Economics of preoperative evaluation clinics

The inductor role of cardiac consultation in the pre-anesthetic evaluation of asymptomatic patients submitted to non-cardiac minor and intermediate-risk surgery: a cross-sectional study

INTRODUCTION

Asymptomatic patients with moderate functional capacity do not require Coronary Artery Disease (CAD) workup in the preoperative period of non-cardiac surgeries, especially when scheduled for minor and intermediate-risk surgeries. The workup is inappropriate because it promotes over diagnosing and pointless treatments. Moreover, those patients usually undergo cardiology assessment, in addition to pre-anesthetic evaluation.

OBJECTIVE

Investigate the role of cardiology consultation as mediator in inappropriate assessment of CAD for preoperative of non-cardiac surgeries.

METHOD

Retrospective study performed in a private anesthesia service using medical charts of asymptomatic patients with a history of controlled systemic disease and moderate functional capacity, submitted to pre-anesthetic consultation for minor and intermediate risk surgeries. Cardiology consultations were identified by the presence of a consultation report by a cardiologist. CAD workup was defined as undergoing cardiac stress tests.

RESULTS

We included 390 medical charts of patients with mean age of 48.6 ± 15.4 years, 67% women and 69% intermediate risk surgeries. CAD workup was infrequent and performed in 3.9% of patients. Besides, pre-anesthetic evaluation, 93 (24%) patients had a cardiology consultation. Among those patients, 15.1% were submitted to CAD workup, compared to 0.34% of patients without cardiology assessment (p < 0.001; RR = 4.4; 95% CI: 3.5-5.6).

CONCLUSIONS

Inappropriate testing for CAD investigation is infrequent for asymptomatic individuals submitted to minor and intermediate risk surgeries. However, cardiology consultation increases substantially the likelihood of a patient undergoing CAD workup, suggesting that, unlike the anesthesiologist, the cardiologist is a major mediator of this kind of management.

Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality

BACKGROUND

As specialists in perioperative medicine, anesthesiologists are well equipped to design and oversee the preoperative patient preparation process; however, the impact of an anesthesiologist-led preoperative evaluation clinic (PEC) on clinical outcomes has yet to be fully elucidated. The authors compared the incidence of in-hospital postoperative mortality in patients who had been evaluated in their institution's PEC before elective surgery to the incidence in patients who had elective surgery without being seen in the PEC.

METHODS

A retrospective review of an administrative database was performed. There were 46 deaths from 64,418 patients (0.07%): 22 from 35,535 patients (0.06%) seen in PEC and 24 from 28,883 patients (0.08%) not seen in PEC. After propensity score matching, there were 13,964 patients within each matched set; there were 34 deaths (0.1%). There were 11 deaths from 13,964 (0.08%) patients seen in PEC and 23 deaths from 13,964 (0.16%) patients not seen in PEC. A subanalysis to assess the effect of a PEC visit on deaths as a result of failure to rescue (FTR) was also performed.

RESULTS

A visit to PEC was associated with a reduction in mortality (odds ratio, 0.48; 95% CI, 0.22 to 0.96, P = 0.04) by comparison of the matched cohorts. The FTR subanalysis suggested that the proportion of deaths attributable to an unanticipated surgical complication was not significantly different between the two groups (P = 0.141).

CONCLUSIONS

An in-person assessment at the PEC was associated with a reduction in in-hospital mortality. It was difficult to draw conclusions about whether a difference exists in the proportion of FTR deaths between the two cohorts due to small sample size.

The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study

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.

Contract anesthesia: the good news and the challenge

The dramatic pace of change in health care is intimidating, and results can be unpredictable and often negative. The practice of contract anesthesia delivery is an excellent example of how a clinical microsystem interacts with the constant change common in today's health care environment. This article identifies many of the issues of concern in contract anesthesia. Awareness of issues will afford nurses, nurse anesthetists, and managers a structure for a smooth, safe, and effective transition of contracting providers.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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