Rethinking the routine: Preoperative laboratory testing among American Society of Anesthesiologists class 1 and 2 patients before low-risk ambulatory surgery in the 2017 National Surgical Quality Improvement Program cohort

Taylor, George A.; Oresanya, Lawrence B.; Kling, Sarah M.; Saxena, Vishal; Mutter, Olga; Raman, Swathi; Cho, Eric Y.; Deitrick, Paul; Philp, Matthew M.; Sanserino, Kathryne; Kuo, Lindsay E.

doi:10.1016/j.surg.2021.07.036

Cited by 12 publications

(6 citation statements)

References 25 publications

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“…Nowadays, medical practices and medical knowledge evolves quickly. Technologies and web access permit diffusion over the world, but most physicians do not have time to keep up with the ever-increasing amount of information 15 . The lack of familiarity or the lack of awareness regarding current recommendations 14,[16][17][18] is an evident obstacle to try following guidelines.…”

Section: Resultsmentioning

confidence: 99%

Routine Preoperative Tests in Low-Risk Surgery. What About Adherence to Clinical Guidelines?

Ruiz

Olmedo²,

González³

et al. 2023

MRAJ

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In 2002, the American Heart Association guidelines established that routinary preoperative studies in low-risk patients (ASA I and II) are unnecessary. This fact has been supported by many other publications after that. However, the medical adherence to these recommendations in clinical practice is low. The aim of this review is to identify the reasons associated with a poor guideline’s adherence. Articles published between 2002 and 2022 reporting data on “preoperative test”, “routine preoperative test”, and “low-risk surgery” were identified through a computerized literature research using Pubmed, Scopus, Medigraphic and Cochrane databases and by selecting all of the articles related to adherence to clinical guidelines. The full text of relevant articles was reviewed by all authors. This review found that some of the causes of the limited adherence to clinical guidelines are: lack of awareness regarding current recommendations or lack of familiarity with them; physician attitudes about the guidelines (including outcome expectancy, lack of agreement, poor motivation to modify previous practice, question efficacy); and environmental labor factors of medical institutions, including lack of communication among the consultants involved in the perioperative care, and medicolegal concerns and fear of litigation. Hence, in order to propose effective alternatives to improve guidelines adherence, this review discuss some of the main reasons why in clinical practice there is still a poor compliance to surgical preoperative guidelines, even when more than 20 years have passed since the concept of routinary preoperative studies in low risk patients was eliminated by a myriad of clinical guidelines and medical associations.

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Section: Resultsmentioning

confidence: 99%

Routine Preoperative Tests in Low-Risk Surgery. What About Adherence to Clinical Guidelines?

Ruiz

Olmedo²,

González³

et al. 2023

MRAJ

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“…13,14 This finding has been further identified in various national cohorts [15][16][17][18][19][20][21][22] culminating in the 2022 study by Taylor et al using 2017 ACS-NSQIP data from 111,589 low-risk patients, which demonstrated that 51.6% of low-risk patients received at least one preoperative laboratory test. 12 The present study adds an assessment of 8 years prior and 6 years following the introduction of the ASA guidelines equating to an analysis of 972,431 low-risk patients, suggesting that the majority of low-risk patients continue to undergo testing not recommended by the ASA.…”

Section: Discussionmentioning

confidence: 96%

“…Patients were excluded if they were less than 18 years of age, were not from the nine primary surgical specialties of the ACS‐NSQIP, or had missing data. Patients were defined as “low‐risk” using a previously published study by Taylor, et al 12 . This included patients who were ASA 1 or 2 physical status undergoing outpatient, elective procedures, in line with the ASA guidelines.…”

Section: Methodsmentioning

confidence: 99%

The deimplementation of laboratory testing in low‐risk patients as recommended by the American society of anesthesiologists: An ACS‐NSQIP longitudinal analysis

Stuart,

Bronsert,

Meguid

et al. 2024

World j. surg.

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BackgroundIn 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.MethodsThe 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.ResultsOf 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.ConclusionsWhile 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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“…In 2020, the total expenditure on preoperative testing in the United States alone was estimated to be 18 billion dollars [ 13 ]. The National Surgical Quality Improvement Program (NSQIP) recommendations when it was applied to low-risk ambulatory surgery patients, it was found that the ASA 1 and 2 categories may not even require preoperative laboratory testing, and the authors recommended to "re-think the routine" in such cohorts of patients [ 14 ]. The National Institute of Health and Care Excellence (NICE), United Kingdom guidelines clearly advise that the primary factors used to determine which preoperative investigations are appropriate would be the patient’s clinical history and examination, the ASA grade, and the intended surgical intervention [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

An Economic Evaluation of the Preoperative Investigations for Elective Surgical Patients at a Caribbean Tertiary Care Teaching Hospital

Hinds¹,

Hariharan²

2023

Cureus

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IntroductionPreoperative assessment using widespread laboratory investigations and ancillary tests as preoperative screening may be unnecessary and lead to an economic burden. This study aimed to determine the routine preoperative investigations performed in a tertiary care teaching hospital in the Caribbean that could be categorized as unnecessary and the costs incurred for these tests. MethodsPatient and surgery-specific data were collected prospectively from adult elective surgery patients over a three-month period. Surgical intensity, American Society of Anesthesiologists (ASA) grade and the National Institute for Health and Care Excellence (NICE) (UK, 2016) Clinical Guideline for Preoperative Investigations were used to determine which tests to deem unnecessary. The overall economic burden of unnecessary testing was assessed. ResultsData were prospectively collected from 636 patients during the study period. Sixty-four percent of the preoperative investigations performed were deemed unnecessary. The money spent on these unnecessary investigations amounted to $44,622. When extrapolated, this can amount to approximately $178,488 per annum. This represented 59% of the total money spent on the overall preoperative investigations performed. Relatively healthier patients (ASA I and II) had a significantly higher number of unnecessary investigations performed. ConclusionThis study found that the majority of preoperative investigations performed routinely may be deemed unnecessary. This results in a huge economic burden on the healthcare system. There is a need to update and strictly implement clinical guidelines for preoperative investigations.

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Rethinking the routine: Preoperative laboratory testing among American Society of Anesthesiologists class 1 and 2 patients before low-risk ambulatory surgery in the 2017 National Surgical Quality Improvement Program cohort

Cited by 12 publications

References 25 publications

Routine Preoperative Tests in Low-Risk Surgery. What About Adherence to Clinical Guidelines?

Routine Preoperative Tests in Low-Risk Surgery. What About Adherence to Clinical Guidelines?

The deimplementation of laboratory testing in low‐risk patients as recommended by the American society of anesthesiologists: An ACS‐NSQIP longitudinal analysis

An Economic Evaluation of the Preoperative Investigations for Elective Surgical Patients at a Caribbean Tertiary Care Teaching Hospital

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