (%) | P Value† | Received Preop BB (n = 85) n (%) | Did not Receive Preop BB (n = 515) n (%) | P Value† | |
| Age, y (mean±SD) | 70±12 | 67±12 | .15 | 73±12 | 67±15 | .0004 |
| Female | 185 (54) | 23 (59) | .28 | 53 (62) | 302 (59) | .53 |
| Race | .999 | |||||
| White | 215 (62) | 19 (49) | .10 | 47 (55) | 305 (59) | .48 |
| Black | 50 (14) | 4 (10) | .47 | 13 (15) | 91 (18) | .59 |
| Hispanic | 57 (17) | 10 (26) | .15 | 21 (25) | 84 (16) | .06 |
| CAD | 142 (41) | 13 (33) | .35 | 23 (27) | 89 (17) | .03 |
| Cerebrovascular disease | 58 (17) | 5 (13) | .52 | 10 (12) | 57 (11) | .85 |
| Diabetes mellitus | 124 (36) | 16 (41) | .53 | 41 (48) | 163 (32) | .003 |
| Chronic renal insufficiency | 39 (11) | 6 (15) | .45 | 8 (9) | 38 (7) | .52 |
| Hypertension | 313 (91) | 38 (97) | .17 | 77 (91) | 374 (73) | .0004 |
| Current tobacco user | 51 (15) | 8 (21) | .35 | 11 (13) | 103 (20) | .12 |
| Hypercholesterolemia | 187 (54) | 21 (54) | .97 | 41 (48) | 234 (46) | .64 |
| Nonelective surgery | 73 (21) | 10 (26) | .52 | 46 (54) | 98 (19) | <.0001 |
| Vascular surgery | 37 (11) | 1 (3) | .11 | 5 (6) | 30 (6) | .99 |
| Gynecologic surgery | 10 (3) | 4 (10) | .02 | 2 (2) | 37 (7) | .09 |
| HR ≤65 | 93 (27) | 6 (15) | .12 | 20 (24) | 87 (17) | .14 |
| Received postop BB | 327 (95) | 30 (77) | <.0001 | 76 (89) | 93 (18) | <.0001 |
| Discharged with BB | 330 (96) | 32 (82) | <.0001 | 61 (72) | 49 (10) | <.0001 |
BB+ at admit, patient had been receiving B-blocker before hospital admission for surgery; BB−, patient had not been receiving B-blocker before hospital admission for surgery; Received preop BB, patients with indications for preoperative B-blocker without contraindications who received this therapy; Did not receive preop BB, patients with indications for preoperative B-blocker without contraindications who did not receive therapy; CAD, established diagnosis of coronary artery disease; cerebrovascular disease, defined as a history of stroke or transient ischemic attack; chronic renal insufficiency, defined as Cr≥2.0; HR≤65, average HR ≤65 bpm during the intraoperative and postoperative period; Received postop BB, received B-blocker during the postoperative period; discharged with BB, discharged with B-blocker; HR, heart rate.
Values are given as number (percentage) of patients or mean ± SD.
The t test was used for continuous variables and theχ2 test for categorical variables.
A multivariate analysis was performed clustering on hospital and adjusting for potential confounders. In the total population studied, the overwhelming predictor of preoperative B-blocker administration was outpatient use of B-blocker (adjusted OR=64.8; 95% confidence interval [CI]=14.6, 287.6). Separate models were then developed to predict B-blocker use in patients who were receiving B-blocker in the outpatient setting before surgery and those who were not (Table 4). In the subset of patients receiving B-blocker as an outpatient, the major predictors of preoperative B-blocker administration included vascular surgery (adjusted OR=8.08; 95% CI=1.58, 41.5) and patients who had risk factors that placed them in a high-risk category (adjusted OR = 4.01; 95% CI = 1.45, 11.06).
Table 4.
Multivariate Analysis Predicting Administration of Preoperative B-blocker
| Predictor Variable | Adjusted OR | 95% CI | P Value |
|---|---|---|---|
| BB+ at admit | |||
| Vascular surgery | 8.08 | 1.58 to 41.5 | .012 |
| High risk | 4.01 | 1.45 to 11.06 | .007 |
| Hospital B | 2.39 | 1.77 to 3.23 | <.0001 |
| Age | 1.03 | 1.02 to 1.04 | <.0001 |
| Hospital A | 0.66 | 0.48 to 0.89 | .007 |
| Nonelective surgery | 0.54 | 0.38 to 0.76 | .001 |
| Hospital C | 0.33 | 0.24 to 0.46 | <.0001 |
| Gynecologic surgery | 0.29 | 0.11 to 0.80 | .017 |
| Hospital E | 0.09 | 0.04 to 0.21 | <.0001 |
| BB− at admit | |||
| Nonelective surgery | 4.35 | 2.03 to 9.34 | <.0001 |
| Hypertension | 3.48 | 2.22 to 5.45 | <.0001 |
| Diabetes mellitus | 2.01 | 1.32 to 3.06 | .001 |
| Hospital E | 1.53 | 1.19 to 1.97 | .001 |
| Age | 1.03 | 1.03 to 1.04 | <.0001 |
| Hospital C | 0.78 | 0.71 to 0.84 | <.0001 |
| Hospital B | 0.51 | 0.39 to 0.68 | <.0001 |
Logistic regression model clustered on hospital adjusted for gender, race, and preoperative HR.
BB+ at admit, patient had been receiving B-blocker before hospital admission for surgery; BB−, patient had not been receiving B-blocker before hospital admission for surgery; non-elective surgery, surgery that was not scheduled as an outpatient; OR, odds ratio; CI, confidence interval, HR, heart rate.
Among patients who had not previously received a B-blocking agent, the major predictors of B-blocker initiation during hospitalization for surgery included undergoing nonelective surgery (adjusted OR=4.35; 95% CI=2.03, 9.34), hypertension (adjusted OR=3.48; 95% CI=2.22, 5.45), and DM (adjusted OR=2.01; 95% CI=1.32, 3.06). Gender, race, and insurance status were not predictive of receiving preoperative B-blocker in multivariate analysis. Multiple clinical risk factors and preoperative heart rate were also not predictive. Individual hospital sites were predictive of preoperative B-blocker continuation and initiation independent of other risk factors.
Variation Across Hospitals
Across hospitals, the range of preoperative B-blocker use varied from 34% (28/82) to 56% (105/188), with the highest overall use observed with Institution D (Table 5). Institution D differed from the others in the use of a standardized preadmission history and physical exam form documenting preoperative B-blocker use and contraindications to B-blockade. Among patients who were not taking B-blocker medication as an outpatient, few had B-blocker initiated after hospitalization ranging from 10% (25/255) to 21% (25/121) across institutions. No significant difference was observed based on size, teaching status, or location of the study hospitals.
Table 5.
Preoperative B-blocker Use Across Hospitals
| Received Preop BB | Hospital | |||||
|---|---|---|---|---|---|---|
| A % (n) | B % (n) | C % (n) | D % (n) | E % (n) | P Value | |
| BB+ at admit | 85 (53/62) | 96 (146/152) | 83 (39/47) | 93 (89/96) | 67 (18/27) | <.0001 |
| BB− at admit | 21 (25/121) | 10 (25/255) | 12 (9/76) | 17 (16/92) | 18 (10/55) | .04 |
| Total | 43 (78/183) | 42 (171/407) | 39 (48/123) | 56 (105/188) | 34 (28/82) | .003 |
BB+ at admit, patient had been receiving B-blocker before hospital admission for surgery; BB−, patient had not been receiving B-blocker before hospital admission for surgery.
CONCLUSIONS
We found significant underutilization of preoperative B-blocker compared with guideline recommendations despite quality improvement initiatives. Overall, most patients who received preoperative B-blocker were started on it as an outpatient. Very few patients had B-blocker initiated before surgery even among patients with multiple risk factors and established CAD. In addition, among the patients who received preoperative B-blocker, the target heart goals established in clinical trials for effective B-blockade were not achieved. Once patients received preoperative B-blocker, however, the majority of patients were continued on it through hospitalization and discharge. Furthermore, using multivariable analysis, predictors of continuing B-blocker started in the outpatient setting included undergoing vascular surgery and the presence of 3 or more major risk factors. Among patients who were not receiving B-blocker before hospitalization, undergoing nonelective surgery, and the presence of hypertension and DM predicted the initiation of preoperative B-blocker. Finally, variation in the use of preoperative B-blocker was observed across hospitals and surgical indication. This study contributes to the literature in that it is the first multicenter chart review to examine the utilization of preoperative B-blocker throughout hospitalization and discharge, to study the heart rate response of B-blocker use in clinical practice, and to identify predictors of its administration in multivariable analysis.
There is good evidence from secondary prevention studies that B-blockers are broadly underutilized outside of the surgical setting despite overwhelming support for their use. 16, 17 The lapses in care that have been observed in the nonsurgical setting may be contributing to the underutilization of B-blockers in the preoperative setting as well. In our study, the institution with the highest utilization of preoperative B-blocker used a standardized preadmission form in which the current recommendations were listed and providers were asked to document B-blocker use. Owing to the size limitations of our study, we are unable to draw further conclusions regarding the organizational characteristics that may contribute to the dissemination and adherence to evidence based guidelines. Nevertheless, the increased use of standardized forms and protocols coupled with computer technology to facilitate communication and the development of electronic reminders all may potentially improve upon current practice. 18, 19
Rather than attributing all underutilization to lapses in care, however, there are other potential contributing factors. First, the literature has not defined the appropriate selection of patients, timing of initiation and discontinuation, and guidelines for dosing perioperative B-blocker. 20, 21 Second, current guidelines are conflicting and diverging opinions exist regarding the strength of the evidence for the recommendations. Supporting this conclusion are qualitative surveys that have reported a high degree of provider awareness of preoperative guidelines but differing views on the use of preoperative B-blocker among low-risk surgical patients. 22, 23 In addition, recent preliminary findings from DIPOM, a large randomized trial of patients with DM as the sole CAD risk factor, have not demonstrated a mortality benefit or reduction in cardiac events with the use of preoperative metoprolol. 24 Whether patients with a limited number of risk factors benefit from preoperative B-blockade is still awaiting further study. Third, organizational, cultural, and technical factors may make the uniform administration of this therapy difficult to coordinate. Given the multidisciplinary nature of perioperative medicine, it is unclear who should ultimately be held responsible for B-blocker initiation and management. 25
Although all patients in the study had risk factors warranting the use of preoperative B-blocker, only hypertension, DM, and the need for nonelective surgery predicted B-blocker initiation in multivariable models among patients who were not receiving B-blocker at the time of hospital admission. In these instances, medical inpatient consultation may have been used more frequently, given that the surgery was unplanned and no previous opportunities for outpatient perioperative evaluation would have existed. Among patients already receiving B-blocker in the outpatient setting, the continuation of B-blocker preoperatively was predicted by the need for vascular surgery and a high-risk classification. Many of these patients met the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for preoperative B-blocker use. This subset consists of patients at a higher preoperative risk of adverse cardiac events and may represent a group in which the use of preoperative B-blocker is less controversial.
We observed that the overwhelming predictor of preoperative B-blocker administration was the outpatient use of B-blocker. This study was performed using the inpatient medical record and therefore is limited by chart documentation and the inability to draw conclusions regarding the outpatient setting. However, in either setting, barriers to receiving preoperative B-blocker are significantly higher for B-blocker naive patients, who must first be recognized as meeting criteria for preoperative B-blocker and then initiated on this therapy. Among patients who received preoperative B-blocker, the majority of patients were continued on B-blocker through discharge.
We also observed differences in preoperative B-blocker initiation and continuation across hospital sites. After adjusting for confounders and clinical predictor variables, hospital site was still independently predictive of preoperative B-blocker use. In addition, the type of surgery performed was also related to B-blocker administration, with vascular surgery predicting the continuation of B-blocker in contrast to gynecologic surgery, despite patient-level risk factors warranting preoperative B-blocker use. Although the level of risk imposed by surgery has not been formally incorporated into B-blocker guidelines, in clinical practice, providers seem to be taking this into consideration in the use of preoperative B-blocker. This finding highlights the need for further consensus in the literature regarding the selection of appropriate candidates for preoperative B-blocker administration with strategies to promote its use accordingly.
Finally, in addition to observing underutilization in the use of preoperative B-blocker, this study demonstrated that few patients who received preoperative B-blocker achieved a heart rate reduction in the range of the target goals set in clinical trials. One possible reason for this finding is the lack of consensus in the literature as to what the appropriate target heart rate should be and whether the preoperative benefit to B-blockade is directly related to a reduction in heart rate or is the result of another mechanism of action. 26, 27 Furthermore, within clinical trials, these goals were achieved through aggressive titration of this medication and frequent monitoring, both of which are likely to be difficult outside of a study setting. In light of these observations, it is unclear whether the cardioprotective benefits of preoperative B-blocker are being obtained even among those patients who receive preoperative B-blocker in clinical practice.
In conclusion, significant underutilization of preoperative B-blockade was observed in this study. Lapses in care, diverging clinical recommendations, controversies in the supporting literature, and organizational factors all may be contributing to these findings. In order to improve the use of preoperative B-blockade, there is a need for further studies to address these remaining clinical questions. A large, international, multicenter trial (POISE) of preoperative B-blockade is currently underway, whose results should help to more clearly define the benefits and risks in select groups of patients. 28 In the interim, institutions should take steps to identify patients who are uniformly agreed upon to be at high risk of perioperative events and work toward achieving clinical guideline recommendations within this subset. Patient safety groups monitoring this process of care should be cautious in using preoperative B-blocker as a benchmark for quality of care until further conclusions can be reached regarding the appropriate selection of candidates for this therapy.
Acknowledgments
We wish to thank all of the participating institutions and individuals involved in this study, in particular, Jerry Balentine, DO, Lawrence Kadish, MD, Steven Walerstein, MD, and Fredric Weinbaum, MD. The funding for this project was provided by AHRQ through the NYSDOH. The views herein represent those of the authors and not of the funding agency or the authors' affiliated institutions. The corresponding authors take responsibility for the design, conduction, data analysis, and preparation of this manuscript. We also wish to extend our gratitude to Paul Christos, MPH, MS, at Weill Medical College of Cornell, Department of Public Health, for statistical support, and Alvin Mushlin, MD, ScM, for thoughtful suggestions and editorial assistance.
Source of Support: AHRQ funding through the NYSDOH
REFERENCES
- 1.Auerbach A, Goldman L. B-blockers and reduction of cardiac events in noncardiac surgery. JAMA. 2002;287:1445–7. doi: 10.1001/jama.287.11.1445. [DOI] [PubMed] [Google Scholar]
- 2.Eagle KA, Berger PB, Calkins H, et al. ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [American College of Cardiology Web site] 2005 Available at http://www.acc.org/clinical/guidelines/perio/update/pdf/perio_update.pdf http://www.acc.org/www.americanheart.org Accessed verified December 21.
- 3.American College of Physicians. Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. Ann Intern Med. 1997;127:313–28. doi: 10.7326/0003-4819-127-4-199708150-00011. [DOI] [PubMed] [Google Scholar]
- 4.Boersma E, Poldermans D, Bax J, et al. Predictors of cardiac events after major vascular surgery. JAMA. 2001;285:1865–73. doi: 10.1001/jama.285.14.1865. [DOI] [PubMed] [Google Scholar]
- 5.Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients; population based, retrospective cohort study. BMJ. 2005;331:932. doi: 10.1136/bmj.38603.746944.3A. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Mangano D, Layug E, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med. 1996;335:1713–20. doi: 10.1056/NEJM199612053352301. [DOI] [PubMed] [Google Scholar]
- 7.Poldermans D, Boersam E, Bax J, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery: Dutch echocardiographic cardiac risk evaluation applying stress echocardiography study group. N Engl J Med. 1999;341:1789–94. doi: 10.1056/NEJM199912093412402. [DOI] [PubMed] [Google Scholar]
- 8.B-blocker Heart Attack Study Group. The B-blocker heart attack trial. JAMA. 1981;246:2073–4. [PubMed] [Google Scholar]
- 9.The Norwegian Multi-Center Study Group. Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. N Engl J Med. 1981;204:801–7. doi: 10.1056/NEJM198104023041401. [DOI] [PubMed] [Google Scholar]
- 10.Agency for Healthcare Research and Quality. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: 2001. July 2001. AHRQ Publication No. 01-E057. Available at http://www.ahrq.gov/clinic/ptsafety/summary.htm Accessed December 21, 2005. [Google Scholar]
- 11.The Leapfrog Group. 2004 Available at http://www.leapfroggroup.org Accessed December 21, 2005.
- 12.Safe practices for better healthcare: a consensus report. 2003. National Quality Forum, Washington, DC. (Publication no. NQFCR-05-03).
- 13.Siddiqui AK, Ahmed S, Delbeau H, Conner D, Mattana J. Lack of physician concordance with guidelines on the perioperative use of B-blockers. Arch Intern Med. 2004;164:664–7. doi: 10.1001/archinte.164.6.664. [DOI] [PubMed] [Google Scholar]
- 14.Lindenauer PK, Fitzgerald J, Hoople N, Benjamin EM. The potential preventability of postoperative myocardial infarction: underuse of perioperative beta-adrenergic blockade. Arch Intern Med. 2004;164:762–6. doi: 10.1001/archinte.164.7.762. [DOI] [PubMed] [Google Scholar]
- 15.Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–61. doi: 10.1056/NEJMoa041895. [DOI] [PubMed] [Google Scholar]
- 16.Butler J, Arbogast PG, BeLue R, et al. Outpatient adherence to beta-blocker therapy after acute myocardial infarction. J Am Coll Cardiol. 2002;40:1589–95. doi: 10.1016/s0735-1097(02)02379-3. [DOI] [PubMed] [Google Scholar]
- 17.Krumholz HM, Chen J, Rathore SS, Wang Y, Radford MJ. Regional variation in the treatment and outcomes of myocardial infarction: investigating New England's advantage [see comment] Am Heart J. 2003;146:242–9. doi: 10.1016/S0002-8703(03)00237-0. [DOI] [PubMed] [Google Scholar]
- 18.Eagle KA, Lee TH, Brennan TA, Krumholz HM, Weingarten S. Practice guidelines and the quality of care: task force 2 guideline implementation. J Am Coll Cardiol. 1997;29:1125–79. [Google Scholar]
- 19.Pollard JB, Chow RC, Hansen JR. Effectiveness of preprinted order forms in promoting perioperative B-blocker use. Am J Health-Syst Pharm. 2002;59:359–60. doi: 10.1093/ajhp/59.4.359. [DOI] [PubMed] [Google Scholar]
- 20.Howell SJ, Sear JW, Foex P. Peri-operative B-blockade: a useful treatment that should be greeted with cautious enthusiasm. Br J Anaesth. 2001;86:161–3. doi: 10.1093/bja/86.2.161. [DOI] [PubMed] [Google Scholar]
- 21.Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery: clinical applications. JAMA. 2002;287:1445–7. doi: 10.1001/jama.287.11.1445. [DOI] [PubMed] [Google Scholar]
- 22.London MJ, Itani K, Perrino AC, et al. Perioperative beta-blockade: a survey of physician attitudes in the department of veterans affairs. J Cardiothoracic Vasc Anesth. 2004;18:14–24. doi: 10.1053/j.jvca.2003.10.004. [DOI] [PubMed] [Google Scholar]
- 23.VanDenKerkhof EG, Milne B, Parlow JL. Knowledge and practice regarding prophylactic perioperative beta blockade in patients undergoing noncardiac surgery: a survey of canadian anesthesiologists. Anesth Analg. 2003;96:1558–65. doi: 10.1213/01.ANE.0000058846.45458.9F. [DOI] [PubMed] [Google Scholar]
- 24.Juul AB, Wetterslev J, Kofoed-Enevoldsen A, Callesen T, Jensen G, Gluud C. The diabetic postoperative mortality and morbidity (DIPOM) trial: rationale and design of a multicenter, randomized, placebo-controlled, clinical trial of metoprolol for patients with diabetes mellitus who are undergoing major noncardiac surgery. Am Heart J. 2004;147:677–83. doi: 10.1016/j.ahj.2003.10.030. [DOI] [PubMed] [Google Scholar]
- 25.Rock P. The future of anesthesiology is perioperative medicine. Anesthesiol Clin North Am. 2000;18:495–513. doi: 10.1016/s0889-8537(05)70176-0. [DOI] [PubMed] [Google Scholar]
- 26.Zaugg M, Tagliente T, Lucchinetti E, et al. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing non-cardiac surgery. Anesthesiology. 1999;91:1674–86. doi: 10.1097/00000542-199912000-00020. [DOI] [PubMed] [Google Scholar]
- 27.London MJ, Zaugg M, Schaub MC, Spahn DR. Perioperative B-adrenergic receptor blockade. Anesthesiology. 2004;100:170–5. doi: 10.1097/00000542-200401000-00027. [DOI] [PubMed] [Google Scholar]
- 28.Devereaux PJ, Yusuf S, Yang H, Choi PT-L, Guyatt GH. Are the recommendations to use perioperative {beta}-blocker therapy in patients undergoing noncardiac surgery based on reliable evidence? Can Med Assoc J. 2004;171:245–7. doi: 10.1503/cmaj.1031619. [DOI] [PMC free article] [PubMed] [Google Scholar]