International Comparison of Preoperative Testing and Assessment Protocols and Best Practices to Reduce Surgical Care Costs: A Systematic Literature Review

Kash, Bita A.; Cline, Kayla M.; Timmons, Stephen; Roopani, Rahil; Miller, Thomas R.

doi:10.1108/s1474-823120140000017010

Cited by 5 publications

(4 citation statements)

References 53 publications

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“…For example, medicolegal concerns, limited awareness of evidence-based guidelines, concerns about surgical cancellation, practice tradition, and beliefs about surgeons’ expectations may all play a role in ordering unnecessary tests [ 19 ]. Variations could also explain this variability among hospitals in the availability of workforce to establish preoperative screening clinics universally and among third-party payers in reimbursing for these tests [ 3 , 20 , 21 ]. On the policy level, bundled payment arrangements could induce this variation as not all arrangements to cover preoperative testing [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

“…Patients undergoing elective total hip replacement (THR) and total knee replacement (TKR) usually undergo a medical evaluation before surgery [ 2 ]. The evaluation process involves various laboratory and imaging tests [ 3 ]. Clinical guidelines, such as the one set forth by the American Society of Anesthesiologists, recommend a list of tests for THR and TKR; however, given how these guidelines are written, the tests that are ordered for THR and TKR patients are at the providers’ discretion and may result in considerable variability in practice [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

“…For example, it is hotly debated whether Methicillin Resistant Staphylococcus Aureus (MRSA) testing should be done before TKR to reduce postoperative infection [ 5 ]. In fact, performing preoperative tests is supported by limited scientific evidence [ 3 , 6 ]. In most cases, the results of these tests do not lead to the cancellation of the surgery or a change in the surgical course [ 6 – 10 ].…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

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

Hasan

Kang

Lee

et al. 2022

BMC Musculoskelet Disord

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

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

Hasan

Kang

Lee

et al. 2022

BMC Musculoskelet Disord

View full text Add to dashboard Cite

show abstract

“…Preoperative testing before low-risk surgeries, referring to procedures that have a baseline risk of adverse events of less than 1% (Kirkham et al 2015 ), does not improve patient outcomes (Chan et al 2011 ; Biteker et al 2012 ; Fritsch et al 2012 ; Smetana and Macpherson 2003 ), increases costs to the health care system, (Rayborn et al 2017 ; Finegan et al 2005 ; Kash et al 2015 ), and can prolong time-to-surgery and length of stay (Bernstein et al 2016 ). Based on extensive evidence, Choosing Wisely Canada and most major anesthesia and preoperative guidelines recommend against obtaining any preoperative tests before low-risk procedures (Dobson et al 2021 ; Canadian Anesthesiologists’ Society Five Things Clinicians and Patients Should Question n.d. ).…”

Section: Introductionmentioning

confidence: 99%

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

Jasaui

Mortazhejri²,

Dowling³

et al. 2023

Perioper Med

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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.

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Reducing Preventable Surgical Cancellations: Improving the Preoperative Anesthesia Interview Process

Leite¹,

Hobgood²,

Hill³

et al. 2019

Journal of PeriAnesthesia Nursing

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International Comparison of Preoperative Testing and Assessment Protocols and Best Practices to Reduce Surgical Care Costs: A Systematic Literature Review

Cited by 5 publications

References 53 publications

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

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

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

Reducing Preventable Surgical Cancellations: Improving the Preoperative Anesthesia Interview Process

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