The value of screening preoperative chest x-rays: a systematic review

Predicting categories of coronary artery calcium scores from chest X-ray images using deep learning

BACKGROUND

The coronary artery calcium (CAC) score (CACS) is recommended in clinical guidelines for coronary artery disease evaluation. However, it is being replaced by coronary computed tomography angiography as the primary diagnostic tool for patients with stable chest pain. This study aimed to develop and validate a deep learning model for predicting the CACS categories from chest X-ray radiographs (CXRs).

METHODS

We included 10,230 patients with available CXRs and CACSs obtained within six months. Three models were trained based on the CACS thresholds (0, 100, and 400) to distinguish zero from non-zero CACSs, CACSs of <100 and ​≥ ​100, and CACS of <400 and ​≥ ​400. The final CXR integration models incorporating clinical factors, including age, sex, and body mass index, were also trained. All models were evaluated using 10-fold cross-validation. External validation was also performed. We experimentally demonstrated the prognostic value of the predicted CACS for major adverse cardiovascular events, comparing it to the actual CACS classification.

RESULTS

The CACS classification performance of the deep learning model was promising, with areas under the curve (AUCs) of 0.74 (zero vs non-zero), 0.75 (<100 vs. ≥100), and 0.79 (<400 vs. ≥400). The accuracy of the model further improved upon the integration of clinical factors; the AUCs reached 0.77, 0.79, and 0.82, respectively, for the same CACS categories. The external validation results were consistent (AUCs of 0.78, 0.79, and 0.81, respectively).

CONCLUSIONS

The deep learning model effectively classified the CACS from CXRs, especially for cases of severe calcification. This approach can cost-effectively improve coronary artery disease risk assessment and support clinical decision-making while minimizing radiation exposure.

Comprehensive Strategies for Preoperative Pulmonary Risk Evaluation and Management

Postoperative pulmonary complications (PPCs) significantly increase morbidity and mortality in surgical patients, particularly those with pulmonary conditions. PPC incidence varies widely, influenced by factors such as surgery type, patient age, smoking status, and comorbid conditions, including chronic obstructive pulmonary disease (COPD) and congestive heart failure. While preoperative pulmonary function tests and chest radiographs are crucial for lung resection surgery, their use should be judiciously tailored to individual risk profiles. Effective risk stratification models, such as the American Society of Anesthesiologists classification, Arozullah respiratory failure index, Gupta Calculators, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) model, play a key role in predicting PPCs. Key strategies to diminish PPCs include preoperative optimization of respiratory conditions, smoking cessation, and respiratory rehabilitation. In patients with COPD and asthma, it is crucial to maintain optimal disease control through inhaled therapies, systemic corticosteroids, and tailored preoperative respiratory exercises. Anemia and hypoalbuminemia are significant predictors of PPCs and require meticulous management. The choice and duration of anesthesia also notably influence PPC risk, with regional anesthesia being preferable to general anesthesia when possible. Comprehensive preoperative evaluations and tailored interventions are essential for enhancing surgical outcomes and reducing PPC incidence. Additional studies involving domestic patients are necessary to refine national guidelines for managing those at risk of PPCs.

The value of preoperative diagnostic testing and geriatric assessment in frail institutionalized elderly with a hip fracture; a secondary analysis of the FRAIL-HIP study

PURPOSE

The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture.

METHODS

Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients.

RESULTS

A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients.

CONCLUSION

A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.

[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.

The Incidence of Abnormal Preoperative Testing Among Elective Surgery Patients in a Referral Hospital in Southern Saudi Arabia

Background Preoperative investigations are important to assess the clinical condition of patients who undergo elective surgical procedures. However, there is still debate about the usefulness of performing preoperative investigations. We aimed to determine the prevalence of routine preoperative investigation abnormalities among elective general surgery patients. Methodology This retrospective hospital-record-based study was conducted at the King Abdullah Hospital in Bisha Province, southern Saudi Arabia. General and clinical data of 968 patients who underwent elective surgical interventions from February 2022 to January 2023 were retrieved and analyzed. Result A total of 968 patients (578 females and 390 males) aged between 14 and 80 years were included in the study. Four hundred and eleven (42.5%) patients were in the age group of 40 years and above. The commonly detected comorbidities among the patients were diabetes (15%), hypertension (12%), respiratory diseases (7.5%), and cardiac diseases (2.5%). Abnormalities related to hemoglobin (31%), total leucocyte count (12.7%), and platelets (8.5%) were found in 968 patients. Around 15% of patients had increased creatinine levels. Hypokalemia was observed in 6.8% of patients. Increased liver enzymes were reported in limited proportions (10% to 14%) of patients. Slightly abnormal radiological findings were reported for chest X-ray (CXR) (2.8%), electrocardiogram (ECG) (2%), and Doppler echocardiography (Echo) (0.8%). A statistically significant association between the age of the patient and abnormal findings of ECG (p <.001), Echo (p = .001), and CXR (p <.001). Cardiac abnormalities were commonly associated with patients of ≥ 40 years. Abnormal cardiac findings (CXR, ECG, Echo) were significantly (p<.05) increased with the presence of diabetes, hypertension, and cardiovascular comorbidities. Conclusions Preoperative testing revealed limited proportions of abnormal findings among patients with elective surgical procedures. Routine ordering of many preoperative investigations without specifications may not predict postoperative complications of the patients. Therefore, undertaking preoperative testing should be guided by targeted history, physical examination, clinical risk factors, and type of surgical procedure intended to be performed.

State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time

This review delves into the challenge of pediatric anesthesia, underscoring the necessity for tailored perioperative approaches due to children's distinctive anatomical and physiological characteristics. Because of the vulnerability of pediatric patients to critical incidents during anesthesia, provider skills are of primary importance. Yet, almost equal importance must be granted to the adoption of a careful preanesthetic mindset toward patients and their families that recognizes the interwoven relationship between children and parents. In this paper, the preoperative evaluation process is thoroughly examined, from the first interaction with the child to the operating day. This evaluation process includes a detailed exploration of the medical history of the patient, physical examination, optimization of preoperative therapy, and adherence to updated fasting management guidelines. This process extends to considering pharmacological or drug-free premedication, focusing on the importance of preanesthesia re-evaluation. Structural resources play a critical role in pediatric anesthesia; components of this role include emphasizing the creation of child-friendly environments and ensuring appropriate support facilities. The results of this paper support the need for standardized protocols and guidelines and encourage the centralization of practices to enhance clinical efficacy.

Optimizing the Yield of Abnormal Preoperative Chest Radiographs in Elective Non-cardiothoracic Surgery: Development of a Risk Prediction Score and External Validation

BACKGROUND

Guideline recommendations for preoperative chest radiographs vary to the extent that individual patient benefit is unclear. We developed and validated a prediction score for abnormal preoperative chest radiographs in adult patients undergoing elective non-cardiothoracic surgery.

METHODS

Our prospective observational study recruited 703 adult patients who underwent elective non-cardiothoracic surgery at Ramathibodi Hospital. We developed a risk prediction score for abnormal preoperative chest radiographs with external validation using data from 411 patients recruited from Thammasat University Hospital. The discriminative performance was assessed by receiver operating curve analysis. In addition, we assessed the contribution of abnormal chest radiographs to perioperative management.

RESULTS

Abnormal preoperative chest radiographs were found in 19.5% of the 703 patients. Age, pulmonary disease, cardiac disease, and diabetes were significant factors. The model showed good performance with a C-statistics of 0.739 (95% CI, 0.691-0.786). We classified patients into four groups based on risk scores. The posttest probabilities in the intermediate-, intermediate-high-, and high-risk groups were 33.2%, 59.8%, and 75.7%, respectively. The model fitted well with the external validation data with a C statistic of 0.731 (95% CI, 0.674-0.789). One (0.4%) abnormal chest radiograph from the low-risk group and three (2.4%) abnormal chest radiographs from the intermediate-to-high-risk group had a major impact on perioperative management.

CONCLUSIONS

Four predictors including age, pulmonary disease, cardiac disease, and diabetes were associated with abnormal preoperative chest radiographs. Our risk score demonstrated good performance and may help identify patients at higher risk of chest abnormalities.

Reviewing methods of deep learning for diagnosing COVID-19, its variants and synergistic medicine combinations

The COVID-19 pandemic has necessitated the development of reliable diagnostic methods for accurately detecting the novel coronavirus and its variants. Deep learning (DL) techniques have shown promising potential as screening tools for COVID-19 detection. In this study, we explore the realistic development of DL-driven COVID-19 detection methods and focus on the fully automatic framework using available resources, which can effectively investigate various coronavirus variants through modalities. We conducted an exploration and comparison of several diagnostic techniques that are widely used and globally validated for the detection of COVID-19. Furthermore, we explore review-based studies that provide detailed information on synergistic medicine combinations for the treatment of COVID-19. We recommend DL methods that effectively reduce time, cost, and complexity, providing valuable guidance for utilizing available synergistic combinations in clinical and research settings. This study also highlights the implication of innovative diagnostic technical and instrumental strategies, exploring public datasets, and investigating synergistic medicines using optimised DL rules. By summarizing these findings, we aim to assist future researchers in their endeavours by providing a comprehensive overview of the implication of DL techniques in COVID-19 detection and treatment. Integrating DL methods with various diagnostic approaches holds great promise in improving the accuracy and efficiency of COVID-19 diagnostics, thus contributing to effective control and management of the ongoing pandemic.

ACR Appropriateness Criteria® Routine Chest Imaging

Routine chest imaging has been used to identify unknown or subclinical cardiothoracic abnormalities in the absence of symptoms. Various imaging modalities have been suggested for routine chest imaging. We review the evidence for or against the use of routine chest imaging in different clinical scenarios. This document aims to determine guidelines for the use of routine chest imaging as initial imaging for hospital admission, initial imaging prior to noncardiothoracic surgery, and surveillance imaging for chronic cardiopulmonary disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within the Veterans Health Administration

BACKGROUND

Low-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA).

OBJECTIVE

To examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery.

DESIGN

Retrospective cohort study using VHA administrative data from fiscal years 2017-2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not.

PARTICIPANTS

National cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery.

MAIN MEASURES

Difference in rate of receipt and attributed cost of potential cascade services in Veterans who underwent low-value preoperative testing compared to those who did not KEY RESULTS: Among 635,824 Veterans undergoing low-risk procedures, 7.8% underwent preoperative EKG. Veterans who underwent a preoperative EKG experienced an additional 52.4 (95% CI 47.7-57.2) cascade services per 100 Veterans, resulting in $138.28 (95% CI 126.19-150.37) per Veteran in excess costs. Among 739,005 Veterans undergoing low- or intermediate-risk surgery, 3.9% underwent preoperative CXR. These Veterans experienced an additional 61.9 (95% CI 57.8-66.1) cascade services per 100 Veterans, resulting in $152.08 (95% CI $146.66-157.51) per Veteran in excess costs. For both cohorts, care cascades consisted largely of repeat tests, follow-up imaging, and follow-up visits, with low rates invasive services.

CONCLUSIONS

Among a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service. These findings may guide de-implementation policies within VHA and other integrated healthcare systems that target those services whose downstream effects are most prevalent and costly.

Clinical Factors Predictive of COPD Diagnosis in a Community Hospital

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an irreversible obstructive airway disease. Diagnosis can be made using a spirometry which may not be available in resource-limited setting or developing countries. AIM: This study aimed to evaluate if clinical factors can be predictive of COPD diagnosis. MATERIALS AND METHODS: This study was a retrospective cohort study conducted at community hospital. The inclusion criteria were adult patients who had clinical symptoms suggestive of COPD and had performed adequate pulmonary function tests. Patients were categorized into two groups by diagnosis of COPD. Clinical predictors of being COPD were executed by multivariate logistic regression analysis. RESULTS: There were 200 patients who met the study criteria. Of those, 136 patients (68.00%) had compatible pulmonary function test with COPD. There were eight factors in the final predictive model for being COPD (Table 1). Among these factors, three factors were independently associated with being COPD: Productive sputum, body mass index, and hyperinflation by chest X-ray. The hyperinflation by chest X-ray had highest adjusted odds ratio of 10.93 (95% CI 3.23, 36.96). CONCLUSIONS: Productive sputum, body mass index, and hyperinflation by chest X-ray were independent factors for COPD diagnosis. Physicians in resource-limited setting may use these clinical factors as diagnostic tool for COPD.

Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico

BACKGROUND

Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources.

METHODS

A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question.

RESULTS

From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made.

CONCLUSIONS

This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

Estimation of the Overuse of Preoperative Chest X-rays According to "Choosing Wisely", "No Hacer", and "Essencial" Initiatives: Are They Equally Applicable and Comparable?

BACKGROUND

Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice.

METHODS

This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to "Choosing Wisely", "No Hacer" and "Essencial" initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units.

RESULTS

A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the "No Hacer" recommendation and 73.3% according to "Choosing Wisely" and "Essencial" criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to "Choosing Wisely" and "Essencial"; 4.1% according to "No Hacer"). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to "No Hacer" and EUR 3895.29 (2276.1 Relative Value Units) according to "Choosing Wisely" or "Essencial" criteria.

CONCLUSIONS

There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.

Factors influencing preoperative chest radiography request for elective endoscopic procedures among medical personnel

Background

Chest radiography is not routinely recommended before elective endoscopies. A high incidence of perioperative chest radiography requests was observed at our institution. This study aims to investigate factors influencing preoperative chest radiography request for patients undergoing elective gastrointestinal (GI) endoscopies.

Methods

This cross-sectional clinical study recruited 264 participants from different medical specialties who were responsible for preoperative endoscopic chest x-ray (CXR) ordering including anesthesiologists, surgeons and gastroenterologists. They completed questionnaires exploring their general knowledge and attitudes about preoperative chest radiography. Demographic characteristic of the participants affecting the knowledge on preoperative chest radiography was determined. A Structural Equation Model (SEM) was constructed from validated conceptual framework to find causal relationships between hypothesized factors and intention for preoperative endoscopic chest radiography request. Statistical analyses were performed using the SPSS software version 18.0 and Analysis of Moment Structures (AMOS) version 18.0.

Results

The questionnaire response rate was 53.79%. Baseline general knowledge on preoperative chest radiography of the participants was comparable. The SEM results showed unsupported relationship between hypothesized factors and the intention for preprocedural GI endoscopic CXR request (p < 0.1).

Conclusions

General knowledge of medical personnel on tuberculosis needs improvement. To rectify the unnecessary chest radiography request before elective GI endoscopic procedures, awareness of the patients’ health conditions, adherence to the hospital’s policy and realizing of possible patient-related mishaps are not the determinants for preprocedural endoscopic chest radiography request. Future works are required to explore other alternative factors involved for reducing chest radiography requests which are not indicated.

Mini Review: Deep Learning for Atrial Segmentation From Late Gadolinium-Enhanced MRIs

Segmentation and 3D reconstruction of the human atria is of crucial importance for precise diagnosis and treatment of atrial fibrillation, the most common cardiac arrhythmia. However, the current manual segmentation of the atria from medical images is a time-consuming, labor-intensive, and error-prone process. The recent emergence of artificial intelligence, particularly deep learning, provides an alternative solution to the traditional methods that fail to accurately segment atrial structures from clinical images. This has been illustrated during the recent 2018 Atrial Segmentation Challenge for which most of the challengers developed deep learning approaches for atrial segmentation, reaching high accuracy (>90% Dice score). However, as significant discrepancies exist between the approaches developed, many important questions remain unanswered, such as which deep learning architectures and methods to ensure reliability while achieving the best performance. In this paper, we conduct an in-depth review of the current state-of-the-art of deep learning approaches for atrial segmentation from late gadolinium-enhanced MRIs, and provide critical insights for overcoming the main hindrances faced in this task.

Preoperative Laboratory Testing

Obtaining routine preoperative laboratory tests increases health care costs and has been listed, by the Choosing Wisely Campaign, as one of the top 5 practices anesthesiologists should avoid. Routine testing without clinical indication is not cost-effective and could cause harm and unnecessary delays. Abnormal findings are more likely to be false positive and costly to pursue, introduce new risks, and increase anxiety for the patient. Preoperative testing need to be performed only following a targeted history and physical examination, factoring severity of surgery, and comorbidities such that the benefit of the test outweighs risk.

Low-Value Service Use in Provider Organizations

OBJECTIVE

To assess whether provider organizations exhibit distinct profiles of low-value service provision.

DATA SOURCES

2007-2011 Medicare fee-for-service claims and enrollment data.

STUDY DESIGN

Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variation across organizations, persistence within organizations over time, and correlations in use of different types of low-value services within organizations were estimated via multilevel modeling, with adjustment for beneficiary sociodemographic and clinical characteristics.

PRINCIPAL FINDINGS

Organizations provided 45.6 low-value services per 100 beneficiaries on average, with considerable variation across organizations (90th/10th percentile ratio, 1.78; 95 percent CI, 1.72-1.84), including substantial between-organization variation within hospital referral regions (90th/10th percentile ratio, 1.66; 95 percent CI, 1.60-1.71). Low-value service use within organizations was highly correlated over time (r, 0.98; 95 percent CI, 0.97-0.99) and positively correlated between 13 of 15 pairs of service categories (average r, 0.26; 95 percent CI, 0.24-0.28), with the greatest correlation between low-value imaging and low-value cardiovascular testing and procedures (r, 0.54).

CONCLUSIONS

Use of low-value services in provider organizations exhibited substantial variation, high persistence, and modest consistency across service types. These findings are consistent with organizations shaping the practice patterns of affiliated physicians.

Frequency of abnormal findings on routine chest radiography before cardiac surgery

OBJECTIVE

Preoperative chest radiograph screening is widely used before cardiac surgery. The objective of this study was to investigate the frequency of abnormal findings on a routine chest radiograph before cardiac surgery.

METHODS

In this retrospective cohort study, 1136 patients were included. Patients were scheduled for cardiac surgery and underwent a preoperative chest radiograph. The primary outcome was the frequency of abnormalities on the chest radiograph. Secondary outcome was the effect of those abnormalities on surgery.

RESULTS

One half of the patients (570/1136; 50%) had 1 or more abnormalities on the chest radiograph. Most frequent abnormalities were cardiomegaly, aortic elongation, signs of chronic obstructive pulmonary disease, vertebral fractures or height loss, possible pulmonary or mediastinal mass, pleural effusion, and atelectasis. In 2 patients (2/1136; 0.2%), the chest radiograph led to postponement of surgery, whereas in none of the patients the surgery was cancelled. In 1 patient (1/1136; 0.1%) the surgical approach was altered and in 15 patients (15/1136; 1.3%) further analysis was performed without having an impact on the planned surgical approach.

CONCLUSIONS

Although abnormalities are frequently found on preoperative chest radiographs before cardiac surgery, change in clinical management with regard to planned surgery or surgical approach occurs infrequently.

Evaluation of thoracic radiographs as a screening test for dogs and cats admitted to a tertiary-care veterinary hospital for noncardiopulmonary disease

Thoracic radiographs are used as a screening tool for dogs and cats with a variety of disorders that have no clinical signs associated with thoracic structures. However, this practice has never been supported by an evidence-based study. The objective of this retrospective observational study was to determine if certain canine and feline populations have a higher proportion of radiographic abnormalities, and whether any of these abnormalities are associated with patient hospitalization and outcome. Patients were excluded if current or previous examinations revealed evidence of primary respiratory or cardiac disease, malignant neoplasia, or an abnormal breathing pattern consistent with pulmonary pathology. Any notable thoracic change in the radiology report was considered important and evaluated in this study. One hundred and sixty-six of these included patients were dogs and 65 were cats. Of the 166 dog radiographs evaluated, 120 (72.3%) had normal thoracic radiographs, while 46 (27.7%) had radiographic abnormalities. Of the sixty-five cats included, 36 (55.4%) had normal radiographs, while 29 (44.6%) had abnormal radiographs. Canine patients with abnormal radiographs had a significantly higher lactate level (P-value 0.0348) and feline patients with abnormal radiographs had a significantly lower packed cell volume (P-value 0.012). A large proportion of patients that had screening thoracic radiographs (32.5%) had documented abnormalities, but a relatively low percentage (6.5%) of our total population had their clinical plan changed as a consequence of detection of these abnormalities. Findings indicated that abnormal screening thoracic radiographs are more likely in dogs with an elevated lactate and cats with anemia, or a low normal hematocrit.

Preoperative chest radiographs in hip fracture patients: is there any additional value?

Purpose

Preoperative screening in hip fracture patients is vital to minimize perioperative complications. Preoperative chest radiographs (POCR) are performed in many hip fracture patients. Earlier research showed that few POCR abnormalities influence perioperative policy. However, no studies in nonelective patient with a specific surgical conditions have been performed. With many hip fractures per year worldwide, a significant cost reduction could be made by performing selective POCR without compromising the quality of care. This study assessed the need for POCR in hip fracture patients.

Method

Retrospective analysis of low-energy trauma patients was performed aged 18 years and older in the VU University Medical Center for a hip fracture in a 5-year period. All preoperative diagnostics were analyzed. All adjourned operations were evaluated.

Results

A total of 642 patients were included, 70% female, matching current epidemiologic figures. The POCR showed abnormalities in 22.6%. In 0.6% the POCR lead to an adjournment of the operation (2.8% of abnormal POCR’s). These patients suffered from pneumonia. The POCR in these cases acted as a confirmation of the clinical diagnosis.

Conclusion

Many factors involving the treatment of hip fracture patients are of importance in minimizing the risk of complications and mortality during and after admission. In 0.6% of all performed POCR’s an abnormality leads to the adjournment of the operation. In all four cases the POCR matched the clinical findings. Because the additional value of the POCR in hip fracture patients was limited, we think that its selective use in clinical abnormalities is safe and will reduce unnecessary costs.

ACR Appropriateness Criteria® Routine Chest Radiography

Chest radiographs are sometimes taken before surgeries and interventional procedures on hospital admissions and outpatients. This manuscript summarizes the American College of Radiology review of the literature and recommendations on routinely performed chest radiographies in these settings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Cost Savings Opportunities in Perioperative Management of the Patients With Orthopaedic Trauma

Considerable opportunities for cost savings exist surrounding the perioperative management of patients with orthopaedic fracture and trauma. Scientific evidence is available to support each potential cost savings measure. Much of these data had been documented for years but has never been adhered to, resulting in millions of dollars in unnecessary testing and treatment. Careful attention to preoperative laboratory testing can save huge amounts of money and expedite medical clearance for injured patients. The use of a dedicated orthopaedic trauma operating room has been shown to improve resource utilization, decrease costs, and surgical complications. A variety of anesthetic techniques and agents can reduce operative time, recovery room time, and hospital lengths of stay. Strict adherence to blood utilization protocols, appropriate deep venous thrombosis prophylaxis, and multimodal postoperative pain control with oversight from dedicated hip fracture hospitalists is critical to cost containment. Careful attention to postoperative disposition to acute care and management of postoperative testing and radiographs can also be another area of cost containment. Institutional protocols must be created and followed by a team of orthopaedic surgeons, hospitalists, and anesthesiologists to significantly impact the costs associated with care of patient with orthopaedic trauma and fracture.

An observational cohort study on pre-operative investigations and referrals: How far are we following recommendations?

BACKGROUND AND AIMS

Pre-operative investigations are often required to supplement information for risk stratification and assessing reserve for undergoing surgery. Although there are evidence-based recommendations for which investigations should be done, clinical practice varies. The present study aimed to assess the pre-operative investigations and referral practices and compare it with the standard guidelines.

METHODS

The present observational study was carried out during 2014-appen2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre-anaesthetic check-up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA).

RESULTS

Seventy-five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist-ordered testing was more focused than surgeons.

CONCLUSION

More than two-third of pre-operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre-operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.

"Do not do" recommendations of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy. "Commitment to Quality by Scientific Societies" Project

In April 2013 the Ministry of Health (MSSSI) adopted the project called "Commitment to Quality by Scientific Societies in Spain", in response to social and professional demands for sustainability of the health system. The initiative is part of the activities of the Spanish Network of Agencies for Health Technology Assessment and Services of the National Health System, and is coordinated jointly by the Quality and Cohesion Department, the Aragon Institute of Health Sciences (IACS), and the Spanish Society of Internal Medicine (SEMI). All the scientific societies in Spain have been included in this project, and its main objective is to reduce the unnecessary use of health interventions in order to agree "do not do" recommendations, based on scientific evidence. The primary objective was to identify interventions that have not proven effective, have limited or doubtful effectiveness, are not cost-effective, or do not have priority. Secondary objectives were: reducing variability in clinical practice, to spread information between doctors and patients to guide decision-making, the appropriate use of health resources and, the promotion of clinical safety and reducing iatrogenesis. The selection process of the 5 "do not do" recommendations was made by Delphi methodology. A total of 25 panellists (all anaesthesiologists) chose between 15 proposals based on: evidence that supports quality, relevance, or clinical impact, and the people they affect. The 5 recommendations proposed were: Do not maintain deep levels of sedation in critically ill patients without a specific indication; Do not perform preoperative chest radiography in patients under 40 years-old with ASA physical status I or II; Do not systematically perform preoperative tests in cataract surgery unless otherwise indicated based on clinical history and physical examination; Do not perform elective surgery in patients with anaemia at risk of bleeding until a diagnostic workup is performed and treatment is given; and not perform laboratory tests (blood count, biochemistry and coagulation) prior to surgery in healthy or low risk patients (ASA I and II) with minimal estimated blood loss.

Variation in Practice of the Diagnostic Workup of Asymptomatic Patients Diagnosed with Invasive Breast Cancer

INTRODUCTION

Breast cancer is frequently diagnosed, yet variation remains in terms of practice patterns in presurgical workup. We sought to determine factors associated with this variation.

METHODS

An anonymous web-based survey was distributed to surgeons regarding their practices. Statistical analyses were conducted using SPSS.

RESULTS

A total of 253 surgeons responded to the survey. 17.0% were in academic practice, 37.5% were hospital employed, and 41.5% were in private practice. 53.3% claimed that >50% of their practice was breast related. Surgeons were asked how often they would use various tests in the workup of an otherwise healthy asymptomatic patients, presenting with a non-palpable mammographic abnormality and a core needle biopsy showing invasive breast cancer. 23.5% stated that they always would obtain a breast ultrasound, 17.2% stated that they never would. 12.8% stated that they never order a breast MRI; 4.1% always would. Workup of patients did not vary significantly based on number of years in practice nor practice setting. However, those whose practice was >50% breast were more likely to state that they would always order a breast ultrasound (32.5 vs. 12.9%, p < 0.001), and less likely to state that they would never order a breast MRI (3.4 vs. 25.8%, p < 0.001). However, the proportions of surgeons who would always order a breast MRI were similar in the two groups (3.4 and 3.2%, respectively).

CONCLUSION

These data highlight the lack of uniformity in the workup of asymptomatic patients presenting with non-palpable breast cancers, pointing to potential areas for improving value by minimizing variability.

Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program

IMPORTANCE

Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services.

OBJECTIVE

To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services.

DESIGN, SETTING, AND PARTICIPANTS

In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries' sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services.

MAIN OUTCOMES AND MEASURES

Use of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries.

RESULTS

During the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (-1.2 to -0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (-2.9% to -0.9%) and a 4.5% differential reduction in spending on low-value services (-7.5% to -1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets' mean baseline levels of low-value service use experienced greater service reductions (-1.2 services per 100 beneficiaries; -1.7 to -0.7; P < .001) than did ACOs with use below the mean (-0.2 services per 100 beneficiaries, -0.6 to -0.2; P = .41; P = .003 for test of difference between subgroups).

CONCLUSIONS AND RELEVANCE

During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization-like risk contracts may be able to discourage use of low-value services even without specifying services to target.

[Screening prior to surgery and interventions]

Routine preoperative screening is often performed but seldom indicated. The evidence for such procedures is weak or lacking. Advanced patient age is also not a reasonable trigger to initiate testing. Obtaining a detailed, standardized bleeding history, for example using a questionnaire, is much more valuable than blind testing for coagulation parameters. Of primary importance are a detailed medical history with special focus on the patient's individual fitness and a thorough physical examination. Specific blood tests may then follow. Renal function tests are indicated as routine if major surgery with intraoperative volume restriction is planned. Routine preoperative chest radiography is almost never indicated.

Optimizing perioperative care for patients with hip fracture

Hip fracture is one of the most common orthopedic conditions associated with significant morbidity and mortality. Patients with hip fracture are usually older, with significant comorbidities. Delayed surgical treatment beyond 48 hours after admission is associated with significantly higher mortality. Hereby clinicians are presented with the challenge to optimize the complex hip fracture within a short time period. This article reviews the evidence regarding preoperative, intraoperative, and postoperative considerations, and provides insights into the best strategies with which to optimize the patient's condition and improve perioperative outcomes.

Measuring low-value care in Medicare

IMPORTANCE

Despite the importance of identifying and reducing wasteful health care use, few direct measures of overuse have been developed. Direct measures are appealing because they identify specific services to limit and can characterize low-value care even among the most efficient providers.

OBJECTIVES

To develop claims-based measures of low-value services, examine service use (and associated spending) detected by these measures in Medicare, and determine whether patterns of use are related across different types of low-value services.

DESIGN, SETTING, AND PARTICIPANTS

Drawing from evidence-based lists of services that provide minimal clinical benefit, we developed 26 claims-based measures of low-value services. Using 2009 claims for 1,360,908 Medicare beneficiaries, we assessed the proportion of beneficiaries receiving these services, mean per-beneficiary service use, and the proportion of total spending devoted to these services. We compared the amount of use and spending detected by versions of these measures with different sensitivity and specificity. We also estimated correlations between use of different services within geographic areas, adjusting for beneficiaries' sociodemographic and clinical characteristics.

MAIN OUTCOMES AND MEASURES

Use and spending detected by 26 measures of low-value services in 6 categories: low-value cancer screening, low-value diagnostic and preventive testing, low-value preoperative testing, low-value imaging, low-value cardiovascular testing and procedures, and other low-value surgical procedures.

RESULTS

Services detected by more sensitive versions of measures affected 42% of beneficiaries and constituted 2.7% of overall annual spending. Services detected by more specific versions of measures affected 25% of beneficiaries and constituted 0.6% of overall spending. In adjusted analyses, low-value spending detected in geographic regions at the 5th percentile of the regional distribution of low-value spending ($227 per beneficiary) exceeded the difference in detected low-value spending between regions at the 5th and 95th percentiles ($189 per beneficiary). Adjusted regional use was positively correlated among 5 of 6 categories of low-value services (mean r for pairwise, between-category correlations, 0.33; range, 0.14-0.54; P ≤ .01).

CONCLUSIONS AND RELEVANCE

Services detected by a limited number of measures of low-value care constituted modest proportions of overall spending but affected substantial proportions of beneficiaries and may be reflective of overuse more broadly. Performance of claims-based measures in supporting targeted payment or coverage policies to reduce overuse may depend heavily on how the measures are defined.

Preoperative risk assessment--from routine tests to individualized investigation

BACKGROUND

Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications.

METHOD

This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies.

RESULTS

The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period.

CONCLUSION

In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.

Where to begin and where to end? Preoperative assessment for patients undergoing metabolic surgery

Bariatric surgery is the most effective treatment of obesity and its associated diseases like type 2 diabetes mellitus. Given the obesity epidemic and the efficacy of surgical treatment, the number of surgical weight loss procedures has grown in recent years. Nevertheless, there is little consensus regarding the extent of preoperative investigations required prior to patients undergoing surgery. This article aims to discuss the available evidence on which preoperative tests are useful for the detection and treatment of conditions such as venous thromboembolism, obstructive sleep apnea syndrome and Helicobacter pylori-positive gastritis prior to an operation. The present literature suggests that only a few preoperative investigations are essential, but that preoperative multidisciplinary care is beneficial.

Relevance of routine testing in low-risk patients undergoing minor and medium surgical procedures

BACKGROUND AND OBJECTIVES

Preoperative tests aim to reduce morbidity and mortality of surgical patients, cost of perioperative care, and preoperative anxiety. Clinical evaluation allows defining the need for additional tests and strategies to reduce the surgical-anesthetic risk. The aim of this study was to evaluate the benefit of routine preoperative testing of low-risk patients undergoing minor and medium surgical procedures.

METHODS

A descriptive cross-sectional study of 800 patients seen at the preanesthetic assessment department of Hospital Santo Antonio, Salvador, BA. Patients with physical status ASA I, aged 1-45 years and scheduled to undergo elective minor and medium surgeries were include in the study. We evaluated changes in blood count, coagulation profile, electrocardiogram, chest X-ray, blood sugar, kidney function, sodium and potassium levels, and eventual change in clinical approach occurring due to these changes.

RESULTS

Of 800 patients evaluated, a blood count was performed in 97.5%, coagulation in 89%t, electrocardiogram in 74.1%, chest X-ray in 62%, fasting glucose in 68%, serum urea and creatinine in 55.7%, and plasma levels of sodium and potassium in 10.1%. Of these 700 patients, 68 (9.71%) showed changes in preoperative routine tests and only 10 (14.7%) of the patients with abnormal tests had a preoperative modified approach (i.e., new tests ordered, referral to a specialist or surgery postponement). No surgery was suspended.

CONCLUSION

We found that preoperative additional tests are excessively ordered, even for young patients with low surgical risk, with little or no interference in perioperative management. Laboratory tests, besides generating high and unnecessary costs, are not good standardized screening instruments for diseases.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

Postoperative pulmonary complications: reducing risks for noncardiac surgery

Postoperative pulmonary complications (PPCs) are a major contributor to the overall risk of noncardiac surgery that may lead to serious postoperative morbidity and long-term mortality. Nurse practitioners should be familiar with risk indices for PPCs, clinical guidelines, and risk reduction strategies to prevent PPCs and improve PPC outcomes.

Role of routine laboratory investigations in preoperative evaluation

Traditionally, routine investigations prior to surgery are considered an important element of preanesthetic evaluation to determine the fitness for anesthesia and surgery. During past few decades this practice has been a subject of close scrutiny due to low yield and high aggregate cost. Performing routine screening tests in patients who are otherwise healthy is invariably of little value in detecting diseases and in changing the anesthetic management or outcome. Thorough history and investigation of positive answers by the clinicians, combined with physical examination of patient represents the best method for screening diseases followed by few selective tests as guided by patient's health condition, invasiveness of planned surgery and potential for blood loss. A large number of investigations which are costly to pursue often detect minor abnormalities of no clinical relevance, may be risky to patients, cause unnecessary delay or cancellation of surgery, and increase medico-legal liability. An approach of selective testing reduces cost without sacrificing safety or quality of surgical care.

Complications of hysterectomy

Hysterectomy is the most common gynecologic procedure performed in the United States, with more than 600,000 procedures performed each year. Complications of hysterectomy vary based on route of surgery and surgical technique. The objective of this article is to review risk factors associated with specific types of complications associated with benign hysterectomy, methods to prevent and recognize complications, and appropriate management of complications. The most common complications of hysterectomy can be categorized as infectious, venous thromboembolic, genitourinary (GU) and gastrointestinal (GI) tract injury, bleeding, nerve injury, and vaginal cuff dehiscence. Infectious complications after hysterectomy are most common, ranging from 10.5% for abdominal hysterectomy to 13.0% for vaginal hysterectomy and 9.0% for laparoscopic hysterectomy. Venous thromboembolism is less common, ranging from a clinical diagnosis rate of 1% to events detected by more sensitive laboratory methods of up to 12%. Injury to the GU tract is estimated to occur at a rate of 1-2% for all major gynecologic surgeries, with 75% of these injuries occurring during hysterectomy. Injury to the GI tract after hysterectomy is less common, with a range of 0.1-1%. Bleeding complications after hysterectomy also are rare, with a median range of estimated blood loss of 238-660.5 mL for abdominal hysterectomy, 156-568 mL for laparoscopic hysterectomy, and 215-287 mL for vaginal hysterectomy, with transfusion only being more likely after laparoscopic compared to vaginal hysterectomy (odds ratio 2.07, confidence interval 1.12-3.81). Neuropathy after hysterectomy is a rare but significant event, with a rate of 0.2-2% after major pelvic surgery. Vaginal cuff dehiscence is estimated at a rate of 0.39%, and it is more common after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-assisted vaginal hysterectomy (0.28%), total abdominal hysterectomy (0.15%), and total vaginal hysterectomy (0.08%). With an emphasis on optimizing surgical technique, recognition of surgical complications, and timely management, we aim to minimize risk for women undergoing hysterectomy.

Perioperative management of chronic respiratory disease

Respiratory disease contributes significantly to the perioperative challenges of surgery. Preexisting pulmonary co-morbidities and respiratory complications can have profound effects on patient outcomes. Knowledge of these conditions and the potentially deleterious effects of anaesthesia and surgery can enable clinicians to optimise lung function, reduce complications and improve results.