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Is there reason for routine pre-op tests? New research raises question
Is routine preoperative testing an outdated concept? Despite the fact that many outpatient surgery programs continue to perform the testing, even for simple eye operations, a recent study raises the question about whether such testing has an impact on clinical outcomes.1
In the pilot study, 1,061 eligible patients were randomized to have indicated pre-op testing or no pre-op testing. The pre-op testing included, as needed, a complete blood count, electrolytes, blood glucose, creatinine, electrocardiogram, and chest radiograph. The primary outcome measures were the rate of peri-op adverse events and the rates of adverse events within seven to 30 days after surgery. Patients' age, gender, American Society of Anesthesiologists status, type of surgery, and anesthesia were similar between the two groups. All ages and types of outpatient surgery were included. The study was randomized, single-blind, prospective, and controlled.
The finding? There were no significant differences in the rates of peri-op adverse events and the rates of adverse events within 30 days after surgery between the no-testing group and the indicated testing group. Hospital revisits seven days or later were higher in the indicated testing group. None of the adverse events were related to the indicated testing or no testing.
"This pilot study showed that there was no increase in the perioperative adverse events as a result of no preoperative testing in our study population," the researchers wrote. "A larger study is needed to demonstrate that indicated testing may be safely eliminated in selected patients undergoing ambulatory surgery without increasing perioperative complications."
The bottom line is that the value of routine pre-op testing is questionable, as long as a thorough history is performed, say sources interviewed by Same-Day Surgery. Providers point to earlier research by Oliver Schein, MD, MPH, professor of ophthalmology at The Wilmer Eye Institute, Johns Hopkins University School Of Medicine, Baltimore, in The New England Journal of Medicine, which indicated that patients who did not have routine pre-op tests before cataract surgery fared as well as patients who did have the tests.
"The additive value of additional testing continues to be questioned," says Lee A. Fleisher, MD, Robert D. Dripps Professor and chair of anesthesiology and critical care at the University of Pennsylvania School of Medicine in Philadelphia.
At the ambulatory surgical unit at the University Health Network in Toronto, routine pre-op testing was stopped for eye patients after the Schein study was published, reports Frances Chung, FRCPC, lead author of the recently published research and professor of anesthesia at the University of Toronto and medical director of the ambulatory surgical unit. A history and physical (H&P) is obtained by a physician, she adds.
What Chung's study illustrates is that if you're certain patients are stable, and you have had a thorough H&P, that the likelihood that testing would have any additional value is "extremely rare," Fleisher says. A large-scale study still might be needed to prove that finding, he adds.
Fleisher's opinions about pre-op testing aren't rare, particularly in terms of cataract surgery. "Routine pre-op testing confers no value for cataract surgery and presumably for other low medical risk surgical interventions," says Schein. At Johns Hopkins, no routine lab testing is required for cataract surgery. "Lab testing occasionally – rarely – changes management, but we usually don't know if it actually affects the clinical outcome," Schein says.
Don't uniformly throw out pre-op evaluation or even all pre-op testing, providers warn.
"This is not to say that if you stop taking a good history, and therefore stop identifying conditions that warrant further evaluation because they're less stable, we won't be developing increasing complications," Fleisher says.
At the University of Pennsylvania, the nurse practitioners conduct a thorough history in the surgeons' offices, he reports. "Between the patient self-assessment and the nurse practitioner assessment, we get that info, and we have a very low cancellation rate," Fleisher says. Pre-op tests are conducted only if they find some progression or some type of unstable symptom, he adds.
Selective patients will need pre-op testing, Chung says. She points to patients with significant heart disease and obstructive sleep apnea.
"I don't think we need to indiscriminately do [pre-op testing] in every single patient now," Chung says. "Testing is still overutilized at present."