Virtual Preoperative Assessment: Clinical Utility, Evidence, and Future Directions

Abstract

Virtual preoperative assessment (VPA) has rapidly gained prominence as an innovative approach to evaluating surgical candidates, especially in the context of global healthcare digitization and the COVID-19 pandemic. This review synthesizes current scientific evidence, clinical guidelines, and practical considerations related to VPA. We discuss the epidemiology of its adoption, pathophysiological rationale for risk stratification, associated risk factors, and the clinical workflow of virtual assessments. Emphasis is placed on diagnostic accuracy, management strategies, recent technological advances, and guideline-driven recommendations. The article aims to assist clinicians in integrating VPA into perioperative care pathways to optimize patient outcomes and resource utilization.

Introduction

The preoperative assessment is fundamental for surgical risk stratification, perioperative management, and patient safety. Traditionally, this has been conducted through in-person consultations involving history-taking, physical examination, and review of investigations. However, the surge in telemedicine, propelled by the COVID-19 pandemic and advances in digital health, has catalyzed the adoption of virtual preoperative assessment (VPA). VPA leverages secure telecommunication platforms to conduct comprehensive preoperative evaluations remotely. This transformation aligns with broader healthcare trends emphasizing patient-centered care, accessibility, and efficient resource use. For clinicians, understanding the evidence, limitations, and best practices of VPA is critical for safe implementation and optimal patient care.

Epidemiology / Disease Burden

Globally, millions undergo surgical procedures annually, with preoperative assessment considered standard care for elective surgeries. The COVID-19 pandemic accelerated the deployment of virtual healthcare solutions, including VPA, to minimize patient exposure and maintain elective surgical services. Recent surveys indicate a significant uptick in VPA adoption across high-income countries, with over 60% of major academic centers integrating virtual platforms into their preoperative workflow by 2022. While adoption in low- and middle-income countries remains lower due to infrastructure limitations, pilot programs have demonstrated feasibility and acceptability, suggesting an expanding global footprint. The burden of perioperative complications and the growing surgical caseload underscore the importance of efficient assessment modalities such as VPA.

Pathophysiology

Preoperative risk stratification relies on identifying physiological vulnerabilities that predispose patients to perioperative morbidity and mortality. The pathophysiology underlying perioperative complications often involves cardiovascular, pulmonary, metabolic, and infectious pathways. VPA utilizes structured history-taking, validated risk calculators (e.g., ASA score, Revised Cardiac Risk Index), and remote review of investigations to assess these physiological domains. While VPA cannot directly replicate all elements of physical examination, surrogate markers (e.g., patient-reported symptoms, video-assisted functional assessments) and integration of electronic health records help bridge this gap. Mechanistically, early identification of comorbidities and modifiable risk factors via VPA enables timely optimization.

Risk Factors

Risk stratification in VPA encompasses traditional perioperative risk factors such as advanced age, cardiovascular and pulmonary disease, diabetes, renal dysfunction, and frailty. Additional virtual care-specific risk factors include digital literacy, access to reliable internet, and the presence of sensory or cognitive impairments that may compromise virtual communication. Importantly, patients at highest risk for perioperative complications—such as those with advanced comorbidities or complex surgical needs—may require hybrid models, combining virtual with targeted in-person evaluation. Understanding these risk factors allows clinicians to select appropriate candidates for VPA, ensuring patient safety while maximizing efficiency.

Clinical Features

The clinical workflow of VPA mirrors traditional assessment in many respects. Core components include detailed history-taking, medication reconciliation, review of allergies, assessment of functional status, and clarification of surgical plans. Video consultations allow for limited physical assessment, such as evaluation of airway anatomy, gait analysis, and inspection for peripheral edema or wounds. Patient-reported questionnaires and digital tools enhance symptom tracking and risk scoring. Key clinical features to elicit virtually include exercise tolerance, history of anesthesia-related complications, bleeding disorders, and social determinants of health that may impact perioperative care and discharge planning.

Diagnosis

Diagnostic accuracy in VPA hinges on comprehensive review of existing medical records, laboratory findings, and imaging studies. Digital platforms enable real-time data sharing and multidisciplinary collaboration. While certain diagnoses—such as new murmurs or subtle neurological deficits—may elude detection without in-person assessment, most comorbidities relevant to perioperative risk can be identified through structured history and review of investigations. Emerging evidence suggests that VPA achieves comparable diagnostic accuracy to in-person assessment for low- and moderate-risk surgical candidates. For high-risk or complex cases, clinical judgment remains essential in deciding when in-person evaluation is warranted.

Treatment & Management

Management strategies following VPA are tailored to individual risk profiles. Interventions include medication adjustments, referral for additional investigations, optimization of comorbidities, and patient education regarding perioperative care. Virtual platforms facilitate multidisciplinary team meetings and enable rapid communication of perioperative plans to surgical, anesthetic, and nursing teams. Importantly, VPA can streamline preoperative optimization by identifying issues early and coordinating care across specialties. For patients requiring prehabilitation or smoking cessation, digital resources and remote monitoring can reinforce adherence. Documentation and communication remain critical to ensure continuity of care from virtual assessment to perioperative management on the day of surgery.

Recent Advances / Emerging Therapies

Recent technological advances have enhanced the scope and quality of VPA. Integration of artificial intelligence-driven risk calculators, mobile health (mHealth) apps for functional assessment, and wearable devices for real-time monitoring are transforming remote preoperative care. Secure telemedicine platforms now feature high-definition video, electronic consent, and interoperability with electronic health records, facilitating seamless information exchange. Research into automated symptom triage and decision support algorithms aims to further improve safety and efficiency. Pilot studies of remote airway assessment and telemonitoring of perioperative vitals indicate promising directions for future expansion of VPA capabilities.

Guideline Recommendations

Major anesthesia and surgical societies, including the American Society of Anesthesiologists (ASA) and Royal College of Anaesthetists, have issued guidance supporting the use of VPA for selected patient populations. Recommendations emphasize careful patient selection, robust protocols for virtual assessment, and clear criteria for conversion to in-person evaluation when required. The use of validated risk assessment tools, comprehensive documentation, and secure communication platforms is strongly advocated. Guidelines also highlight the importance of training clinicians in virtual consultation skills and ensuring equitable access to digital health services across patient populations.

Conclusion

Virtual preoperative assessment represents a paradigm shift in perioperative care, offering a safe, efficient, and patient-centered alternative to traditional in-person assessment for many surgical candidates. While certain limitations persist—particularly for complex or high-risk patients—growing evidence and robust guidelines support its clinical utility. Continued research, technological innovation, and careful integration into perioperative pathways will be essential for realizing the full potential of VPA in improving surgical outcomes and healthcare delivery.