Usefulness of selectively ordered preoperative tests

"Too much information with little meaning," relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review

Aim:

In the recent times due to accessibility of tools and advent of technology advising battery of laboratory tests prior to any electeve surgical procedure has become a norm. This review aims at investigating relevance of such tests in healthy patients undergoing routine elective oral and maxillofacial surgical procedures.

Methods:

Various search engines were thoroughly searched to identify relevant literature. The population of interest was asymptomatic adults above 18 years of age undergoing elective surgery.

Results:

The preoperative tests of interest for the current study included complete blood count, coagulation tests, biochemistry, and chest X-rays. An algorithm for preoperative tests has been proposed.

Conclusion:

We conclude that advising battery of routine tests in such patients leads to further delays and rise in overall cost of the surgery.

International comparison of preoperative testing and assessment protocols and best practices to reduce surgical care costs: a systematic literature review

PURPOSE

Health care institutions in many Western countries have developed preoperative testing and assessment guidelines to improve surgical outcomes and reduce cost of surgical care. The aims of this chapter are to (1) summarize the literature on the effect of preoperative testing on clinical outcomes, efficiency, and cost; and (2) to compare preoperative testing guidelines developed in the United States, the United Kingdom, and Canada.

DESIGN/METHODOLOGY/APPROACH

We reviewed the literature from 1975 to 2014 for studies and preoperative testing guidelines.

FINDINGS

We identified 29 empirical studies and 8 country-specific guidelines for review. Most studies indicate that preoperative testing is overused and comes at a high cost. Guidelines are tied to payment only in one country studied. This is the most recent review of the literature on preoperative testing and assessment with a focus on quality of care, efficiency, and cost outcomes. In addition, this chapter provides an international comparison of preoperative guidelines.

What laboratory tests are required for ambulatory surgery?

Current recommendations from the 2002 ASA Task Force on Preanesthesia Evaluation are not specific to ambulatory surgery and are not based on strongly designed and adequately powered studies. Furthermore, although the ASA does not advocate routine testing or testing without indication, the guidelines for "selective" or "indicated" testing are unclear. As a result, preoperative testing in the United States is overused relative to the current ASA Task Force recommendations. Uncertainty regarding indications leads to wide variation in the use of preoperative testing across providers. There is evidence to suggest that current guidelines may recommend testing more than is necessary. Several studies reviewed in this article have shown that the elimination of routine testing and more selective use based on patient history and physical examination findings would decrease cost and increase patient satisfaction without detriment to patient care. Future studies should evaluate the effectiveness of testing in specific clinical situations, allowing for identification of clear conditions under which preoperative testing should be performed. This approach would allow the promulgation of clear guidelines, the development of which should involve surgeons (as members of a multidisciplinary team), anesthesiologists, and hospital administrators, together with governing bodies such as the ASA and American College of Surgeons that offer support for the dissemination and broad adoption of guidelines. In the future, studies should focus not only on identifying specific clinical situations whereby preoperative testing will be beneficial but also on determining current barriers to improving adherence to guidelines. Potential barriers include institutional policies for testing, physician reluctance to change practice, problems in communication between members involved in perioperative care, and legal consequences of not ordering preoperative tests. Identification of reasons for overuse of testing is the first step toward changing practice. Once clear guidelines are developed, the creation of preoperative clinics that centralize preoperative care, or promoting the use of clinical pathways and/or checklists for determining appropriate tests, may improve the adequate use of preoperative tests. It will be critical for quality improvement measures to include surgeons, anesthesiologists, hospital administrators, and governing bodies such as the ASA and American College of Surgeons to achieve success.

Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery

BACKGROUND

Routine preoperative laboratory testing for ambulatory surgery is not recommended.

METHODS

Patients who underwent elective hernia repair (N = 73,596) were identified from the National Surgical Quality Improvement Program (NSQIP) database (2005-2010). Patterns of preoperative testing were examined. Multivariate analyses were used to identify factors associated with testing and postoperative complications.

RESULTS

A total of 46,977 (63.8%) patients underwent testing, with at least one abnormal test recorded in 61.6% of patients. In patients with no NSQIP comorbidities (N = 25,149) and no clear indication for testing, 54% received at least one test. In addition, 15.3% of tested patients underwent laboratory testing the day of the operation. In this group, surgery was done despite abnormal results in 61.6% of same day tests. In multivariate analyses, testing was associated with older age, ASA (American Society of Anesthesiologists) class >1, hypertension, ascites, bleeding disorders, systemic steroids, and laparoscopic procedures. Major complications (reintubation, pulmonary embolus, stroke, renal failure, coma, cardiac arrest, myocardial infarction, septic shock, bleeding, or death) occurred in 0.3% of patients. After adjusting for patient and procedure characteristics, neither testing nor abnormal results were associated with postoperative complications.

CONCLUSIONS

Preoperative testing is overused in patients undergoing low-risk, ambulatory surgery. Neither testing nor abnormal results were associated with postoperative outcomes. On the basis of high rates of testing in healthy patients, physician and/or facility preference and not only patient condition currently dictate use. Involvement from surgical societies is necessary to establish guidelines for preoperative testing.

Ambulatory surgery: how much testing do we need?

Ambulatory surgery currently represents more than two thirds of surgeries performed. It is considered low-risk surgery and patients expect to be discharged home safely and comfortably the same day. More than 30 years of evidence supports the idea that preoperative assessment is best done by a focused history and physical, and only minimal, selective, further laboratory investigations. Costs are optimized by this approach and outcomes have not been shown to be adversely affected, possibly even improved, with less harm inflicted by additional testing. This article focuses on what is appropriate testing for ambulatory surgery patients.

The Management of Postoperative Bleeding

This article addresses the management of postoperative bleeding. The problem is called postoperative bleeding rather than postoperative hemorrhage to emphasize the fact that perfect postoperative hemostasis rather than acceptable postoperative blood loss is the ideal. Postoperative bleeding is a risk of all surgical procedures. The best way to reduce the risk of hemorrhage is to identify and correct potential causes of coagulopathy both pre- and post-operatively.

The case against routine preoperative laboratory testing

In this article, we have shown that almost all "routine" laboratory tests before surgery have limited clinical value. Clinicians should order only a small number of routine tests based on age as noted in Table 13. Selective use of other preoperative tests should be based on history and physical examination findings that identify subgroups of patients who are more likely to have abnormal results. In general, clinicians should order tests only if the outcome of an abnormal test will influence management. When an abnormal test results from such testing, it is critical that physicians document their thinking about the result. Most routine preoperative tests are neither expensive nor risky. For this reason, clinicians can have a low threshold for ordering these tests in patients for whom the frequency of abnormalities is increased compared with a healthy population. We believe that physicians should not be criticized for selective test ordering before surgery. Physicians and institutions recommending routine preoperative testing for all patients provide no clinical value to their patients at considerable cost.

Is haemostasis biological screening always useful before performing a neuraxial blockade in children?

BACKGROUND

Because of the lack of controlled studies, there is no consensus of opinion about the practice of routine haemostasis tests before neuraxial blockade in children. The purpose of this study was to compare the influence of two different strategies of coagulation evaluation on the incidence of diagnosed coagulopathies leading to a modification of the preoperative or anaesthetic management in children who were scheduled for caudal, epidural or intrathecal block.

METHODS

For a 24-month period (period 1, retrospective study, n=751), haemostasis screening was undertaken only after family and personal history and physical examination in all patients. For the following 24 months (period 2, prospective study, n=958), a standardized questionnaire was used. In addition, routine tests (prothrombin, partial thromboplastin time, platelet count) were performed in children who where not yet walking. In older children, coagulation tests were undertaken as in period 1.

RESULTS

Overall, 26 significant abnormalities were diagnosed. Coagulation tests were performed in 16.2% (period 1) and 78.2% (period 2) of the children, who were not yet walking. Routine tests did not improve the diagnosis of haemostasis abnormalities justifying a modification of the preoperative and anaesthetic management (2.2% from 406 children in period 1 vs 4.1% from 266 children in period 2). The predictive positive value of routine tests (period 2) was 19%, vs 45% for specific tests (period 1) (P < 0.001). In older children, the use of a standardized form increased the number of haemostasis screenings without improvement of diagnosis leading to modified preoperative management (0.3% from 315 children in period 1 vs 0.5% from 628 children in period 2).

CONCLUSIONS

When routine testing is performed in nonwalking children, the screening number increases without leading to a higher number of anaesthetic management changes, suggesting that routine testing does not seem to provide much extra information in the absence of a positive history.

Preoperative assessment of the elderly patient

Organ system functional reserve variability increases progressively with age. In elderly patients, cardiopulmonary, central nervous system, and metabolic functional reserve seem to be the most important predictors of the ability to undergo surgery. Directed testing for the assessment of organ system functional reserve and identification of organs at risk, rather than the diagnosis of disease itself, is the primary goal of preoperative evaluation prior to surgery and is essential to the formulation of an effective anesthetic plan. The risks of adverse drug interaction, already high in the elderly, make a thorough review of the indications and dosage of perioperative medication an important part of the preoperative assessment process.

Routine preoperative investigation. Results of a multicenter survey in Italy. Collaborator Group

We conducted a study to acquire information on the current behavior of a sample of Italian surgeons and anesthesiologists about prescribing, interpreting, and using routine preoperative investigations. Consultants in surgery and anesthesiology in 60 hospitals in northern, central, and southern Italy were interviewed. Prescription of these procedures by doctors were driven more by personal experience than by updated scientific knowledge. This practice often led to ineffective and inefficient clinical practice, with healthy patients undergoing useless, time-consuming, costly, and sometimes harmful procedures.

"Routine" preoperative studies. Which studies in which patients?

The utility of mass screening of preoperative patients has never been demonstrated for the majority of tests. Although screening patients to uncover occult disease appears logical, in reality it has resulted in excessive expenditure of our health care dollars with limited benefit. More than $30 billion is spent annually on preoperative examinations, 60% of which are unnecessary. In addition, iatrogenic injury has resulted from the further evaluation and treatment of false-positive results. A selective utilization of routine examinations can accurately supplement the clinician's evaluation, providing the patient with a complete preoperative assessment. The benefits of selective testing must be balanced against the possible omission of warranted examinations, highlighting the need for a more reliable system for test ordering.

Preoperative laboratory testing: should any tests be "routine" before surgery?

Routine preoperative testing of all patients before elective surgery is unjustified. The frequency of unanticipated abnormalities or abnormalities shown to change patient management is too low to justify a practice pattern of testing all patients. Furthermore, little evidence exists that test result abnormalities are associated with perioperative morbidity. Table 12 lists a compilation of the findings from this article and recommendations regarding routine testing.

The role of expert systems in improving the test requesting patterns of clinicians

The many strategies proposed for influencing the test requesting patterns of clinicians have had only limited success, largely because they are labour intensive and depend on motivation and commitment. Clinical protocols which have been locally agreed between laboratory staff and clinicians are potentially one of the more successful strategies, but detailed study of their application in different clinical settings has been limited by practical problems. Expert systems offer a way of implementing locally agreed protocols and, consequently, of assisting the identification, audit and refinement of laboratory testing strategies. Where these systems have been applied in specialist units they have resulted in savings in time by both clinical and laboratory staff, and an overall reduction in the number of clinical chemistry tests done within and out of hours. These systems offer promise as a method of improving laboratory utilization.

Achieving consensus on out-of-hours laboratory tests

Many reports on guidelines for investigation describe either the guidelines themselves or their implementation. Implicitly these assume that there has been general agreement about the guidelines, whereas there may be uncertainty about the appropriateness of a particular investigation in a given situation. We report the use of a technique for developing guidelines which explicitly seeks to identify areas of agreement and disagreement, and focuses on the reasons that particular decisions were made and the causes of disagreement.

Factors influencing mortality after curative resection for large bowel cancer in elderly patients

Mortality rates from the Large Bowel Cancer Project are presented with special reference to patients older than 70 years. The in-hospital mortality rate among those who underwent curative resection for colorectal carcinoma was 7%. Unlike long-term prognosis, which is influenced by pathological features, in-hospital mortality is influenced largely by clinical factors. Age was an adverse factor (78% of deaths occurred among those aged over 70, who formed 46% of the study population), as was obstruction or perforation. 55% of deaths were due to cardiopulmonary complications. Educating patients to seek treatment early, careful preoperative assessment and postoperative monitoring of cardiopulmonary function, and, in selected patients, use of local treatments rather than wide resections may help to reduce mortality in elderly patients.