Effect of specialty and recent experience on perioperative decision-making for abdominal aortic aneurysm repair

Abstract

Objectives: To determine whether recent experience and specialty choice would affect physician adherence to evidence-based guidelines.

Design: In a series of computer-simulated encounters, participants weighed the risk of spontaneous abdominal aortic aneurysm (AAA) rupture against the risk of perioperative death to determine timing for elective repair. Guideline recommendations and statistical information on the risks of rupture and surgical death were provided.

Setting: Annual meetings of the American Geriatrics Society, American College of Surgeons, and American Society of Anesthesiologists.

Participants: Physicians.

Intervention: Before the simulation, each participant was randomly exposed to one of three simulated outcomes: death during watchful waiting (WWD), perioperative death (PD), or successful outcome (SO).

Measurements: Adherence to recommended guidelines for AAA treatment.

Results: Against guideline recommendations, 67% of geriatricians, 74% of anesthesiologists, and 77% of surgeons chose surgery when the rupture risk was lower than the risk of perioperative death (P < .05). Surgeons exposed to the WWD experience chose surgery significantly earlier than if they were exposed to a PD or SO experience (P < .001). Anesthesiologist choices did not differ with recent experience.

Conclusion: Geriatrician decisions more closely followed guideline recommendations for AAA management than those of two other specialties typically involved in AAA care. A prior WWD affected surgeons most, geriatricians next, and anesthesiologists least. Geriatricians referring patients for AAA surgery should be aware of specialty-specific differences in perioperative decision behavior.