Forecasting the impact of a clinical practice guideline for perioperative beta-blockers to reduce cardiovascular morbidity and mortality

Background: β-Blockers reduce morbidity and mortality when administered to high-risk patients undergoing major noncardiac surgery, yet little is known about how often they are being prescribed. Clinical practice guidelines are tools that can be used to speed the translation of research into practice and may be one method to improve the use of β-blockers. Before implementing any guideline, it is important to forecast its potential clinical and financial impact. Methods: We conducted a retrospective cohort study, using administrative and medical record review data, of all adult patients undergoing major noncardiac surgery at Baystate Medical Center, Springfield, Mass, during a 1-month period in 1999. Patients with 2 or more cardiac risk factors or with documented coronary artery disease were classified as high risk and were considered eligible for treatment with a β-blocker if they had no obvious contraindications to its use. We estimated the potential clinical benefit of treating eligible patients with a β-blocker by extrapolating the treatment effect observed in a previously reported randomized clinical trial. Results: Of 158 patients undergoing major noncardiac surgery, 67 (42.4%) seemed to be ideal candidates for treatment with perioperative β-blockers. Of these 67 patients, 25 (37%) received a β-blocker at some time perioperatively. During the course of a year, we estimate that between 560 and 801 patients who do not receive β-blockers might benefit from treatment with these medications. Full use of β-blockers among eligible patients at our institution could result in 62 to 89 fewer deaths each year at an overall cost of $33 661 to $40 210. Conclusions: There seems to be a large opportunity to improve the quality of care of patients undergoing major noncardiac surgery by increasing the use of β-blockers in the perioperative period. A clinical practice guideline may be one method to achieve these goals at little cost.