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Stuart CM, Bronsert MR, Meguid RA, Mott NM, Abrams BA, Dyas AR, Gleisner AL, Colborn KL, Henderson WG. The deimplementation of laboratory testing in low-risk patients as recommended by the American society of anesthesiologists: An ACS-NSQIP longitudinal analysis. World J Surg 2024; 48:1014-1024. [PMID: 38549187 DOI: 10.1002/wjs.12154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/08/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low-risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low-risk versus higher-risk patients before and after release of these guidelines. METHODS The ACS-NSQIP database, 2005-2018, was separated into low-risk versus higher-risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low- and higher-risk patients. A difference-in-differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery. RESULTS Of 7,507,991 patients, 972,431 (13.0%) were defined as low-risk and 6,535,560 (87.0%) higher-risk. Use of any preoperative laboratory test declined in low-risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%-91.9% in higher-risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk-adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76-0.78) in low-risk versus 0.93 (0.92-0.94) in higher-risk patients. In low-risk patients, lack of any preoperative testing was not associated with worse outcomes. CONCLUSIONS While a majority of low-risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low-risk patients.
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Affiliation(s)
- Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicole M Mott
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Benjamin A Abrams
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ana L Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - William G Henderson
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
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Sun Z, Zhang Y, Xia Y, Ba X, Zheng Q, Liu J, Kuang X, Xie H, Gong P, Shi Y, Mao N, Wang Y, Liu M, Ran C, Wang C, Wang X, Li M, Zhang W, Fang Z, Liu W, Guo H, Ma H, Song Y. Association between CT-based adipose variables, preoperative blood biochemical indicators and pathological T stage of clear cell renal cell carcinoma. Heliyon 2024; 10:e24456. [PMID: 38268833 PMCID: PMC10803934 DOI: 10.1016/j.heliyon.2024.e24456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/26/2024] Open
Abstract
Background Clear cell renal cell carcinoma (ccRCC) is corelated with tumor-associated material (TAM), coagulation system and adipocyte tissue, but the relationships between them have been inconsistent. Our study aimed to explore the cut-off intervals of variables that are non-linearly related to ccRCC pathological T stage for providing clues to understand these discrepancies, and to effectively preoperative risk stratification. Methods This retrospective analysis included 218 ccRCC patients with a clear pathological T stage between January 1st, 2014, and November 30th, 2021. The patients were categorized into two cohorts based on their pathological T stage: low T stage (T1 and T2) and high T stage (T3 and T4). Abdominal and perirenal fat variables were measured based on preoperative CT images. Blood biochemical indexes from the last time before surgery were also collected. The generalized sum model was used to identify cut-off intervals for nonlinear variables. Results In specific intervals, fibrinogen levels (FIB) (2.63-4.06 g/L) and platelet (PLT) counts (>200.34 × 109/L) were significantly positively correlated with T stage, while PLT counts (<200.34 × 109/L) were significantly negatively correlated with T stage. Additionally, tumor-associated material exhibited varying degrees of positive correlation with T stage at different cut-off intervals (cut-off value: 90.556 U/mL). Conclusion Preoperative PLT, FIB and TAM are nonlinearly related to pathological T stage. This study is the first to provide specific cut-off intervals for preoperative variables that are nonlinearly related to ccRCC T stage. These intervals can aid in the risk stratification of ccRCC patients before surgery, allowing for developing a more personalized treatment planning.
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Affiliation(s)
- Zehua Sun
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Yumei Zhang
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Yuanhao Xia
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
- Department of Radiology, Binzhou Medical University, Yantai, 264000, Shandong, China
| | - Xinru Ba
- Department of Radiology, Yantaishan Hospital, Yantai, 264000, Shandong, China
| | - Qingyin Zheng
- Department of Otolaryngology-Head & Neck Surgery, Case Western Reserve University, Cleveland, OH, 44106, United States
| | - Jing Liu
- Department of Pediatrics, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Xiaojing Kuang
- School of Basic Medicine, Qingdao University, Qingdao, 266021, Shandong, China
| | - Haizhu Xie
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Peiyou Gong
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Yinghong Shi
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Ning Mao
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Yongtao Wang
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Ming Liu
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Chao Ran
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Chenchen Wang
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Xiaoni Wang
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Min Li
- Department of Radiology, Yantai Traditional Chinese Medicine Hospital, Yantai, 264000, Shandong, China
| | - Wei Zhang
- Department of Radiology, Yantai Penglai People's Hospital, Yantai, 265600, Shandong, China
| | - Zishuo Fang
- School of Electronic Science and Engineering, University of Electronic Science and Technology of China, Chengdu, 610000, China
| | - Wanchen Liu
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Hao Guo
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Heng Ma
- Department of Radiology, Yantai Yuhuangding Hospital, Qingdao University School of Medicine, Yantai, 264000, Shandong, China
| | - Yang Song
- Department of Nutrition and Food Hygiene, School of Public Health, College of Medicine, Qingdao University, Qingdao, 266021, Shandong, China
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Richburg CE, Pesavento CM, Vastardis A, Antunez AG, Gavrila V, Cuttitta A, Nathan H, Byrnes ME, Dossett LA. Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study. J Surg Res 2024; 293:28-36. [PMID: 37703701 DOI: 10.1016/j.jss.2023.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/10/2023] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts. METHODS We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD). RESULTS Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (TICD Social, Political, and Legal Factors), (2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and (3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers. CONCLUSIONS Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.
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Affiliation(s)
- Caroline E Richburg
- University of Michigan Medical School, Ann Arbor, Michigan; National Institute of Health Short-Term Biomedical Research Training Program, Bethesda, Maryland
| | - Cecilia M Pesavento
- University of Michigan Medical School, Ann Arbor, Michigan; National Institute of Health Short-Term Biomedical Research Training Program, Bethesda, Maryland
| | - Andrew Vastardis
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Alexis G Antunez
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Valerie Gavrila
- University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Anthony Cuttitta
- University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Mary E Byrnes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan.
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Chirinos Muñoz MS, Orrego C, Montoya C, Sunol R. Relationship between adverse events prevalence, patient safety culture and patient safety perception in a single sample of patients: a cross-sectional and correlational study. BMJ Open 2023; 13:e060695. [PMID: 37620259 PMCID: PMC10450132 DOI: 10.1136/bmjopen-2021-060695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/24/2023] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVE To assess the relationship between adverse events prevalence (AEP), patient safety culture (PSC) and patient safety perception (PSP). DESIGN Cross-sectional, ex post facto comparative study on a single sample of patients. SETTING Four medium-high-level hospitals were included in the study-two public and two private from Zulia State in Venezuela. PARTICIPANTS 556 medical records and patients were studied for the prevalence and PSP study, and 397 of the healthcare providers involved in the care of these patients were surveyed for the PSC study, at two public and two private hospitals. OUTCOME MEASUREMENT The primary outcome of this study was the association between AEP, PSC and PSP, and according to hospital funding type, private and public. RESULTS An inverse association was observed between AEP and its severity and Patient Safety Culture Index (rho=-0.8, p=0.5) (95% CI 0.26-0.10) and Patient Safety Perception Index (rho=-0.6, p=0.18) (95% CI 0.10-0.28), which were protective factors for patient safety. No association was identified between PSC and PSP (rho=0.0001). No statistical differences were identified by hospital type (p=0.93) (95% CI 0.70-1.2). CONCLUSIONS The analysis of the variable correlations studied (AEP, PSC and PSP) within the same sample offers an interesting and useful perspective. In this sample, although no correlation was observed between the three variables as an interacting set, some correlation patterns were observed between pairs of variables that could guide further studies.
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Affiliation(s)
- Mónica Susana Chirinos Muñoz
- Health Sector Administration Program, University of Zulia, Maracaibo, Zulia, Bolivarian Republic of Venezuela
- Doctorate, Autonomous University of Barcelona, Barcelona, Spain
- Scientific and Humanistic Development Council of the University of Zulia, University of Zulia, Maracaibo, Zulia, Bolivarian Republic of Venezuela
| | - Carola Orrego
- Avedis Donabedian Research Institute (FAD) - Universitat Autonoma de Barcelona, Barcelona, Spain
- RICAPPS, Network for Research on Chronicity, Primary Care, and Health Promotion, Barcelona, Spain
| | - Cesar Montoya
- Data Analysis Center, Rafael Belloso Chacin University, Maracaibo, Zulia, Bolivarian Republic of Venezuela
| | - Rosa Sunol
- Avedis Donabedian Research Institute (FAD) - Universitat Autonoma de Barcelona, Barcelona, Spain
- RICAPPS, Network for Research on Chronicity, Primary Care, and Health Promotion, Barcelona, Spain
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Podolsky E, Hudek N, McCudden C, Presseau J, Yanikomeroglu S, Brouwers M, Brehaut JC. Choosing which in-hospital laboratory tests to target for intervention: a scoping review. Clin Chem Lab Med 2023; 61:388-401. [PMID: 36410390 PMCID: PMC9876731 DOI: 10.1515/cclm-2022-0910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Some laboratory testing practices may be of low value, leading to wasted resources and potential patient harm. Our scoping review investigated factors and processes that developers report using to inform decisions about what tests to target for practice improvement. METHODS We searched Medline on May 30th, 2019 and June 28th, 2021 and included guidelines, recommendation statements, or empirical studies related to test ordering practices. Studies were included if they were conducted in a tertiary care setting, reported making a choice about a specific test requiring intervention, and reported at least one factor informing that choice. We extracted descriptive details, tests chosen, processes used to make the choice, and factors guiding test choice. RESULTS From 114 eligible studies, we identified 30 factors related to test choice including clinical value, cost, prevalence of test, quality of test, and actionability of test results. We identified nine different processes used to inform decisions regarding where to spend intervention resources. CONCLUSIONS Intervention developers face difficult choices when deciding where to put scarce resources intended to improve test utilization. Factors and processes identified here can be used to inform a framework to help intervention developers make choices relevant to improving testing practices.
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Affiliation(s)
- Eyal Podolsky
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Natasha Hudek
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christopher McCudden
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada,Division of Biochemistry, Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada,Eastern Ontario Regional Laboratory Association, Ottawa, ON, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sezgi Yanikomeroglu
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Melissa Brouwers
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jamie C. Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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Lof P, Engelhardt EG, van Gent MDJM, Mom CH, Rosier-van Dunné FMF, van Baal WM, Verhoeve HR, Hermsen BBJ, Verbruggen MB, Hemelaar M, van de Swaluw JMG, Knipscheer HC, Huirne JAF, Westenberg SM, van Driel WJ, Bleiker EMA, Amant F, Lok CAR. Psychological impact of referral to an oncology hospital on patients with an ovarian mass. Int J Gynecol Cancer 2022; 33:ijgc-2022-003753. [PMID: 36600495 DOI: 10.1136/ijgc-2022-003753] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES In patients with an ovarian mass, a risk of malignancy assessment is used to decide whether referral to an oncology hospital is indicated. Risk assessment strategies do not perform optimally, resulting in either referral of patients with a benign mass or patients with a malignant mass not being referred. This process may affect the psychological well-being of patients. We evaluated cancer-specific distress during work-up for an ovarian mass, and patients' perceptions during work-up, referral, and treatment. METHODS Patients with an ovarian mass scheduled for surgery were enrolled. Using questionnaires we measured (1) cancer-specific distress using the cancer worry scale, (2) patients' preferences regarding referral (evaluated pre-operatively), and (3) patients' experiences with work-up and treatment (evaluated post-operatively). A cancer worry scale score of ≥14 was considered as clinically significant cancer-specific distress. RESULTS A total of 417 patients were included, of whom 220 (53%) were treated at a general hospital and 197 (47%) at an oncology hospital. Overall, 57% had a cancer worry scale score of ≥14 and this was higher in referred patients (69%) than in patients treated at a general hospital (43%). 53% of the patients stated that the cancer risk should not be higher than 25% to undergo surgery at a general hospital. 96% of all patients were satisfied with the overall work-up and treatment. No difference in satisfaction was observed between patients correctly (not) referred and patients incorrectly (not) referred. CONCLUSIONS Relatively many patients with an ovarian mass experienced high cancer-specific distress during work-up. Nevertheless, patients were satisfied with the treatment, regardless of the final diagnosis and the location of treatment. Moreover, patients preferred to be referred even if there was only a relatively low probability of having ovarian cancer. Patients' preferences should be taken into account when deciding on optimal cut-offs for risk assessment strategies.
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Affiliation(s)
- Pien Lof
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Ellen G Engelhardt
- Division of Psychological Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Mignon D J M van Gent
- Department of Gynecologic Oncology, Amsterdam University Medical Center, location Academic Medical Center, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Constantijne H Mom
- Department of Gynecologic Oncology, Amsterdam University Medical Center, location Academic Medical Center, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | | | | | | | | | | | - Majoie Hemelaar
- Department of Gynecology, Dijklander Hospital, Hoorn and Purmerend, The Netherlands
| | | | - Haye C Knipscheer
- Department of Gynecology, Spaarne Hospital, Haarlem and Hoofddorp, The Netherlands
| | - Judith A F Huirne
- Department of Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Willemien J van Driel
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Eveline M A Bleiker
- Division of Psychological Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Frédéric Amant
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
- Department of Gynecologic Oncology, UZ Leuven, Leuven, Belgium
| | - Christianne A R Lok
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
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Barriers to reducing preoperative testing for low-risk surgical procedures: A qualitative assessment guided by the Theoretical Domains Framework. PLoS One 2022; 17:e0278549. [PMID: 36480568 PMCID: PMC9731462 DOI: 10.1371/journal.pone.0278549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/02/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. AIM Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. METHOD We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. RESULTS We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years' experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. CONCLUSION These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.
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Is there variation in utilization of preoperative tests among patients undergoing total hip and knee replacement in the US, and does it affect outcomes? A population-based analysis. BMC Musculoskelet Disord 2022; 23:972. [PMID: 36357880 PMCID: PMC9647906 DOI: 10.1186/s12891-022-05945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Study objective To describe recent practice patterns of preoperative tests and to examine their association with 90-day all-cause readmissions and length of stay. Design Retrospective cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS). Setting SPARCS from March 1, 2016, to July 1, 2017. Participants Adults undergoing Total Hip Replacement (THR) or Total Knee Replacement (TKR) had a preoperative screening outpatient visit within two months before their surgery. Interventions Electrocardiogram (EKG), chest X-ray, and seven preoperative laboratory tests (RBCs antibody screen, Prothrombin time (PT) and Thromboplastin time, Metabolic Panel, Complete Blood Count (CBC), Methicillin Resistance Staphylococcus Aureus (MRSA) Nasal DNA probe, Urinalysis, Urine culture) were identified. Primary and secondary outcome measures Regression analyses were utilized to determine the association between each preoperative test and two postoperative outcomes (90-day all-cause readmission and length of stay). Regression models adjusted for hospital-level random effects, patient demographics, insurance, hospital TKR, THR surgical volume, and comorbidities. Sensitivity analysis was conducted using the subset of patients with no comorbidities. Results Fifty-five thousand ninety-nine patients (60% Female, mean age 66.1+/− 9.8 SD) were included. The most common tests were metabolic panel (74.5%), CBC (66.8%), and RBC antibody screen (58.8%). The least common tests were MRSA Nasal DNA probe (13.0%), EKG (11.7%), urine culture (10.7%), and chest X-ray (7.9%). Carrying out MRSA testing, urine culture, and EKG was associated with a lower likelihood of 90-day all-cause readmissions. The length of hospital stay was not associated with carrying out any preoperative tests. Results were similar in the subset with no comorbidities. Conclusions Wide variation exists in preoperative tests before THR and TKR. We identified three preoperative tests that may play a role in reducing readmissions. Further investigation is needed to evaluate these findings using more granular clinical data. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05945-y.
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Affiliation(s)
- Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anthony L Edelman
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shannon M Ruzycki
- Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Admass BA, Ego BY, Tawye HY, Ahmed SA. Preoperative investigations for elective surgical patients in a resource limited setting: Systematic review. Ann Med Surg (Lond) 2022; 82:104777. [PMID: 36268455 PMCID: PMC9577970 DOI: 10.1016/j.amsu.2022.104777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Methods Results Conclusion Ordering preoperative investigation is a common practice. Routine laboratory tests has significant burden on health care costs. Preoperative tests should be guided by the patient's clinical history, co-morbidities, and physical examination. Ordering preoperative investigations based on recommendation of guidelines is very essential.
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Trabelsi B, Ben Taleb I, Trifa M, Ben Ali M. Systematic preoperative tests prescription in elective surgery: it's high time to appraise! LA TUNISIE MEDICALE 2022; 100:541-546. [PMID: 36571743 PMCID: PMC9703908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The prescription of preoperative complementary tests aims to decrease morbidity and mortality associated to the perioperative period. AIM To assess the practice and the financial cost of the systematic prescription of preoperative tests. METHODS This was a retrospective study including all patients older than three years, scheduled for elective surgery from November 2018 to January 2019. Two attendings analyzed the data collected during the pre-anesthetic assessment and evaluated the usefulness of the ordered preoperative tests. The overall cost of prescribed preoperative tests and the cost generated by inappropriate prescriptions were also estimated. RESULTS This study included 1006 patients. The average age was 46.9 ± 22.05 years old. Five hundred and twenty three of them (51.98%) have no medical history. Among the planned procedures, 6.46% had an intermediate or major bleeding risk. Preoperative prescriptions were ordered by surgeons in 99% of cases. Prescriptions were justifiable in only 9.42% of cases. Abnormal findings were noted in 4.98% of the patients. The total cost was almost 80992 Dinars (≈ 24543 €). Complying the guidelines would save 70245 Dinars (≈ 21286 €) during the three months' study. CONCLUSION The routine prescription of preoperative complementary tests results in a significant additional economic cost. Developing national guidelines would change this attitude of unnecessary prescription.
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Affiliation(s)
- Becem Trabelsi
- 1. Service d’Anesthésie et de Réanimation de l’Hôpital Universitaire Mohamed Tahar Maamouri de Nabeul / Université Tunis El Manar, Faculté de Médecine de Tunis
| | - Ibtissem Ben Taleb
- 1. Service d’Anesthésie et de Réanimation de l’Hôpital Universitaire Mohamed Tahar Maamouri de Nabeul / Université Tunis El Manar, Faculté de Médecine de Tunis
| | - Mehdi Trifa
- 2. Service d’Anesthésie et de Réanimation de l’Hôpital d’Enfants Béchir Hamza de Tunis / Université Tunis El Manar, Faculté de Médecine de Tunis
| | - Mechaal Ben Ali
- 1. Service d’Anesthésie et de Réanimation de l’Hôpital Universitaire Mohamed Tahar Maamouri de Nabeul / Université Tunis El Manar, Faculté de Médecine de Tunis
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Assessment of Clinical Diagnostic Efficacy of Pulmonary Function Test Based on DBN-SVM of Pediatric Asthma and Cough Variant Asthma. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:1182114. [PMID: 35401730 PMCID: PMC8989593 DOI: 10.1155/2022/1182114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/04/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022]
Abstract
The diagnosis of asthma depends on the unprejudiced proof of the varying airflow obstruction. The pulmonary function tests are carried out to evaluate the clinical value of different types of respiratory diseases in children or infants. This study is focused on the clinical evaluation of the pulmonary function tests in the diagnosis of pediatric asthma and cough variant asthma. A differential diagnosis method for chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap with complementary diagnostic value is proposed. For the pulmonary function tests, the COPD gene dataset was selected and feature selection was performed using the DBN-SVM scoring method. For analysis and comparison, the differential diagnosis models were built using ROC curves for the accuracy of the deep belief network model and the support vector machine model. The sensitive features associated with COPD and ACO classification using the deep belief network model were found to be in good agreement with known clinical diagnostic strategies. The clinical diagnosis tests for pulmonary pediatric asthma and cough variant asthma were conducted on two groups of children, with both groups containing a basis of comparison. 80 cases of pediatric asthma and cough variant asthma were admitted from 2013 to 2014 and 80 cases of children with a healthy physical examination. The results of the two groups were compared. The results showed that the levels of FEV1, PEF, and FVC were significantly lower (P < 0.05), in healthy children, and FEV1/FVC%, RV, and RV/TCL% were significantly higher (P < 0.05) in children with asthma and cough variant asthma during acute exacerbation and chronic persistence. There were no statistically significant differences in the duration of clinical remission (P > 0.05). Thus, the study suggests that confirmed cases of the diagnosis of pediatric asthma and cough variant asthma by pulmonary function tests were significantly higher than those of conventional tests (P < 0.05). From this study, we can conclude that pulmonary function tests can accurately diagnose pediatric asthma and cough variant asthma, and also accurately reflect the development of the child's disease, which is of high clinical value.
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Keeney E, Memtsa M, Goodhart V, Jurkovic D, Ambler G, Khan N, Round J. An observational cohort study of health outcomes and costs associated with early pregnancy assessment units in the UK. BMC Health Serv Res 2022; 22:319. [PMID: 35264163 PMCID: PMC8905996 DOI: 10.1186/s12913-022-07709-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/18/2022] [Indexed: 11/14/2022] Open
Abstract
Background The objective of this study was to assess the impact of consultant presence, volume of patients seen and weekend opening on the health and cost-related outcomes associated with different Early Pregnancy Assessment Unit (EPAU) configurations. Methods This was an observational study with a prospective cohort design. Six thousand six hundred six pregnant women (16 years of age and over) attending EPAUs because of suspected early pregnancy complications were recruited from 44 EPAUs across the UK. The main outcome measures were quality of life, costs, and anxiety. Results Costs, quality of life and anxiety scores were similar across configurations with little evidence to suggest an impact of consultant presence, weekend opening or volume of patients seen. Mean overall costs varied from £92 (95% CI £85 - £98) for a diagnosis of normally developing pregnancy to £1793 (95% CI £1346 - £2240) for a molar pregnancy. EQ-5D-5L score increased from 0.85 (95% CI 0.84–0.86) at baseline to 0.91 (95% CI 0.90–0.92) at 4 weeks for the 573 women who completed questionnaires at both time points, largely due to improvements in the pain/discomfort and anxiety/depression dimensions. 78% of women reported a decrease in their anxiety score immediately following their EPAU appointment. Conclusions EPAU configuration, as specified in this study, had limited impact on any of the outcomes examined. However, it is clear that care provided in the EPAU has a positive overall effect on women’s health and emotional wellbeing, with significant improvements in EQ-5D and anxiety shown following an EPAU visit. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07709-9.
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Affiliation(s)
- Edna Keeney
- Health Economics Bristol, Population Health Sciences, University of Bristol, Bristol, UK.
| | - Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Nazim Khan
- Modelling and Analytical Systems Solutions Ltd, Edinburgh, UK
| | - Jeff Round
- Institute of Health Economics, Edmonton, Alberta, Canada.,Faculty of Medicine and Dentistry, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Shahid R, Chaya M, Lutz I, Taylor B, Xiao L, Groot G. Exploration of a quality improvement process to standardised preoperative tests for a surgical procedure to reduce waste. BMJ Open Qual 2021; 10:bmjoq-2021-001570. [PMID: 34580084 PMCID: PMC8477314 DOI: 10.1136/bmjoq-2021-001570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/16/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Preoperative tests are done to determine a patient's fitness for anaesthesia and surgery. LOCAL PROBLEM Although routine tests before surgery in the absence of specific clinical indications are not recommended, we observed high volumes of routine preoperative tests were performed in our institution. We describe a process to implement a standardised preoperative investigational approach to reduce unnecessary testing before surgeries. METHODS A series of six Plan-Do-Study-Act (PDSA) cycles was conducted for root cause analysis and process mapping, development of standardised tool (GRID), collection of baseline data, education and feedback, pilot testing and implementation and uptake of GRID.Root cause analysis revealed a lack of awareness of guidelines and a lack of a standardised tool to guide preoperative testing. We undertook a pilot quality improvement project to reduce unnecessary testing before knee and hip arthroplasty by developing and implementing a standardised tool (GRID) and engaging all stakeholders. INTERVENTIONS A clinical development team (CDT) was formed, including all the stakeholders. Our CDT focused on a continuous rapid cycle improvement strategy. RESULTS After implementation of the tool in a subgroup of patients undergoing elective hip or knee arthroplasty, unnecessary coagulation tests (activated partial thromboplastin time and the international normalised ratio), electrolyte/renal panel tests and electrocardiograms were reduced by 81% (91%-17%), 81% (41%-7%) and 68% (35%-11%), respectively. No surgery was delayed or cancelled due to tests not performed before surgery. CONCLUSIONS A standardised preoperative investigational approach based on patients' medical conditions rather than routine testing can reduce unnecessary tests before surgery. Further, implementing guidelines is more complex than developing guidelines. Hence, continuous PDSA cycles are essential to evaluate the processes in a quality improvement project. It can take time to build teams and have shared goals; however, once this is achieved, the success of a quality improvement project is certain.
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Affiliation(s)
- Rabia Shahid
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Malone Chaya
- Department of Anesthesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ian Lutz
- Department of Orthopedic, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brian Taylor
- Department of Anesthesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lily Xiao
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Groot
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Romero RJ, Martinez-Mier G, Ayala-García MA, Beristain-Hernández JL, Chan-Nuñez LC, Chapa-Azuela O, Dominguez-Rosado I, Flores-Villalba E, Fuentes-Orozco C, García-Covarrubias L, González-Ojeda A, Herrera-Hernández MF, Martinez-Ordaz JL, Medina-Franco H, Mercado MA, Montalvo-Jave E, Nuño-Guzmán CM, Torices-Escalante E, Torres-Villalobos GM, Vilatoba-Chapa M, Zamora-Godinez J, Zapata-Chavira H, Zerrweck-Lopez C. Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico. HPB (Oxford) 2021; 23:685-699. [PMID: 33071151 DOI: 10.1016/j.hpb.2020.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/16/2020] [Accepted: 09/25/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Rey Jesus Romero
- Department of Bariatric & Metabolic Surgery, Spanish Hospital of Veracruz, 16 de Septiembre 955 Col. Centro, 91700, Veracruz, Ver., Mexico.
| | - Gustavo Martinez-Mier
- Department of Hepato-Biliary Surgery & Transplantation, High Speciality Medical Unit 14, Mexican Institute of Social Security, Cuahutémoc Col. Formando Hogar, 91810, Veracruz, Ver., Mexico
| | - Marco A Ayala-García
- Department of Surgery & Research, General Hospital Zone 58, Mexican Institute of Social Security, Boulevard Jorge Vértiz Campero 1949 Col, San Miguel de Rentería, 37238, León, Gto., Mexico
| | - Jose Luis Beristain-Hernández
- Department of Hepato-Biliary Surgery, National Medical Center "Antonio Fraga Mouret, La Raza", Seris y Zaachila Col. La Raza, 02990, Mexico City, Mexico
| | - Luis Carlos Chan-Nuñez
- Department of Hepato-Biliary Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Oscar Chapa-Azuela
- Department of Hepato-Pancreato-Biliary Surgery, General Hospital of Mexico "Dr. Eduardo Liceaga", Dr. Balmis 148 Col. Doctores, 06720, Mexico City, Mexico
| | - Ismael Dominguez-Rosado
- Department of Hepato-Biliary Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Eduardo Flores-Villalba
- Department of Hepato-Biliary Surgery & Transplantation, Zambrano Hellion Medical Center Monterrey Institute of Technology and Higher Education, Batallón de San Patricio 112 Col. Real San Agustín, 66278, San Pedro Garza García, N.L., Mexico
| | - Clotilde Fuentes-Orozco
- Department of Surgery & Research, Western National Medical Center, Mexican Institute of Social Security, Belisario Dominguez 1000 Col. Belisario Dominguez, 44329, Guadalajara, Jal., Mexico
| | - Luis García-Covarrubias
- Department of Transplantation, General Hospital of Mexico "Dr. Eduardo Liceaga", Dr. Balmis 148 Col. Doctores, 06720, Mexico City, Mexico
| | - Alejandro González-Ojeda
- Department of Surgery & Research, Western National Medical Center, Mexican Institute of Social Security, Belisario Dominguez 1000 Col. Belisario Dominguez, 44329, Guadalajara, Jal., Mexico
| | - Miguel Francisco Herrera-Hernández
- Department of Endocrine Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - José Luis Martinez-Ordaz
- Department of Surgery, XXI Century National Medical Center, Mexican Institute of Social Security, Av. Cuahutémoc 33 Col. Doctores, 06720, Mexico City, Mexico
| | - Heriberto Medina-Franco
- Department of Surgical Oncology, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Miguel Angel Mercado
- Department of Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Eduardo Montalvo-Jave
- Department of Hepato-Pancreato-Biliary Surgery, General Hospital of Mexico "Dr. Eduardo Liceaga", Dr. Balmis 148 Col. Doctores, 06720, Mexico City, Mexico
| | - Carlos Martine Nuño-Guzmán
- Department of Surgery, Civil Hospital "Fray Antonio Alcalde", Hospital 278 Col. El Retiro, 44280, Guadalajara, Jal., Mexico
| | - Eduardo Torices-Escalante
- Department of Gastrointestinal Endoscopy, Regional Hospital October 1st, Institute for Social Security and Services for State Workers, Av. Politécnico Nacional 1669 Col. Magdalena de las Salinas, 07300, Mexico City, Mexico
| | - Gonzalo Manuel Torres-Villalobos
- Department of Experimental Surgery & Minimally Invasive Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Mario Vilatoba-Chapa
- Department of Transplantation, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Jordán Zamora-Godinez
- Department of Surgery, General Hospital Zone 8, Mexican Institute of Social Security, Calle 18 de julio 214 Col. Periodistas, 42060, Pachuca, Hgo., Mexico
| | - Homero Zapata-Chavira
- Department of Surgery & Transplantation, University Hospital "Dr. José E. González", Av. Gonzalitos 235 Col. Mitras Centro, 64460, Monterrey, N.L., Mexico
| | - Carlos Zerrweck-Lopez
- Department of Bariatric & Metabolic Surgery, Tláhuac General Hospital, Av. La Turba 655 Col. Villa Centroamericana, 13250, Mexico City, Mexico
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Perioperative nursing principles guided by the concept of enhanced recovery after surgery†. FRONTIERS OF NURSING 2021. [DOI: 10.2478/fon-2021-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective
To explore the clinical effect of perioperative nursing guided by the concept of enhanced recovery after surgery and summarize them.
Methods
Pubmed, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, and VIP Database were searched to obtain the relevant literature involving enhanced recovery after surgery (ERAS) guidance, obtain the effective clinical data, review the reports in literature, and obtain the effective scheme.
Results
Compared with the traditional nursing program, perioperative nursing principles guided by the concept of ERAS provide more accurate nursing care to patients and reduce the occurrence of intraoperative stress events through comprehensive nursing measures such as preoperative pre-rehabilitation measures, intraoperative body temperature and fluid management, postoperative analgesia, prevention of nausea and vomiting, early mobilization, catheter nursing, and better out-of-hospital follow-up.
Conclusions
Perioperative nursing principles guided by the concept of ERAS can significantly reduce the incidence of perioperative complications, shorten the hospital stay of patients, and promote postoperative rehabilitation of patients. The transformation and implementation of this concept can bring significant benefits to hospitals, medical care, and patients.
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Memtsa M, Goodhart V, Ambler G, Brocklehurst P, Keeney E, Silverio S, Anastasiou Z, Round J, Khan N, Hall J, Barrett G, Bender-Atik R, Stephenson J, Jurkovic D. Variations in the organisation of and outcomes from Early Pregnancy Assessment Units: the VESPA mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background
Early pregnancy complications are common and account for the largest proportion of emergency work in gynaecology. Although early pregnancy assessment units operate in most UK acute hospitals, recent National Institute of Health and Care Excellence guidance emphasised the need for more research to identify configurations that provide the optimal balance between cost-effectiveness, clinical effectiveness and service- and patient-centred outcomes [National Institute for Health and Care Excellence (NICE). Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. URL: http://guidance.nice.org.uk/CG154 (accessed 23 March 2016)].
Objectives
The primary aim was to test the hypothesis that the rate of hospital admissions for early pregnancy complications is lower in early pregnancy assessment units with high consultant presence than in units with low consultant presence. The key secondary objectives were to assess the effect of increased consultant presence on other clinical outcomes, to explore patient satisfaction with the quality of care and to make evidence-based recommendations about the future configuration of UK early pregnancy assessment units.
Design
The Variations in the organisations of Early Pregnancy Assessment Units in the UK and their effects on clinical, Service and PAtient-centred outcomes (VESPA) study employed a multimethods approach and included a prospective cohort study of women attending early pregnancy assessment units to measure clinical outcomes, an economic evaluation, a patient satisfaction survey, qualitative interviews with service users, an early pregnancy assessment unit staff survey and a hospital emergency care audit.
Setting
The study was conducted in 44 early pregnancy assessment units across the UK.
Participants
Participants were pregnant women (aged ≥ 16 years) attending the early pregnancy assessment units or other hospital emergency services because of suspected early pregnancy complications. Staff members directly involved in providing early pregnancy care completed the staff survey.
Main outcome measure
Emergency hospital admissions as a proportion of women attending the participating early pregnancy assessment units.
Methods
Data sources – demographic and routine clinical data were collected from all women attending the early pregnancy assessment units. For women who provided consent to complete the questionnaires, clinical data and questionnaires were linked using the women’s study number. Data analysis and results reporting – the relationships between clinical outcomes and consultant presence, unit volume and weekend opening hours were investigated using appropriate regression models. Qualitative interviews with women, and patient and staff satisfaction, health economic and workforce analyses were also undertaken, accounting for consultant presence, unit volume and weekend opening hours.
Results
We collected clinical data from 6606 women. There was no evidence of an association between admission rate and consultant presence (p = 0.497). Health economic evaluation and workforce analysis data strands indicated that lower-volume units with no consultant presence were associated with lower costs than their alternatives.
Limitations
The relatively low level of direct consultant involvement could explain the lack of significant impact on quality of care. We were also unable to estimate the potential impact of factors such as scanning practices, level of supervision, quality of ultrasound equipment and clinical care pathway protocols.
Conclusions
We have shown that consultant presence in the early pregnancy assessment unit has no significant impact on key outcomes, such as the proportion of women admitted to hospital as an emergency, pregnancy of unknown location rates, ratio of new to follow-up visits, negative laparoscopy rate and patient satisfaction. All data strands indicate that low-volume units run by senior or specialist nurses and supported by sonographers and consultants may represent the optimal early pregnancy assessment unit configuration.
Future work
Our results show that further research is needed to assess the potential impact of enhanced clinical and ultrasound training on the performance of all disciplines working in early pregnancy assessment units.
Trial registration
Current Controlled Trials ISRCTN10728897.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sergio Silverio
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
- Department of Women and Children’s Health, King’s College London, St Thomas’ Hospital, London, UK
| | | | - Jeff Round
- Institute of Health Economics, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nazim Khan
- Modelling and Analytical Systems Solutions Ltd, Edinburgh, UK
| | - Jennifer Hall
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | | | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
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Jones S, Achuthan R, Ooi S, Kim B. Audit of routine preoperative blood test requests for patients undergoing elective breast surgery: Less is more. J Perioper Pract 2020; 31:379-385. [PMID: 32981455 DOI: 10.1177/1750458920952755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 2016, the National Institute for Health and Care Excellence updated guidelines on preoperative blood tests for elective surgery; with failure of adherence having implications for both patients and healthcare providers. A local audit was performed on 919 patients undergoing elective breast surgery that determined compliance and the financial implications of performing inappropriate preoperative blood tests against the National Institute for Health and Care Excellence guideline. Initial findings of an unacceptable quantity of inappropriate blood tests led to the education of the pre-assessment clinic staff regarding the guidelines along with the development of a poster to guide the ordering of appropriate tests. A re-audit of 451 patients assessed impact of interventions which resulted in a significant reduction in the number of blood tests requested with a 71% reduction in financial expenditure. The blood tests considered inappropriate in both the initial and re-audit did not add any relevant clinical information and abnormal results did not alter the clinical course of the patient.
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Affiliation(s)
- Stacey Jones
- Department of Oncoplastic Breast and Reconstructive Surgery, St James's University Hospital, Leeds, UK
| | - Rajgopal Achuthan
- Department of Oncoplastic Breast and Reconstructive Surgery, St James's University Hospital, Leeds, UK
| | - Shiwei Ooi
- School of Medicine, University of Leeds, Leeds, UK
| | - Baek Kim
- Department of Oncoplastic Breast and Reconstructive Surgery, St James's University Hospital, Leeds, UK
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Kaur TS, Chatterjee BP. "Too much information with little meaning," relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review. Natl J Maxillofac Surg 2020; 11:3-9. [PMID: 33041569 PMCID: PMC7518500 DOI: 10.4103/njms.njms_60_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/12/2019] [Accepted: 02/02/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Taranjit S Kaur
- Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Jamnagar, Gujarat, India
| | - Bijoya P Chatterjee
- Department of Biochemistry, M. P. Shah Government Medical College, Guru Gobind Singh Government Hospital, Jamnagar, Gujarat, India
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The Role of Laparoscopic Ultrasonography in the Evaluation of Suspected Choledocholithiasis. A Single-Center Experience. MEDICINA-LITHUANIA 2020; 56:medicina56050246. [PMID: 32443814 PMCID: PMC7279262 DOI: 10.3390/medicina56050246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/02/2022]
Abstract
Background and objectives: Opinions differ regarding the optimal diagnostic methods for patients with suspected choledocholithiasis. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) and compare it to pre-operative magnetic resonance cholangio-pancreatography (MRCP); Materials and Methods: In all patients with suspected choledocholithiasis LUS was performed during laparoscopic cholecystectomy to evaluate biliary stones. According to availability, part of the patients had pre-operative MRCP. Data for diagnostic accuracy and main outcomes were collected prospectively and analyzed retrospectively; Results: Choledocholithiasis was detected in 178 of 297 patients by LUS (59.93%) and in 39 of 87 patients by MRCP (44.8%), p = 0.041. LUS yielded a sensitivity of 99.4%, a specificity of 94.3%, a positive predictive value of 96.1% and a negative predictive value of 99.1%. However, pre-operative MRCP had a sensitivity of 61.7%, a specificity of 92.3%, a positive predictive value of 94.9% and a negative predictive value of 51.1%. Moreover, of the 47 patients with no choledocholithiasis by MRCP, in 23 cases it was later detected by LUS (a false negative MRCP finding—38.3%), p < 0.001. Median duration of hospitalization was significantly shorter in patients evaluated without pre-operative MRCP—8 days (interquartile range – IQR 11–6) vs. 11 days (IQR 14–9), p = 0.001; Conclusions: LUS may reduce the role of pre-operative MRCP and can become a rational alternative to MRCP as a primary imaging technique for the detection of choledocholithiasis.
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Pike A, Mahoney K, Patey AM, Inwood S, Mortazhejri S, Lawrence R, Hall A. Protocol for assessing the determinants of preoperative test-ordering behaviour for low-risk surgical procedures using a theoretically driven, qualitative design. BMJ Open 2020; 10:e036511. [PMID: 32398338 PMCID: PMC7223279 DOI: 10.1136/bmjopen-2019-036511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Current evidence suggests that preoperative tests such as chest X-rays, electrocardiograms and baseline laboratory studies may not be useful for healthy patients undergoing low-risk surgical procedures. Routine preoperative testing for healthy patients having low-risk surgery is not a scientifically sound practice. In this study, we will interview healthcare providers working at medical facilities where low-risk surgical procedures are carried out. This will allow us to gain insight into the determinants of preoperative testing behaviours for healthy patients undergoing low-risk surgeries and their barriers and enablers to guideline adherence. METHODS AND ANALYSIS We will use semistructured interviews with anaesthesiologists, surgeons and preadmission clinic nurses to assess the determinants of preoperative testing behaviours. The interview guide was designed around the Theoretical Domains Framework (TDF), developed specifically to determine the barriers and enablers to implementing evidence-based guidelines. Interviews will be audio-recorded, transcribed verbatim and coded according to the TDF. Key themes will be generated for each of the identified domains. ETHICS AND DISSEMINATION We have received ethics approval from the Health Research Ethics Board in Newfoundland and Labrador (HREB #2018.190) for this study. The results of this work will be disseminated through a peer-reviewed publication, presentation at a healthcare forum and plain-language infographic summaries. Additionally, deidentified data collected and analysed for this study will be available for review from the corresponding author on reasonable request.
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Affiliation(s)
- Andrea Pike
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Krista Mahoney
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Samantha Inwood
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Sameh Mortazhejri
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rebecca Lawrence
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Dorsett M, Cooper RJ, Taira BR, Wilkes E, Hoffman JR. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019; 37:240-245. [PMID: 31874920 DOI: 10.1136/emermed-2019-209031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Maia Dorsett
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Richelle J Cooper
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Breena R Taira
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Erin Wilkes
- Kaiser Permanente LAMC, Los Angeles, California, USA
| | - Jerome R Hoffman
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
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Guttikonda N, Nileshwar A, Rao M, Sushma TK. Preoperative laboratory testing - Comparison of National Institute of Clinical Excellence guidelines with current practice - An observational study. J Anaesthesiol Clin Pharmacol 2019; 35:227-230. [PMID: 31303713 PMCID: PMC6598565 DOI: 10.4103/joacp.joacp_342_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Preoperative laboratory testing is done to detect abnormalities in the body not detected by clinical examination. Often a battery of tests is advocated as a routine for patients scheduled for low or intermediate risk surgery. This prospective observational study was aimed to assess agreement of the current practice of preoperative laboratory investigations with the National Institute of Clinical Excellence (NICE) guidelines, and the impact of investigations on patient care and costs. Material and Methods: The study was conducted at a tertiary referral center on 385 patients aged 18-70 years of either gender, posted for elective general surgical, gynaecological or otolaryngological surgery. Sixteen investigations were examined: hemogram, blood urea, serum creatinine, serum electrolytes, coagulation profile, urinalysis, thyroid function tests, electrocardiogram, echocardiogram, chest x-ray, pulmonary function tests, blood sugar, glycosylated hemoglobin, liver function tests, treadmill test and coronary angiogram. The history and physical examination were reviewed to examine for indication for these laboratory investigations. These were compared with NICE guidelines. Impact of these investigations on anesthetic decision-making was noted. Results: There was almost no agreement of the current practice with the NICE guidelines. The total cost of all tests obtained was Rs 5,48,755. Total additional cost of unindicated tests was Rs 5,10,730 (93%). Average amount spent on additional investigations per patient was Rs 1326.57. Conclusion: Most investigations are overprescribed and have minimal agreement with NICE guidelines. None of the tests had any impact on clinical care. Nearly a million rupees is incurred per year in one referral hospital alone, when NICE guidelines are not followed.
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Affiliation(s)
- Neeraj Guttikonda
- Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Anitha Nileshwar
- Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Madhu Rao
- Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - T K Sushma
- Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
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Haughton B, Haughton J, George Norman J, Navid A, Allport K, Andrews M, Mannan K, Livesey J. Routine monitoring for heparin-induced thrombocytopenia following lower limb arthroplasty: Is it necessary? A prospective study in a UK district general hospital. Orthop Traumatol Surg Res 2019; 105:497-501. [PMID: 30878232 DOI: 10.1016/j.otsr.2018.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/10/2018] [Accepted: 12/17/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is a potentially life-threatening condition associated with heparin administration. Many orthopaedic units routinely prescribe low-molecular-weight heparins as thromboprophylaxis after hip and knee arthroplasty. HYPOTHESIS We postulated that routine platelet monitoring following heparin administration is of no clinical benefit. We therefore asked: firstly, what was the rate of thrombocytopenia in a large population of patients undergoing lower limb arthroplasty? Secondly, did this rate justify routine platelet monitoring? MATERIALS AND METHODS Unless contraindicated, all patients (n=1999, 53.05% female, mean age 69.23 years) at a UK district general hospital undergoing hip and knee arthroplasty were given daily prophylactic enoxaparin. Platelet counts were obtained between the 8th and 10th postoperative days and compared to preoperative baseline. A > 50% fall in platelet count was classified as "possible HIT". The minimal acceptable risk of thrombocytopenia was defined using The American College of Chest Physicians (ACCP) 2012 guidelines, which recommend monitoring platelet counts in patients receiving heparin where the expected risk of HIT is>1% and by descriptive cost-benefit analysis based on the cost of routine platelet monitoring in the clinical setting. RESULTS Complete results were available for 1361 (68.1%) patients, comprising: 653 primary hips, 22 revision hips, 1 hip resurfacing, 665 primary knees, 19 revision knees and 1 unicompartmental knee replacement. Mean platelet level was 281.9×109/L preoperatively and 527.83×109/L postoperatively. Forty-four patients (3.2%) experienced a postoperative fall in platelet levels. However, no patient experienced a drop in platelets to less than 50% of the preoperative value. DISCUSSION The incidence of HIT in the elective arthroplasty population is low. Therefore, routine postoperative monitoring of platelets is not necessary in this population of patients. LEVEL OF EVIDENCE II, prospective study.
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Affiliation(s)
- Benjamin Haughton
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Joanna Haughton
- The Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield, WF1 4DG, United Kingdom
| | - John George Norman
- Hull York Medical School, John Hughlings Jackson Building, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - Ahmad Navid
- Health Education England: West Midlands, St Chads Court, 213 Hagley Road, Edgbaston, Birmingham, B16 9RG, United Kingdom
| | - Kathy Allport
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Mark Andrews
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Ken Mannan
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Jonathan Livesey
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
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Nickel C, Segarra D, Padhya T, Mifsud M. The evidence-based preoperative assessment for the otolaryngologist. Laryngoscope 2019; 130:38-44. [PMID: 30702154 DOI: 10.1002/lary.27845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2019] [Indexed: 11/05/2022]
Abstract
There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient-centric, personalized, and often multidisciplinary approach. We present an up-to-date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope, 130:38-44, 2020.
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Affiliation(s)
- Christopher Nickel
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
| | - Daniel Segarra
- Morsani College of Medicine, University of South Florida, Tampa, Florida, U.S.A
| | - Tapan Padhya
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
| | - Matthew Mifsud
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
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Jokelainen J, Ismail S, Kylänpää L, Udd M, Mustonen H, Lindström O, Pöyhiä R. Effect And Predictive Value Of Routine Preoperative Laboratory Testing For Endoscopic Retrograde Cholangiopancreatography. Scand J Surg 2019; 109:115-120. [PMID: 30654725 DOI: 10.1177/1457496918822616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Several studies and guidelines are questioning routine preoperative laboratory tests in surgical and endoscopic procedures. Their effect in endoscopic retrograde cholangiopancreatography is not currently known. This study was carried out to evaluate the risk of adverse effects in endoscopic retrograde cholangiopancreatography and their association with preoperative lab tests. MATERIALS AND METHODS A single-center, prospective observational study on all 956 patients undergoing 1196 endoscopic retrograde cholangiopancreatographies in the Endoscopy Unit of Helsinki University Central Hospital from 1 March 2012 to 28 February 2013. Routine preoperative laboratory test results (basic blood count, creatinine, potassium, sodium, international normalized ratio/thromboplastin time, and amylase), health status, medication, and demographic information of all patients were analyzed in relation to adverse effects related to endoscopic retrograde cholangiopancreatography and procedural sedation. RESULTS Multivariate analysis showed post-endoscopic retrograde cholangiopancreatography pancreatitis (43 cases, 3.6%) to have no association with abnormal routine preoperative laboratory tests. Respiratory depression caused by sedation (128 cases, 11%) was not associated with abnormal routine preoperative laboratory tests, and anemia was found to be a slightly protecting factor. Cardiovascular depression caused by sedation was associated with thrombocytopenia (odds ratio = 1.87, p = 0.025) and, in male patients, hyponatremia (odds ratio = 3.66, p < 0.001). Incidence of other adverse effects was too low for statistical analysis. CONCLUSION Routine universal preoperative lab testing was not found to be successful in predicting adverse effects in endoscopic retrograde cholangiopancreatography procedures. Laboratory testing should be done focusing on each patient's individual needs.
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Affiliation(s)
- J Jokelainen
- University of Helsinki, Helsinki, Finland.,Department of Anesthesia and Intensive Care Medicine, South Karelia Central Hospital, Lappeenranta, Finland
| | - S Ismail
- University of Helsinki, Helsinki, Finland.,Department of Gastroenterological and General Surgery, Helsinki University Hospital, Helsinki, Finland
| | - L Kylänpää
- University of Helsinki, Helsinki, Finland.,Department of Gastroenterological and General Surgery, Helsinki University Hospital, Helsinki, Finland
| | - M Udd
- University of Helsinki, Helsinki, Finland.,Department of Gastroenterological and General Surgery, Helsinki University Hospital, Helsinki, Finland
| | - H Mustonen
- University of Helsinki, Helsinki, Finland.,Department of Gastroenterological and General Surgery, Helsinki University Hospital, Helsinki, Finland
| | - O Lindström
- University of Helsinki, Helsinki, Finland.,Department of Gastroenterological and General Surgery, Helsinki University Hospital, Helsinki, Finland
| | - R Pöyhiä
- University of Helsinki, Helsinki, Finland.,Kauniala Hospital, Kauniainen, Finland
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O'Sullivan J, Collins J, Cooper D, Magdalina A, Meehan F, Kumar L, Quinlan J, O'Connor D, Fitzpatrick G. Optimisation of perioperative investigations among elective orthopaedic patients in a Dublin-based teaching hospital. J Perioper Pract 2018; 29:291-299. [PMID: 30565523 DOI: 10.1177/1750458918813254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The current National Institute for Health and Care Excellence guidelines, in accordance with the Association of Anaesthetists of Great Britain and Ireland guidelines, recommend the following haematological investigations for all patients undergoing major elective surgery: full blood count, renal profile and coagulation screen if clinically indicated. However, the guidelines fail to specify a time-interval for which normal blood results remain valid. Currently all patients in Ireland undergoing substantial elective surgery requiring general or regional anaesthetic have a preoperative assessment prior to the surgery. Patients have phlebotomy performed as part of this assessment. Patients admitted for elective surgery often have these bloods repeated on the morning of surgery. Objectives To determine if blood investigations taken over a one-year period prior to surgery can be used as a baseline for clinically stable patients undergoing elective surgery. Study design and methods All consecutive day of surgery admission patients >18 years of age undergoing elective orthopaedic surgery in Tallaght Hospital between 1 December 2014 and 1 December 2015 were identified using hospital records. Their blood results in the one-year period prior to surgery were compared to the blood results on the morning of surgery, using a McNemar’s test. A further clinical analysis was performed. Results There was no statistically significant change between blood results from three months prior to the surgery and the morning of surgery (P < 0.05). Furthermore, the blood results remained largely unchanged in the one year prior to surgery. No patient had the operation deferred due to aberrant blood results, following previously normal results prior to surgery. The potential cost-saving of omitting bloods is enormous. Conclusions There appears to be neither a statistical nor clinical benefit to repeating blood tests on the morning of surgery, following normal bloods <3 months in a clinically stable individual.
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Affiliation(s)
- Jane O'Sullivan
- 1 Department of Anaesthetics, Letterkenny University Hospital, Letterkenny, Ireland.,2 Tallaght University Hospital, Dublin, Ireland
| | - Jack Collins
- 1 Department of Anaesthetics, Letterkenny University Hospital, Letterkenny, Ireland.,2 Tallaght University Hospital, Dublin, Ireland
| | - David Cooper
- 3 Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Ana Magdalina
- 4 Department of Statistics, University of Limerick, Limerick, Ireland
| | - Frances Meehan
- 5 Department of Anaesthetics, Tallaght University Hospital, Dublin, Ireland
| | - Lachmann Kumar
- 6 Department of Medicine, Tallaght University Hospital, Dublin, Ireland
| | - John Quinlan
- 7 Department of Orthopaedics, Tallaght University Hospital, Dublin, Ireland
| | - Donal O'Connor
- 3 Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Gerry Fitzpatrick
- 5 Department of Anaesthetics, Tallaght University Hospital, Dublin, Ireland
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Grieve R, Willis S, De Corte K, Sadique MZ, Hawkins N, Perra S, Pennington M, Turner J, Moore C, Wickenden C, Koppitz C, Cho G, Roberts DJ, Miflin G, Cairns JA. Options for possible changes to the blood donation service: health economics modelling. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundEvidence is required on the cost-effectiveness of alternative changes to the blood collection service.Objectives(1) To estimate the cost-effectiveness of alternative minimum interdonation intervals between whole-blood donations. (2) To investigate donors’ frequency of whole-blood donation according to alternative changes to the blood collection service. (3) To estimate the cost-effectiveness of alternative strategies for maintaining the supply of whole blood.MethodsWe undertook a within-trial cost-effectiveness analysis (CEA) of the INTERVAL trial, stated preference (SP) surveys to elicit donor preferences and a CEA of different strategies for blood collection. The strategies considered were reduced minimum intervals between whole-blood donations, introduction of a donor health report and changes to appointment availability and opening times at blood collection venues. The within-trial CEA included 44,863 donors, with men randomly assigned to 12- versus 10- versus 8-week interdonation intervals, and women to 16- versus 14- versus 12-week interdonation intervals. We undertook a SP survey of non-INTERVAL donors (100,000 invitees). We asked donors to state the frequency with which they would be willing to donate blood, according to the service attribute and level. The CEA compared changes to the blood service with current practice by combining the survey estimates with information from the NHS Blood and Transpant database (PULSE) and cost data. The target population was existing whole-blood donors in England, of whom approximately 85% currently donate whole blood at mobile (temporary) blood collection venues, with the remainder donating at static (permanent) blood collection centres. We reported the effects of the alternative strategies on the number of whole-blood donations, costs and cost-effectiveness.ResultsThe reduced donation interval strategies had higher deferral rates caused by low haemoglobin (Hb), but increased frequency of successful donation. For men in the 8- versus 12-week arm of the INTERVAL trial [Di Angelantonio E, Thompson SG, Kaptoge S, Moore C, Walker M, Armitage J,et al.Efficiency and safety of varying the frequency of whole blood donation (INTERVAL): a randomised trial of 45 000 donors.Lancet2017;390:2360–71], the Hb-related deferral rate was 5.7% per session versus 2.6% per session, but the average number of donations over 2 years increased by 1.71 (95% confidence interval 1.60 to 1.80). A total of 25,187 (25%) donors responded to the SP survey. For static donor centres, extending appointment availability to weekday evenings or weekends, or reduced intervals between blood donations, increased stated donation frequency by, on average, 0.5 donations per year. The CEA found that reducing the minimum interval, extending opening times to weekday evenings and extending opening times to weekends in all static donor centres would provide additional whole blood at a cost per additional unit of £10, £23 and £29, respectively, with similar results for donors with high-demand blood types.LimitationsThe study did not consider the long-term rates at which donors will leave the donation register, for example following higher rates of Hb-related deferral.ConclusionsExtending opening hours for blood donation to weekday evenings or weekends for all static donor centres are cost-effective ways of increasing the supply of high-demand blood types.Future workTo monitor the effects of new strategies on long-term donation frequency.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Willis
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kaat De Corte
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Hawkins
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Silvia Perra
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark Pennington
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Department of Health Services & Population Research, King’s College London, London, UK
| | - Jenny Turner
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Carmel Moore
- NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- INTERVAL Coordinating Centre, Department of Public Health and Primary Care, Cambridge, UK
| | | | | | - Gavin Cho
- NHS Blood and Transplant, London, UK
| | - David J Roberts
- NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- NHS Blood and Transplant, London, UK
- Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | | | - John A Cairns
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Garg R. Elderly patients for cancer surgeries: How much to investigate! J Anaesthesiol Clin Pharmacol 2018; 34:539-541. [PMID: 30774238 PMCID: PMC6360899 DOI: 10.4103/joacp.joacp_103_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
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Duddy C, Wong G. Explaining variations in test ordering in primary care: protocol for a realist review. BMJ Open 2018; 8:e023117. [PMID: 30209159 PMCID: PMC6144329 DOI: 10.1136/bmjopen-2018-023117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/29/2018] [Accepted: 08/10/2018] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself. METHODS AND ANALYSIS This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions. ETHICS AND DISSEMINATION Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients. PROSPERO REGISTRATION NUMBER CRD42018091986.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
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Mitchell K, Barletta M, Quandt J, Shepard M, Kleine S, Hofmeister E. Effect of routine pre-anesthetic laboratory screening on pre-operative anesthesia-related decision-making in healthy dogs. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2018; 59:773-778. [PMID: 30026626 PMCID: PMC6005072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The usefulness of pre-anesthetic laboratory screening of healthy veterinary patients is controversial and clear evidence-based guidelines do not exist. The purpose of our study was to determine the influence of preanesthetic laboratory screening on peri-anesthetic plans in canine patients undergoing elective surgery. One hundred medical records were randomly selected between the years 2008 and 2013 and patient information was presented to 5 Diplomates of the American College of Veterinary Anesthesia and Analgesia (ACVAA) for review. They were given pre-anesthetic laboratory screening test results for each patient and asked whether the results would change the way they managed the case from an anesthesia perspective. Peri-operative anesthetic management was altered in 79% of patients based on pre-anesthetic screening results; however, the overall agreement among anesthesiologists was weak with 64% of changes made by only a single anesthesiologist. Pre-anesthetic laboratory screening test results may influence pre-operative anesthesia case management but major discrepancies can occur among ACVAA diplomates.
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Affiliation(s)
- Krista Mitchell
- Department of Small Animal Medicine and Surgery (Mitchell, Quandt, Shepard, Kleine, Hofmeister), Large Animal Medicine (Barletta), College of Veterinary Medicine, University of Georgia, Athens, Georgia 30602, USA
| | - Michele Barletta
- Department of Small Animal Medicine and Surgery (Mitchell, Quandt, Shepard, Kleine, Hofmeister), Large Animal Medicine (Barletta), College of Veterinary Medicine, University of Georgia, Athens, Georgia 30602, USA
| | - Jane Quandt
- Department of Small Animal Medicine and Surgery (Mitchell, Quandt, Shepard, Kleine, Hofmeister), Large Animal Medicine (Barletta), College of Veterinary Medicine, University of Georgia, Athens, Georgia 30602, USA
| | - Molly Shepard
- Department of Small Animal Medicine and Surgery (Mitchell, Quandt, Shepard, Kleine, Hofmeister), Large Animal Medicine (Barletta), College of Veterinary Medicine, University of Georgia, Athens, Georgia 30602, USA
| | - Stephanie Kleine
- Department of Small Animal Medicine and Surgery (Mitchell, Quandt, Shepard, Kleine, Hofmeister), Large Animal Medicine (Barletta), College of Veterinary Medicine, University of Georgia, Athens, Georgia 30602, USA
| | - Erik Hofmeister
- Department of Small Animal Medicine and Surgery (Mitchell, Quandt, Shepard, Kleine, Hofmeister), Large Animal Medicine (Barletta), College of Veterinary Medicine, University of Georgia, Athens, Georgia 30602, USA
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Willis S, De Corte K, Cairns JA, Zia Sadique M, Hawkins N, Pennington M, Cho G, Roberts DJ, Miflin G, Grieve R. Cost-effectiveness of alternative changes to a national blood collection service. Transfus Med 2018; 29 Suppl 1:42-51. [PMID: 29767450 PMCID: PMC7379655 DOI: 10.1111/tme.12537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 12/04/2022]
Abstract
Objectives To evaluate the cost‐effectiveness of changing opening times, introducing a donor health report and reducing the minimum inter‐donation interval for donors attending static centres. Background Evidence is required about the effect of changes to the blood collection service on costs and the frequency of donation. Methods/Materials This study estimated the effect of changes to the blood collection service in England on the annual number of whole‐blood donations by current donors. We used donors' responses to a stated preference survey, donor registry data on donation frequency and deferral rates from the INTERVAL trial. Costs measured were those anticipated to differ between strategies. We reported the cost per additional unit of blood collected for each strategy versus current practice. Strategies with a cost per additional unit of whole blood less than £30 (an estimate of the current cost of collection) were judged likely to be cost‐effective. Results In static donor centres, extending opening times to evenings and weekends provided an additional unit of whole blood at a cost of £23 and £29, respectively. Introducing a health report cost £130 per additional unit of blood collected. Although the strategy of reducing the minimum inter‐donation interval had the lowest cost per additional unit of blood collected (£10), this increased the rate of deferrals due to low haemoglobin (Hb). Conclusion The introduction of a donor health report is unlikely to provide a sufficient increase in donation frequency to justify the additional costs. A more cost‐effective change is to extend opening hours for blood collection at static centres.
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Affiliation(s)
- S Willis
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - K De Corte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - J A Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - N Hawkins
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - M Pennington
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Health Services and Population Research, King's College London, London, UK
| | - G Cho
- NHS Blood and Transplant, London, UK
| | - D J Roberts
- NHS Blood and Transplant, London, UK.,Radcliffe Department of Medicine and BRC Oxford Haematology Theme, University of Oxford, John Radcliffe Hospital, Oxford, UK.,NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - G Miflin
- NHS Blood and Transplant, London, UK
| | - R Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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de Luca U, Mangia G, Tesoro S, Martino A, Sammartino M, Calisti A. Guidelines on pediatric day surgery of the Italian Societies of Pediatric Surgery (SICP) and Pediatric Anesthesiology (SARNePI). Ital J Pediatr 2018. [PMID: 29530049 PMCID: PMC5848546 DOI: 10.1186/s13052-018-0473-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The Italian Society of Pediatric Surgery (SICP) together with The Italian Society of Pediatric Anesthesia (SARNePI) through a systematic analysis of the scientific literature, followed by a consensus conference held in Perugia on 2015, have produced some evidence based guidelines on the feasibility of day surgery in relation to different pediatric surgical procedures. The main aspects of the pre-operative assessment, appropriacy of operations and discharge are reported.
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Affiliation(s)
- Ugo de Luca
- Day Surgery Unit, Santobono-Pausilipon Pediatric Hospital, Napoli, Italy.
| | - Giovanni Mangia
- Department of Anesthesiology, San Camillo Forlanini Hospital, Roma, Italy
| | - Simonetta Tesoro
- Department of Anesthesiology, Perugia University, Perugia, Italy
| | | | - Maria Sammartino
- Department of Anesthesiology, Policlinico A. Gemelli, Roma, Italy
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The Utility of Preoperative Laboratory Testing Before Urogynecologic Surgery. Female Pelvic Med Reconstr Surg 2018; 24:105-108. [PMID: 29474281 DOI: 10.1097/spv.0000000000000551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES National guidelines for preoperative laboratory testing are based on limited, low-quality evidence. The role of age as a risk factor for testing is unclear. We sought to compare the prevalence of abnormal preoperative laboratory results in older vs younger urogynecologic surgical patients. METHODS In this retrospective cohort study of women undergoing urogynecologic surgery, we compared older (age, ≥65 years) with younger (age, 50-64 years) women. Our primary outcome was the prevalence of an abnormal preoperative laboratory result. RESULTS We included 317 women, with 167 (52.7%) in the older cohort (ages, 65-91 years; mean, 73.3 ± 5.6 years) and 150 (47.3%) in the younger cohort (ages, 50-64 years; mean, 57.3 ± 4.1 years). Overall, 18.3% of participants had at least one abnormal preoperative laboratory, with older women more likely to have an abnormal result (28.7% vs 10.7%, P < 0.001). Compared with the younger cohort, older women had higher rates of abnormal hemoglobin (13.8% vs 6.0%, P = 0.02) and creatinine values (10.8% vs 2.7%, P = 0.005), with no significant differences for platelets (3.0% vs 1.3%, P = 0.53), sodium (3.0% vs 0.7%, P = 0.22), or potassium (6.0% vs 3.3%, P = 0.27). After adjusting for potential confounders, older age remained associated with an abnormal preoperative result (odds ratio, 3.6; 95% confidence interval, 1.9-7.1). CONCLUSIONS In our sample, women 65 years or older had a greater than 25% chance of having an abnormal preoperative laboratory result and were at higher risk compared with younger women. Age 65 years or greater should be considered as a criterion for preoperative laboratory testing in urogynecologic patients.
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Tatem A, Kovac JR. The value of medical pre-operative assessment for patients receiving penile prostheses. Transl Androl Urol 2017; 6:S830-S831. [PMID: 29239401 PMCID: PMC5715193 DOI: 10.21037/tau.2017.11.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Alex Tatem
- Department of Urology, Indiana University, Indianapolis, Indiana, USA
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Allan GM, Young J. Complete blood count for screening? CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:772. [PMID: 29025804 PMCID: PMC5638475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- G Michael Allan
- Director of the PEER (Patients, Experience, Evidence, Research) Group and Professor in the Department of Family Medicine at the University of Alberta in Edmonton
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Rodríguez-Borja E, Corchon-Peyrallo A, Aguilar-Aguilar G, Carratala-Calvo A. Utility of routine laboratory preoperative tests based on previous results: Time to give up. Biochem Med (Zagreb) 2017; 27:030902. [PMID: 28900370 PMCID: PMC5575648 DOI: 10.11613/bm.2017.030902] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/27/2017] [Indexed: 12/19/2022] Open
Abstract
Introduction The usefulness and cost-effectiveness of routine laboratory preoperative tests (POTs) have been challenged recently. In fact, the American Society of Anesthesiologists (ASA) Task Force has stated that test results obtained from the medical record within 6 months of surgery generally are mostly acceptable. The aim of our study was to evaluate the degree of utility of POTs and their clinical benefit based on this recommendation. Material and methods We studied retrospectively every routine POT request from 8 randomly selected weeks in 2016. Every POT contained glucose, creatinine, haemoglobin and coagulation tests (PT-INR). Each pathological result for these tests was registered and classified as “expected” (if previous pathological result within 6 months existed for that test) or “unexpected” (if previous pathological result within 6 months did not exist for that test). Results of ASA physical status classification (a system for assessing the fitness of patients before surgery) and changes in patient management after POTs were retrieved from medical history as well. Results A total of 4516 tests (from 1129 patients) were analysed and 498 results were found pathological (11%). Of these, 403 were expected (8.9%) and 95 unexpected (2.1%). There was not any change in anaesthetic management for any patient due to these findings. Conclusions Routine POTs are an inefficient and low-value service. POTs have to be always ordered selectively after a previous consideration of specific information obtained from several sources (medical records, interviews, examinations, type of surgery) and only if the information obtained will result in changes in the management of the patient.
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Shinkins B, Yang Y, Abel L, Fanshawe TR. Evidence synthesis to inform model-based cost-effectiveness evaluations of diagnostic tests: a methodological review of health technology assessments. BMC Med Res Methodol 2017; 17:56. [PMID: 28410588 PMCID: PMC5391551 DOI: 10.1186/s12874-017-0331-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/27/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Evaluations of diagnostic tests are challenging because of the indirect nature of their impact on patient outcomes. Model-based health economic evaluations of tests allow different types of evidence from various sources to be incorporated and enable cost-effectiveness estimates to be made beyond the duration of available study data. To parameterize a health-economic model fully, all the ways a test impacts on patient health must be quantified, including but not limited to diagnostic test accuracy. METHODS We assessed all UK NIHR HTA reports published May 2009-July 2015. Reports were included if they evaluated a diagnostic test, included a model-based health economic evaluation and included a systematic review and meta-analysis of test accuracy. From each eligible report we extracted information on the following topics: 1) what evidence aside from test accuracy was searched for and synthesised, 2) which methods were used to synthesise test accuracy evidence and how did the results inform the economic model, 3) how/whether threshold effects were explored, 4) how the potential dependency between multiple tests in a pathway was accounted for, and 5) for evaluations of tests targeted at the primary care setting, how evidence from differing healthcare settings was incorporated. RESULTS The bivariate or HSROC model was implemented in 20/22 reports that met all inclusion criteria. Test accuracy data for health economic modelling was obtained from meta-analyses completely in four reports, partially in fourteen reports and not at all in four reports. Only 2/7 reports that used a quantitative test gave clear threshold recommendations. All 22 reports explored the effect of uncertainty in accuracy parameters but most of those that used multiple tests did not allow for dependence between test results. 7/22 tests were potentially suitable for primary care but the majority found limited evidence on test accuracy in primary care settings. CONCLUSIONS The uptake of appropriate meta-analysis methods for synthesising evidence on diagnostic test accuracy in UK NIHR HTAs has improved in recent years. Future research should focus on other evidence requirements for cost-effectiveness assessment, threshold effects for quantitative tests and the impact of multiple diagnostic tests.
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Affiliation(s)
- Bethany Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsely Building, Clarendon Way, Leeds, LS2 9LJ, UK.
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Doing Pre-operative Investigations in Emergency Department; a Clinical Audit. EMERGENCY (TEHRAN, IRAN) 2017; 5:e20. [PMID: 28286827 PMCID: PMC5325889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Pre-operative investigations for emergency surgical patients differ between centers. Following established guidelines can reduce unnecessary investigation, cost of treatment and hospital stay. The present audit was carried out to evaluate the condition of doing pre-operative investigations for three common surgical emergencies compared to National Institute for Health and Care Excellence (NICE) guidelines and local criteria. METHODS A retrospective clinical audit of acute-appendicitis, abscess and hernia patients admitted to the emergency department was carried out over a one-year period from July 2014 to July 2015. Data of laboratory investigations, their indication, cost and duration of hospital stay was collected and compared with NICE-guidelines. RESULTS A total of 201 patients were admitted to the emergency department during the audit period. These included 77(38.3%) cases of acute-appendicitis, 112 (55.7%) cases of abscesses, and 12 (6%) cases of hernia. Investigations not indicated by NICE-guidelines included 42 (20.9%) full blood counts, 29 (14.4%) random blood sugars, 26 (12.9%) urea tests, 4 (2%) chest x-rays, 13 (6.5%) electrocardiographs, and 58 (28.9%) urine analyses. These cost 25,675 Rupees (245.46 Dollars) in unnecessary investigation costs and 65.7 days of additional hospital stay. CONCLUSIONS Unnecessary investigations for emergency surgical patients can be reduced by following NICE-guidelines. This will reduce workload on emergency services, treatment costs and the length of hospital stay.
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Gualandro DM, Yu PC, Caramelli B, Marques AC, Calderaro D, Fornari LS, Pinho C, Feitosa ACR, Polanczyk CA, Rochitte CE, Jardim C, Vieira CLZ, Nakamura DYM, Iezzi D, Schreen D, Adam EL, D'Amico EA, Lima EQD, Burdmann EDA, Mateo EIP, Braga FGM, Machado FS, Paula FJD, Carmo GALD, Feitosa-Filho GS, Prado GF, Lopes HF, Fernandes JRC, Lima JJGD, Sacilotto L, Drager LF, Vacanti LJ, Rohde LEP, Prada LFL, Gowdak LHW, Vieira MLC, Monachini MC, Macatrão-Costa MF, Paixão MR, Oliveira MTD, Cury P, Villaça PR, Farsky PS, Siciliano RF, Heinisch RH, Souza R, Gualandro SFM, Accorsi TAD, Mathias W. 3rd Guideline for Perioperative Cardiovascular Evaluation of the Brazilian Society of Cardiology. Arq Bras Cardiol 2017; 109:1-104. [PMID: 29044300 PMCID: PMC5629911 DOI: 10.5935/abc.20170140] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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An analysis of postoperative hemoglobin levels in patients with a fractured neck of femur. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:507-513. [PMID: 27756504 PMCID: PMC6197462 DOI: 10.1016/j.aott.2015.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/22/2015] [Accepted: 11/11/2015] [Indexed: 12/03/2022]
Abstract
Objectives The aim of this study was to analyze the changes in hemoglobin level and to determine a suitable timeline for post-operative hemoglobin monitoring in patients undergoing fixation of femoral neck fracture. Patients and methods Patients who underwent either dynamic hip screw (DHS) fixation (n = 74, mean age: 80 years) or hip hemiarthroplasty (n = 104, mean age: 84 years) for femoral neck fracture were included into the study. The hemoglobin level of the patients was monitored perioperatively. Results Analysis found a statistically and clinically significant mean drop in hemoglobin of 31.1 g/L over time from pre-operatively (D0) to day-5 post-operatively (p < 0.001), with significant reductions from D0 to day-1 and day-1 to day-2 (p < 0.001). At each post-operative time point, DHS patients had lower hemoglobin values over hemiarthroplasty patients (p = 0.046). Conclusion The decrease in hemoglobin in the first 24-h post-operative period (D0 to day-1) is an underestimation of the ultimate lowest value in hemoglobin found at day-2. Relying on the day-1 hemoglobin could be detrimental to patient care. We propose a method of predicting patients likely to be transfused, and recommend a protocol for patients undergoing femoral neck fracture surgery to standardize postoperative hemoglobin monitoring. Level of evidence Level IV Prognostic study.
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Blom AW, Artz N, Beswick AD, Burston A, Dieppe P, Elvers KT, Gooberman-Hill R, Horwood J, Jepson P, Johnson E, Lenguerrand E, Marques E, Noble S, Pyke M, Sackley C, Sands G, Sayers A, Wells V, Wylde V. Improving patients’ experience and outcome of total joint replacement: the RESTORE programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BackgroundTotal hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.ObjectiveTo undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.MethodsWe used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.ResultsSystematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.ConclusionsThe RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.Study registrationCurrent Controlled Trials ISRCTN52305381.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Neil Artz
- School of Health Professions, Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Paul Dieppe
- Medical School, University of Exeter, Exeter, UK
| | - Karen T Elvers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Jepson
- School of Sport, Exercise and Rehabilitation Sciences, Birmingham, UK
| | - Emma Johnson
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Elsa Marques
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sian Noble
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mark Pyke
- North Bristol NHS Trust, Bristol, UK
| | | | - Gina Sands
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Victoria Wells
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65:146-181. [PMID: 27085810 DOI: 10.1016/j.jhep.2016.03.005] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
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Impacto económico de la variabilidad clínica en la petición de pruebas preoperatorias en cirugía mayor ambulatoria. Cir Esp 2016; 94:280-6. [DOI: 10.1016/j.ciresp.2015.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 11/24/2022]
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Onuoha OC, Hatch MB, Miano TA, Fleisher LA. The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study. Perioper Med (Lond) 2015; 4:14. [PMID: 26677410 PMCID: PMC4681056 DOI: 10.1186/s13741-015-0023-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/24/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Despite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery. Using a single-center retrospective cohort study, we aimed to quantify the incidence of un-indicated preoperative testing in an academic ambulatory center by utilizing recommendations by the recently developed American Society of Anesthesiology (ASA) "Choosing Wisely" Top-5 list. METHODS We utilized data from the EPIC medical records of 3111 patients who had ambulatory surgery at the Hospital of the University of Pennsylvania during a 6-month period. Data were abstracted from laboratory studies- complete blood count, electrolyte panel, coagulation studies, and cardiac studies-stress test, and echocardiogram obtained within 30 days prior to surgery. Preoperative tests obtained from each patient were categorized into "indicated" (ASA ≥ 3) and "un-indicated" (ASA 1 and 2) tests, and percentages were reported. RESULTS During the study period, 52.9 % (95 % confidence interval (CI) 37.6-66.4) of all patients had at least one un-indicated laboratory test performed preoperatively. Further analysis revealed variation in the incidence of preoperative ordering between tests; 73 % of all complete blood counts (CBCs), 70 % of all metabolic panels, and 49 % of all coagulation studies were considered un-indicated by "Top-5 List" criteria. Stated differently, of the patients included in the sample, 51 % of patients received an un-indicated CBC, 41 % an un-indicated metabolic panel, and 16 % un-indicated coagulation studies. Twelve percent of "any un-indicated preoperative test" were obtained from ASA 1 healthy patients. Of the 587 patients less than 36 years old, 331 (56 %) had at least one test that was deemed un-indicated. Forty-one patients had either an echocardiogram or stress test ordered and performed within 30 days of surgery. Of these, eight (19.5 %) studies were un-indicated as determined by chart review. CONCLUSIONS The incidence of ordering "at least one un-indicated preoperative test" in low-risk patients undergoing low-risk surgery remains high even in academic tertiary institutions. In the emerging era of optimizing patient safety and financial accountability, further studies are needed to better understand the problem of overuse while identifying modifiable attitudes and institutional influences on perioperative practices among all stakeholders involved. Such information would drive the development of feasible interventions.
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Affiliation(s)
- Onyi C Onuoha
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street Dulles 680, Philadelphia, PA 19104 USA
| | - Michael B Hatch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street Dulles 680, Philadelphia, PA 19104 USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Senior Scholar, Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania USA
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Use and Utility of Hemostatic Screening in Adults Undergoing Elective, Non-Cardiac Surgery. PLoS One 2015; 10:e0139139. [PMID: 26623648 PMCID: PMC4666643 DOI: 10.1371/journal.pone.0139139] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 09/08/2015] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION One view of value in medicine is outcome relative to cost of care provided. With respect to operative care, increased attention has been placed on evaluation and optimization of patients prior to undergoing an elective surgery. We examined more than 2 million patients having elective, non-cardiac surgery to assess the incidence and utility of pre-operative hemostatic screening, compared with a composite of history variables that may indicate a propensity for bleeding, to assess several important outcomes of surgery. MATERIALS & METHODS We queried the NSQIP database to identify 2,020,533 patients and compared hemostatic tests (PT, aPTT, platelet count) and history covariables indicative of potential for abnormal hemostasis. We compared outcomes across predictor values; used Person's chi-square tests to compare differences, and logistic regression to model outcomes. RESULTS Approximately 36% of patients had all three tests pre-operatively while 16% had none of them; 11.2% had a history predictive of potential abnormal bleeding. Outcomes of interest across the cohort included death in 0.7%, unplanned return to the operating room or re-admission within 30 days in 3.8% and 6.2% of patients; 5.3% received a transfusion during or after surgery. Sub-analyses in each of the nine surgical specialties' most common procedures yielded similar results. CONCLUSION The limited predictive value of each hemostatic screening test, as well as excess costs associated with them, across a broad spectrum of elective surgeries, suggests that limiting pre-operative testing to a more select group of patients may be reasonable, equally efficacious, efficient, and cost-effective.
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Abstract
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.
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Affiliation(s)
- M Hübler
- Klinik und Poliklinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - A Hübler
- Klinik und Poliklinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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