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Impact of new guidelines on physicians’ ordering of preoperative tests

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Abstract

OBJECTIVE: To compare the number of preoperative tests ordered for elective ambulatory surgery patients during the 2 years before and the 2 years after the establishment of new hospital testing guidelines.

MEASUREMENTS: The patterns of preoperative testing by surgeons and a medical consultant during the 2 years before and the 2 years after the establishment of new guidelines at one orthopedic hospital were reviewed. All tests ordered preoperatively were determined by review of medical records. Preoperative medical histories, physical examinations, and comorbidities were obtained according to a protocol by the medical consultant (author). Perioperative complications were determined by review of intraoperative and postoperative events, which also were recorded according to a protocol.

MAIN RESULTS: A total of 640 patients were enrolled, 361 before and 279 after the new guidelines. The mean number of tests decreased from 8.0 before to 5.6 after the new guidelines (p=.0001) and the percentage decrease for individual tests varied from 23% to 44%. Except for patients with more comorbidity and patients receiving general anesthesia, there were decreases across all patient groups. In multivariate analyses only time of surgery (before or after new guidelines), age, and type of surgery remained statistically significant (p=.0001 for all comparisons). Despite decreases in surgeons’ ordering of tests, the medical consultant did not order more tests after the new guidelines (p=.60) The majority of patients had no untoward events intraoperatively and postoperatively throughout the study period, with only 6% overall requiring admission to the hospital after surgery, mainly for reasons not related to abnormal tests. Savings from charges totaled $34,000 for the patients in the study.

CONCLUSIONS: Although there was variable compliance among physicians, new hospital guidelines were effective in reducing preoperative testing and did not result in increases in untoward perioperative events or in test ordering by the medical consultant.

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References

  1. Macpherson DS. Preoperative laboratory testing: should any tests be “routine” before surgery? Med Clinic North Am. 1993;77:289–308.

    Article  CAS  Google Scholar 

  2. Macario A, Roizen MF, Thisted RA, Kim S, Orkin FK, Phelps C. Reassessment of preoperative laboratory testing has changed the test-ordering patterns of physicians. Surg Gynecol Obstet. 1992;175:539–47.

    CAS  PubMed  Google Scholar 

  3. Perez A, Planell J, Bacardaz C, et al. Value of routine preoperative tests: a multicentre study in four general hospitals. Br J Anaesth. 1995;74:250–6.

    Article  CAS  PubMed  Google Scholar 

  4. Roizen MF. Preoperative evaluation. In: Miller, RD, ed. Anesthesia. New York, NY: Churchill Livingstone Inc.; 1990.

    Google Scholar 

  5. Velanovich V. Preoperative laboratory screening based on age, gender, and concomitant medical diseases. Surgery. 1994;115:56–61.

    CAS  PubMed  Google Scholar 

  6. Roizen MF. Cost-effective preoperative laboratory testing. JAMA. 1994;271:319–20.

    Article  CAS  PubMed  Google Scholar 

  7. Macpherson DS, Snow R, Lofgren RP. Preoperative screening: value of previous tests. Ann Intern Med. 1990;113:969–73.

    Article  CAS  PubMed  Google Scholar 

  8. Robbins JA, Mushlin AI. Preoperative evaluation of the healthy patient. Med Clin North Am. 1979;63:1145–56.

    Article  CAS  PubMed  Google Scholar 

  9. Roizen MF. The compelling rationale for less preoperative testing. Can J Anaesth. 1988;35:214–8.

    Article  CAS  PubMed  Google Scholar 

  10. Johnson H, Knee-Ioli S, Butler TA, Munoz E, Wise L. Are routine preoperative laboratory screening tests necessary to evaluate ambulatory surgical patients? Surgery. 1988;104:639–45.

    PubMed  Google Scholar 

  11. Jones T, Isaacson JH. Preoperative screening: what tests are necessary? Cleve Clin J Med. 1995;62:374–8.

    Article  CAS  PubMed  Google Scholar 

  12. Turnbull JM, Buck C. The value of preoperative screening investigations in otherwise healthy individuals. Arch Intern Med. 1987;147:1101–5.

    Article  CAS  PubMed  Google Scholar 

  13. Larocque BJ, Maykut RJ. Implementation of guidelines for preoperative laboratory investigations in patients scheduled to undergo elective surgery. Can J Surg. 1994;37:397–401.

    CAS  PubMed  Google Scholar 

  14. Roberts CJ, Fowkes FGR, Ennis WP, Mitchell M. Possible impact of audit on chest X-ray requests from surgical wards. Lancet. 1983;2:446–8.

    Article  CAS  PubMed  Google Scholar 

  15. Wattsman TA, Davies RS. The utility of preoperative laboratory testing in general surgery patients for outpatient procedures. Am Surg. 1997;63:81–90.

    CAS  PubMed  Google Scholar 

  16. Charlson ME, Ales KA, Pompei P, MacKenzie CR. A new method of classification of prognositc comorbidity for longitudinal studies: development and validation. J Chron Dis. 1987;40:373–83.

    Article  CAS  PubMed  Google Scholar 

  17. Charlson ME, Peterson J, Szatrowski T, MacKenzie C, Gold J. Long-term prognosis after peri-operative cardiac complications. J Clin Epidemiol. 1994;47:1389–400.

    Article  CAS  PubMed  Google Scholar 

  18. Charlson ME, MacKenzie C, Gold J. Preoperative autonomic function abnormalities in patients with diabetes mellitus and patients with hypertension. J Am Coll Surg. 1994;179:1–10.

    CAS  PubMed  Google Scholar 

  19. Urmey WF, Stanton J, Peterson M, Sharrock NE. Combined spinalepidural anesthesia for outpatient surgery. Anesthesiology. 1995;83:528–34.

    Article  CAS  PubMed  Google Scholar 

  20. Kaplan EB, Sheiner LB. Boeckmann AJ, et al. The usefulness of preoperative laboratory screening. JAMA. 1985;253:3576–81.

    Article  CAS  PubMed  Google Scholar 

  21. Blery C, Charpak Y, Szatan M, et al. Evaluation of a protocol for selective ordering of preoperative tests. Lancet. 1986;1:139–41.

    Article  CAS  PubMed  Google Scholar 

  22. Vogt AW, Henson LC. Unindicated preoperative testing: ASA physical status and financial implications. J Clin Anesth. 1997;9:437–41.

    Article  CAS  PubMed  Google Scholar 

  23. Nardella A, Pechet L, Snyder M. Continuous improvement, quality control, and cost containment in clinical laboratory testing. Arch Pathol Lab Med. 1995;119:518–22.

    CAS  PubMed  Google Scholar 

  24. Fischer S. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology. 1996;85:196–206.

    Article  CAS  PubMed  Google Scholar 

  25. Fu ES, Scharf JE, Glodek J. Preoperative testing: a comparison between Health Quiz recommendations and routine ordering. Am J Anesth. 1997;24:237–40.

    Google Scholar 

  26. Beers RA, O’Leary CE, Franklin PD. Comparing the history-taking methods used during a preanesthesia visit: the Health Quiz versus the written questionniare. Anesth Analg. 1998;86:134–7.

    CAS  PubMed  Google Scholar 

  27. Schroeder SA, Myers LP, McPhee SJ, et al. The failure of physician education as a cost containment strategy. JAMA. 1984;252:225–30.

    Article  CAS  PubMed  Google Scholar 

  28. Williams SV, Eisenberg JM. A controlled trial to decrease the unnecessary use of diagnostic tests. J Gen Intern Med. 1986;1:8–13.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Received from Cornell University Medical College, Cornell University Graduate School of Medical Sciences, and Hospital for Special Surgery, New York, N.Y.

    Carol A. Mancuso MD

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  1. Carol A. Mancuso MD
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Additional information

Dr. Mancuso is a recipient of a Robert Wood Johnson Generalist Physician Faculty Scholar’s Award.

This work was supported in part by the Hospital for Special Surgery Multipurpose Arthritis and Musculoskeletal Disease Center (NIH P60 AR38520-06).

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Mancuso, C.A. Impact of new guidelines on physicians’ ordering of preoperative tests. J GEN INTERN MED 14, 166–172 (1999). https://doi.org/10.1046/j.1525-1497.1999.00308.x

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