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

Beyond guideline knowledge: a theory-based qualitative study of low-value preoperative testing

BACKGROUND

Choosing Wisely Canada and most major anesthesia and preoperative guidelines recommend against obtaining preoperative tests before low-risk procedures. However, these recommendations alone have not reduced low-value test ordering. In this study, the theoretical domains framework (TDF) was used to understand the drivers of preoperative electrocardiogram (ECG) and chest X-ray (CXR) ordering for patients undergoing low-risk surgery ('low-value preoperative testing') among anesthesiologists, internal medicine specialists, nurses, and surgeons.

METHODS

Using snowball sampling, preoperative clinicians working in a single health system in Canada were recruited for semi-structured interviews about low-value preoperative testing. The interview guide was developed using the TDF to identify the factors that influence preoperative ECG and CXR ordering. Interview content was deductively coded using TDF domains and specific beliefs were identified by grouping similar utterances. Domain relevance was established based on belief statement frequency, presence of conflicting beliefs, and perceived influence over preoperative test ordering practices.

RESULTS

Sixteen clinicians (7 anesthesiologists, 4 internists, 1 nurse, and 4 surgeons) participated. Eight of the 12 TDF domains were identified as the drivers of preoperative test ordering. While most participants agreed that the guidelines were helpful, they also expressed distrust in the evidence behind them (knowledge). Both a lack of clarity about the responsibilities of the specialties involved in the preoperative process and the ease by which any clinician could order, but not cancel tests, were drivers of low-value preoperative test ordering (social/professional role and identity, social influences, belief about capabilities). Additionally, low-value tests could also be ordered by nurses or the surgeon and may be completed before the anesthesia or internal medicine preoperative assessment appointment (environmental context and resources, beliefs about capabilities). Finally, while participants agreed that they did not intend to routinely order low-value tests and understood that these would not benefit patient outcomes, they also reported ordering tests to prevent surgery cancellations and problems during surgery (motivation and goals, beliefs about consequences, social influences).

CONCLUSIONS

We identified key factors that anesthesiologists, internists, nurses, and surgeons believe influence preoperative test ordering for patients undergoing low-risk surgeries. These beliefs highlight the need to shift away from knowledge-based interventions and focus instead on understanding local drivers of behaviour and target change at the individual, team, and institutional levels.

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

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.

Preoperative cardiology referral practices at a tertiary care centre: A retrospective observational study

Background Preoperative consultations and testing add to healthcare costs. Unnecessary consultations lead to further testing and delay in surgery. Guidelines help us in clinical practice but are seldom followed. We studied the appropriateness of our preoperative cardiology referrals according to the guidelines and functional utility of the consultations. Methods We reviewed the records of patients who underwent elective non-cardiac surgery to identify those who had a preoperative cardiology consult. Appropriateness of the referral was assessed by comparing with the 2014 American College of Cardiology/American Heart Association guidelines. Any recommendations made, major adverse cardiac events and perioperative outcome were also noted. Results Only 71 (15.5%) referrals were appropriate according to the guidelines. A majority of them were for preoperative clearance. The most common recommendation was to withhold antiplatelet medications. None of the consultations made any change in the anaesthetic or surgical plan. Six patients had major perioperative adverse cardiac events. Conclusion The majority of consultations were by surgeons and were not indicated according to the guidelines and did not have any impact on patient outcome. A large proportion of these patients had low cardiac risk index. As anaesthesiologists, we are best equipped to quantify risk and optimize a patient and should be the leaders of the perioperative period.

Reducing Preventable Surgical Cancellations: Improving the Preoperative Anesthesia Interview Process

PURPOSE

Thorough and accurate preoperative anesthesia interviews may help improve perioperative efficiency by reducing unnecessary preoperative testing and preventable surgical cancellations, both of which create financial burdens. Standardized anesthesia preoperative interview guidelines and online educational modules for registered nurses (RNs) conducting preoperative interviews may improve this process.

DESIGN

Predesign and postdesign, retrospective chart review.

METHODS

Online educational modules and standardized preoperative anesthesia interview guidelines were developed for RNs conducting preoperative interviews. A retrospective chart review compared preoperative anesthesia interview record completion rates, compliance with laboratory testing, and the total number of preventable surgical cancellations.

FINDINGS

Documentation of preoperative anesthesia interview records increased, whereas unnecessary preoperative testing decreased, neither with statistical significance. Preventable cancellation rates decreased significantly from 34.3% to 20% (P < .5) contributing to a 3-month postimplementation cost savings of approximately $30,000.

CONCLUSIONS

A standardized preoperative anesthesia interview guideline and online anesthesia educational modules for RNs conducting preoperative anesthesia interviews improved preoperative record completion rates, reduced unnecessary laboratory testing, and averted surgical cancellations.