Jointly Sponsored by the Sections on: Anesthesiology and Resuscitation Evidence Based Health Care Pediatrics Radiology Urology Why Bother! The Comprehensive Pre Op Panel Supported in part by a generous grant from the ABIM Foundation

Pre-op testing: a review of the evidence Deborah Korenstein MD, FACP American College of Physicians

Brief intro to the issue  Is this an important issue?: the Choosing Wisely Framework  Evidence that pre-op testing is not helpful  How often is unneeded pre-op testing happening?  Why does it happen?

Preop testing and Choosing Wisely Organizations which have included unnecessary pre-op testing on their Top 5 List:  American College of Physicians  American Academy of Ophthalmology  American Society of Anesthesiologists  American Academy of Family Physicians  Society for General Internal Medicine

Recommended framework for Choosing Wisely items  Evidence of harm or little benefit  Frequent misuse in practice  Measureable  Under provider control Grady D et al. How should top-five lists be developed?: what is the next step? JAMA Int Med (4):498

What do we know about the benefits and harms of preoperative testing?  For patients undergoing cataract surgery, there is strong evidence that preop testing does not change outcomes or cancellation rates.  For other minor surgery, there is lower quality evidence that routine testing does not change management or complication rates. Balk EM et al. Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness [Internet]. AHRQ Comparative Effectiveness Reviews Czoski-Murray C et al. What is the value of routinely testing full blood count, electrolytes and urea, and pulmonary function tests before elective surgery in patients with no apparent clinical indication and in subgroups of patients with common comorbidities: a systematic review of the clinical and cost- effective literature. Health Tech Assess 2012;16(50). Benefits:

What do we know about the benefits and harms of preoperative testing?  Few- mostly bleeding and rare nerve damage from blood draws  Other possible harms: further unnecessary testing to work up false positives, anxiety Balk EM et al. Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness [Internet]. AHRQ Comparative Effectiveness Reviews Harms:

Guidelines  2009 ACCF/AHA guideline on preoperative cardiac testing recommends against testing in patients undergoing low-risk surgery, patients with good exercise tolerance, and patients without cardiac risk factors who have unclear exercise tolerance.  2012 guideline from the American Society of Anesthesiologists recommends against routine testing (labs, CXR, or ECG), but suggests a tailored approach ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. JACC 2009; 54(22):e13. Apfelbaum JL et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.Anesthesiology (3):522.

Recommended framework for Choosing Wisely items  Evidence of harm or little benefit  Frequent misuse in practice  Measureable  Under provider control Grady D et al. How should top-five lists be developed?: what is the next step? JAMA Int Med (4):498

Frequency of unnecessary pre-op testing Two recent studies found that over half (52% - 54%) of low-risk patients received unnecessary preoperative testing So there is clearly frequent misuse in practice. Benarroch-Gampel J et al. Preoperative Laboratory Testing in Patients Undergoing Elective, Low-Risk Ambulatory Surgery. Ann Surg 2012; 256:518. Katz RI et al. Survey Study of Anesthesiologists’ and Surgeons’ Ordering of Unnecessary Preoperative Laboratory Tests. Anesth Analg 2011; 112:207.

Why is there excessive pre-op testing?  Reasons cited in studies:  Unclear responsibility  Belief that others want it done  Lack of knowledge of guidelines  Medicolegal concerns A word about malpractice: closed claims reports have revealed no law suits based on failure to test before surgery, and legal colleagues have shared with us that they know of no such cases Patey AM et al. Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low- risk patients: application of the Theoretical Domains Framework (TDF) to identify factors thatinfluence physicians’ decisions to order pre-operative tests. Implementation Science 2012; 7:52. Brown SR and Brown J. Why Do Physicians Order Unnecessary Preoperative Tests? A Qualitative Study. Fam Med 2011; 43(5): 338. Zenilman JC et al. Closed claim review from a single carrier in New York: the real costs of malpractice in surgery and factors that determine outcomes. Am J Surg 2012; 203:733.