Friday, May 11, 2012

Not "routine" any more

Here is a note from the Director of Preoperative Evaluation of the MA Eye and Ear Infirmary that is indicative of some of the thoughtful work that is going on about whether all tests routinely given in hospitals are necessary:

Dear Colleagues,
After reviewing a number of studies on the subject of preoperative testing, most experts no longer recommend performing "routine" lab (CBC & Chemistries) & EKG on all adult patients undergoing surgery. (1,2,3) 

Instead it is recommended to only perform targeted preoperative tests to help manage existing medical conditions, or before specific surgical procedures, when the results of testing are likely to alter perioperative management. Performing "routine" lab & EKGs on all patients has not been shown to improve patient outcomes." Routine" testing increases costs, results in a large number of abnormal (but rarely clinically significant) results that frequently necessitate performing additional tests, increases perioperative delays and patient anxiety.

As a result of these recommendations, our Anesthesia Department modified and has been using since 2010 (updated in 2011) our requirements for lab work to reflect these recommendations.

Recently our MEEI Medical Evaluation Center (MEC) has also modified their requirements for preoperative for lab and EKG for patients being evaluated in the MEC. The only distinction between the attached Anesthesia and MEC requirements, is that the MEC is now obtaining (in addition to the Anesthesia requirements) EKGs for patients with a history of hypertension, and for patients age 60 or greater undergoing ophthalmic surgery.

If you wish to obtain additional lab tests for a patient being evaluated in the MEC, please complete and fax the attached MEEI Lab Requisition form to the MEC. Please include on the form the date of the patient's MEC appointment. If the MEC appointment is rescheduled please inform the MEC so that the lab requisition can be moved to the new date.  It will be the responsibility of the ordering physician to check the results of any additional tests ordered. 

Thank you very much for your assistance with these issues. Please feel free to contact me or the MEC staff if you have questions or comments about these issues.

Joseph Bayes M.D.
Director of Preoperative Evaluation
Department of Anesthesia
  1. Practice Advisory for Preanesthesia Evaluation: An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.
  2. Hepner DL. The role of testing in the preoperative evaluation. Hepner DL.;76/Suppl_4/S22
  3. Fleischer LA et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Page 1983.


David said...

I hate to disillusion you, but routine preoperative testing went out in the 90s. Routine chest x-rays, CBCs and chemistries were no longer done unless there was a clinical indication, and EKGs were only routinely done on men>40 and women>50. Many depts. upped those age limits by a decade in later years.

As a Senior Board Examiner for 22 years, I know the preoperative testing standards for Oral Boards in Anesthesiology were similarly revised several years before I stepped down from that position in 2000. Therefore, it has been a long time since these tests were routinely required in hospital patients preoperatively.

Peter said...

David, you're correct that guidelines do not recommend routine preoperative testing, but the penetrance of this recommendation in practice is spotty at best. My experience working in two major medical centers in Los Angeles and Boston over the last 5 years has shown that it is still common to see preoperative chest x-ray, EKG, CBC, and even coagulation studies ordered for people without pertinent clinical histories.