There are few areas within perioperative medicine that are well studied beyond the area of predicting cardiac risk. The American Heart Association perioperative guidelines highlighted the paucity of studies on interventions to prevent postoperative cardiac events [3]. Reflecting this statement, respondents globally rated studies that determine the efficacy and safety of interventions as higher priority for future research compared to studies predicting postoperative risk or determining diagnostic yield of tests. Within the category of intervention studies, questions on medical therapy to prevent postoperative cardiac complications were among the highest rated questions. This result is congruent to the significant prevalence, morbidity and mortality associated with postoperative cardiac complications. A study by Devereaux et al also identified this area as an important target for future research after finding considerable practice variation in the management of cardiac medications [4]. Innovative interventions for cardiac protection with antiplatelet agents, angiotensin converting enzyme inhibitors or tight glycemic control were highly rated. Despite the publication of small trials of beta blocker therapy, responding internists felt that there was a need to definitively determine the efficacy of perioperative beta blockade. Respondents may be more skeptical of adopting results from the small trials of beta blocker where methodological controversies have arisen [5]. Other intervention questions that were rated highly focused on understudied areas of perioperative anticoagulation. Determining optimal perioperative anticoagulation strategies for patients with prosthetic valves or atrial fibrillation was rated highly.
Although perioperative risk stratification is well studied for identifying those at risk of cardiac events, pulmonary complications occur more frequent than cardiac complications and are associated with a longer hospital stay [6]. Reflecting this significant morbidity and cost of respiratory complications, development of a prediction rule for postoperative pulmonary complications was among the highest rated topics.
Since the completion of the survey, the ratings also reflect ongoing research activity within perioperative medicine. Tight glycemic control was a high rated topic and a study examining the effect of tight glycemic control in postoperative patients in a critical care setting has been published since the completion of this survey. Also since the completion of this survey, a large multi-center trial examining the efficacy of perioperative beta blockade has been launched. Another highly rated research topic was developing a prediction rule for pulmonary complications. Recently, a study was published to identify those at increased risk of postoperative pneumonia. Two of the highly rated research priority topics have been recently published in major medical journals [7, 8].
There are several potential limitations with this study. The low response rate may be felt to limit the generalizability to other general internists. However, views of those who practice perioperative medicine and who have a particular interest in the area, the research consumers, are important in developing a research agenda. We presume that physicians who practice within an area and who have a particular interest are more likely to respond to a survey than those who do not. Thus, the physicians who responded to the questionnaire and reported practicing perioperative medicine define the group of research consumers we were targeting. This study also only examined the beliefs of general internists on research priorities since greater than 90% of the perioperative medicine consultations are conducted by general internists rather than subspecialists in internal medicine in tertiary care centers [4]. Also, lower response rates are seen in physician surveys but surveys with response rates of 10–45% are published in major medical journals [9–15]. Another limitation is that anesthesiologists, cardiologists or primary care physicians perform perioperative medicine consultations and their opinions were not elicited in this survey. Another potential limitation is that not all important research questions could be examined. However, only one respondent indicated additional research topics suggesting that there were no major omissions in the research topics listed. Additionally, it is difficult to interpret meaningful differences in mean Likert response scores among individual questions. Individual scores and their confidence intervals should be interpreted to give a general idea of high- priority questions, rather than a strict ranking of research pursuits.