Preoperative Laboratory Testing in Patients Undergoing Elective, Low-Risk Ambulatory Surgery
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1 Preoperative Laboratory Testing in Patients Undergoing Elective, Low-Risk Ambulatory Surgery Jaime Benarroch-Gampel, Kristin M. Sheffield, Casey B. Duncan, Kimberly M. Brown, Yimei Han, Courtney M. Townsend, Jr., and Taylor S. Riall Department of Surgery Center for Comparative Effectiveness and Cancer Outcomes The University of Texas Medical Branch Galveston, TX
2 Which of the following preoperative laboratory test is routinely indicated in an 80 years old male undergoing low-risk ambulatory surgery A.Complete blood count B.Chemistry panel C.Coagulation tests D.All of the test E.None of the test
3 Ambulatory surgery <1-2 hours in duration Low expected blood loss Low complication rates INTRODUCTION Minimal expected postoperative care Performed in patients with no medical problems or stable chronic medical conditions 60-70% of procedures in the U.S. performed in the ambulatory setting
4 INTRODUCTION Potential benefits of preoperative testing Predicting patient risk for postoperative complications Screening for unsuspected abnormalities Establishing baseline values for tests that may change after surgery Providing medical-legal protection
5 Potential risks of preoperative testing Cost: estimated between 3-18 billion Increased pain and inconvenience Anxiety for patients Abnormal results in some cases are of questionable clinical significance Harm to patients due to overtreatment of false-positive results Medical-legal risk INTRODUCTION
6 INTRODUCTION Current recommendations based on 2002 Practice Advisory from American Society of Anesthesiologists (ASA) Based on expert opinion and underpowered studies Inconsistencies between societies Imprecise language Many advocate against routine testing Fail to outline clear and consistent guidelines for specific tests
7 INTRODUCTION INDICATION Hg/CBC Creatinine Electrolytes LFTs Albumin Coagulation Parameters Advanced age ASA OPTG OPTG OPTG Bleeding disorders ASA ASA CAS OPTG Cardiovascular CAS disease Renal disease Liver disease OPTG CAS OPTG CAS OPTG CAS OPTG ASA CAS OPTG OPTG ASA ASA CAS OPTG Hypertension OPTG CAS OPTG CAS OPTG Diabetes OPTG CAS OPTG Smoking OPTG Alcohol abuse OPTG OPTG OPTG ASA: American Society of Anesthesiologists, CAS: Canadian Anesthesiologists Society, OPTG: Ontario Preoperative Testing Grid, LFT: Liver Function Tests
8 OBJECTIVES Use population-based data (NSQIP) to: Describe the current use of preoperative testing in elective, low-risk ambulatory surgery All patients Subgroup with no comorbidities Identify patient factors associated with preoperative testing Evaluate the association between preoperative testing and 30-day outcomes
9 National Surgical Quality Improvement Program Participant Use Data File (PUF) Study period: Contains 240 variables: Patient characteristics Procedure characteristics Anatomic site Open vs. laparoscopic Initial vs. recurrent METHODS Data Source
10 Inclusion criteria: >18 years old Preoperative Testing in Ambulatory Surgery Elective hernia repair (CPT codes) Inguinal hernia (49505, 49520, 49525, 49650, 49651) Umbilical hernia (49585) Epigastric hernia (49570) Femoral hernia (49550, 49555) Same day admission METHODS Cohort Selection No surgery in previous 30 days No additional surgical procedures at time of hernia repair
11 Cohort Selection (continued)
12 METHODS Laboratory Testing Preoperative testing defined as testing in the 30 days up to and including surgery Normal values were defined using our institutional laboratory ranges Hematology Hematocrit WBC Platelets Chemistry Sodium BUN creatinine Coagulation PT PTT INR LFTs Albumin Total bilirubin AST Alkaline phosphatase 92% 90% 77% 89%
13 METHODS Additional outcome variables: Major complications: unplanned intubation, PE, stroke, coma >24h, acute renal failure, MI, cardiac arrest, sepsis/septic shock, blood transfusions, or death Wound-related complications: superficial and deep surgical site infections, organ space infections, and wound dehiscence
14 Use of preoperative testing described Chi-square to compare categorical variables and T-test to compare continuous variables Multivariate logistic regression models used to determine: Factors associated with preoperative testing Association between METHODS Statistical Analysis Preoperative testing and 30-day outcomes Abnormal results and 30-day outcomes
15 RESULTS Demographics and Procedures NO LABS (N=26,619) 36% LABS (N=46,977) 64% P-value PATIENT CHARACTERISTICS Age 48.6 ± 16.0 yrs 57.7 ± 15.9 yrs < Male gender 84.3% 84.4% 0.66 White 82.7% 79.5% < ASA Class % 26.0% < At least 1 comorbidity 56.6% 71.1% < PROCEDURE DETAILS General anesthesia 76.1% 78.1% < Inguinal hernia 72.6% 74.5% < Laparoscopic repair 17.3% 18.4% Recurrent hernia 6.7% 7.3% 0.001
16 RESULTS Preoperative Testing Use
17 RESULTS Preoperative Testing Use OVERALL COHORT (N=73,596) % Use % Abnormal Any Test 63.8% 61.6% Hematology 58.6% 39.3% Chemistry 53.5% 40.2% Coagulation 18.7% 11.3% LFT 23.7% 22.8%
18 RESULTS Preoperative Testing Use SUBGROUP WITHOUT COMORBIDITIES N=25,146 (34% of overall cohort) % Use % Abnormal Any test 54.0% 54.1% Hematology 51.8% 36.2% Chemistry 41.8% 33.0% Coagulation 14.8% 5.9% LFT 19.6% 18.4%
19 RESULTS Preoperative Testing Use SAME-DAY TESTING N=7,209 (9.7% of overall cohort) % Use % Abnormal Any Test 100.0% 61.6% Hematology 86.0% 41.9% Chemistry 76.5% 40.9% Coagulation 35.4% 22.9% LFT 25.8% 33.2%
20 RESULTS Preoperative Testing Use Age group All patients Without comorbidities Younger than 20y 34.9% 33.5% 21y 30y 42.1% 40.0% 31y 40y 47.9% 43.7% 41y 50y 56.5% 49.9% 51y 60y 66.2% 58.5% 61y 70y 73.8% 66.3% 71y 80y 79.5% 71.8% Older than 81y 83.2% 75.0%
21 RESULTS Multivariate Analysis: Factors Predicting Testing Factors associated with receipt of testing across all test types: Increased age Black or Hispanic race ASA class 2 and 3 Receipt of general anesthesia Laparoscopic procedures Hypertension Diabetes Ascites Bleeding disorders Steroid use
22 RESULTS Adverse Outcomes and Testing Major complications: 0.3% (N=239) Wound complications: 0.8% (N=567) Major Complications Wound-Related OR 95% CI OR 95% CI OVERALL COHORT Hematology 1.17 ( ) 0.99 ( ) Chemistry 1.30 ( ) 1.03 ( ) Coagulation 1.25 ( ) 1.05 ( ) LFT 1.02 ( ) 1.07 ( )
23 RESULTS Adjusted Outcomes: Tested vs. Not Tested Major Complications Wound-Related OR 95% CI OR 95% CI SUBGROUP WITHOUT COMORBIDITIES Hematology 0.77 ( ) 1.36 ( ) Chemistry 1.00 ( ) 1.35 ( ) Coagulation 1.38 ( ) 1.04 ( ) LFT 0.94 ( ) 1.07 ( )
24 RESULTS Adjusted Outcomes: Abnormal vs. Normal Tests Major Wound-related OR 95% CI OR 95% CI ABNORMAL vs. NORMAL (Tested patients only) Hematology 1.29 ( ) 0.96 ( ) Chemistry 1.28 ( ) 1.15 ( ) Coagulation 1.52 ( ) 1.16 ( ) LFT 1.50 ( ) 1.14 ( )
25 Selection bias Preoperative Testing in Ambulatory Surgery LIMITATIONS Unable to identify patients who had changes in planned surgery or repeat testing due to abnormal results NSQIP does not report all tests types Unable to identify ordering physician nor can we evaluate variation among providers
26 MEDICARE TESTING RATES HERNIA REPAIR Test All patients (N=13,029) No comorbidities (N=3,187) Any test 84.5% 78.9% CXR 43.5% 38.1% EKG 62.0% 59.5% Hg/Hematocrit 53.1% 49.6% Platelets 51.8% 48.3% Creatinine 27.0% 23.2% Electrolytes 53.6% 48.2% LFTs 35.2% 30.9% Coagulation 16.2% 9.2%
27 MEDICARE TESTING RATES ARTHROSCOPY Test All patients (N=21,993) No comorbidities (N=5,515) Any test 81.2% 73.4% CXR 41.0% 34.9% EKG 57.6% 51.0% Hg/Hematocrit 57.3% 49.1% Platelets 54.1% 46.0% Creatinine 29.9% 24.9% Electrolytes 60.6% 50.4% LFTs 35.9% 27.9% Coagulation 18.8% 12.4%
28 MEDICARE: VARIATION IN TESTING
29 MEDICARE: GEOGRAPHIC VARIATION
30 SUMMARY Preoperative testing is overused Increased age was associated with increased rates of preoperative testing irrespective of presence of comorbidities Overuse of preoperative testing is not only limited to laboratory tests but include chest x-ray and EKG, both mostly used in the elderly Neither preoperative testing nor abnormal results were associated with worse outcomes
31 Future studies must evaluate the comparative effectiveness of testing for specific age groups Clear guidelines need to be developed for testing in the elderly Goals: Preoperative Testing in Ambulatory Surgery CONCLUSIONS Decrease unnecessary testing Decrease cost In order to succeed physician awareness must be increase and all parties must be willing to participate
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