Why Bother! The Comprehensive Pre Op Panel
Jointly Sponsored by the Sections on:
Anesthesiology and Resuscitation
Evidence Based Health Care
Pediatrics
Radiology
Urology
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:
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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
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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 2014.
174(4):498
What do we know about the benefits and
harms of preoperative testing?
Benefits:
 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 2014.
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 costeffective literature. Health Tech Assess 2012;16(50).
What do we know about the benefits and
harms of preoperative testing?
Harms:
 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 2014.
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.
2009 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 2012. 116(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 2014.
174(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:
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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 lowrisk 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.