Original articleEconomic Impact of Clinical Variability in Preoperative Testing for Major Outpatient SurgeryImpacto económico de la variabilidad clínica en la petición de pruebas preoperatorias en cirugía mayor ambulatoria☆,☆☆
Introduction
The objective of preoperative evaluations is to provide information about the physical and mental health status of patients, to assess their risks for anaesthesia/surgery, and to outline a plan for anaesthesia/analgesia as well as perioperative care. As the physical status of patients correlates with different surgical risks in the American Society of Anesthesiologists (ASA) classification,1 it is necessary to properly select and evaluate patients to undergo surgical intervention. Hence, anaesthesia evaluations include a series of diagnostic tests in order to detect previously undiagnosed diseases, thereby guaranteeing that the patient has met certain safety criteria before surgery. These tests, however, are often routinely requested, with no specific clinical indication, based on the erroneous concept that they are a substitution for proper patient medical history and physical examination.2 These tests are an unnecessary expense, have questionable diagnostic value, are generally useless, and their impact on the final results of the operation is very limited. Meanwhile, patients are being subjected to studies that are not free of risks themselves. This reduces the quality of the healthcare received while considerably increasing costs per patient, in addition to other indirect costs such as travel expenses, lost productivity at work, etc. Although many preoperative tests are low cost, if we consider the elevated number of patients treated who are classified as ASA I and II, the final result is a needless expenditure of millions of euros for the public healthcare system.3 With the current search for ways to guarantee the sustainability of the Spanish national healthcare system, increased efficacy in the administration of these resources is a highly relevant goal.
The protocol for ordering preoperative studies at our centre is based on the recommendations of the Spanish Society for Anaesthesia, Reanimation and Pain Therapy and the Spanish Association of Major Ambulatory Surgery. The protocol establishes the criteria by which diagnostic tests should be requested for patients who are scheduled for low-risk surgery, according to ASA grade. At our hospital, this information had been distributed to all the surgical departments that conduct major ambulatory surgery (MAS).
Although many studies have discussed the existence of great variability in performing the same procedure within the healthcare system of our country, to our knowledge there have been no studies estimating the cost attributable to the variability in preoperative evaluations for MAS.
The main objective of this study was to calculate the economic impact associated with clinical variability and lack of adherence to the protocol established in our hospital for the anaesthesia evaluation of ASA I and II patients. As a secondary objective, the authors proposed to report and analyse patient profiles and surgical specialties according to the degree of protocol compliance.
Section snippets
Methods
We conducted a retrospective cost minimisation study using a simple randomised sample of cases that had been treated in the anaesthesia consultation of the MAS unit over a period of 12 months (June 2012 – May 2013).
Regarding preoperative testing, the protocol establishes that patients classified as ASA I and II who are scheduled for low-risk surgery (usually ambulatory procedures) should have complete blood work-up with coagulation, glycemia, creatinine, urea and ions. In patients over the age
Results
Our study included 353 patients, 329 of which (93.2%; 95%CI: 90.1–95.4) belonged to ASA physical status classes I and II. The population characteristics studied are described in Table 1. The remaining 6.8% were ASA III and therefore excluded from the study.
Overall, Non-compliance with the protocol was observed in 70% (95%CI: 65–75) of cases (Table 2). The departments with higher non-compliance rates were Urology, Plastic and Reconstructive Surgery and General Surgery, in which 100, 93 and 92%
Discussion
The main findings of this study have been the limited adherence to the protocol by the surgery units in a population of healthy patients proposed for low-risk ambulatory surgical procedures, and the consequent increase in costs incurred by our hospital. Several reasons, such as tradition, inertia, fear of medical or legal repercussions, etc., together with the demonstrated slowness with which scientific advances are implemented in daily clinical practice,4, 5 may explain these results.
As for
Authorship
Gil-Borrelli was responsible for the study design, analysis and interpretation of the data and writing of the manuscript. Agustí and Zaballos were involved in the study design and data acquisition/collection. Pla and Díaz contributed with the data analysis and interpretation, as well as the critical review and final approval of the manuscript.
Conflict of Interests
The authors have no conflict of interests to declare.
References (15)
- et al.
The case against routine preoperative laboratory testing
Med Clin North Am
(2003) - et al.
Estudio Delphi para el desarrollo de pautas de indicación de pruebas preoperatorias. Consenso de anestesiólogos y cirujanos
Rev Calid Asist
(2002) - et al.
Preoperative tests recommendations in adult patients for ambulatory surgery [article in Spanish]
Rev Esp Anestesiol Reanim
(2015) - American Society of Anesthesiologists [Internet]. Washington: the Association; c1995–2014 [Updated in 2001; consulted 3...
More preoperative assessment by physicians and less by laboratory tests
N Engl J Med
(2000)- et al.
Routine preoperative testing: a systematic review of the evidence
Health Technol Assess
(1997) - Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG; American Society of...
Cited by (0)
- ☆
Please cite this article as: Gil-Borrelli CC, Agustí S, Pla R, Díaz-Redondo A, Zaballos M. Economic impact of clinical variability in preoperative testing for major outpatient surgery. Cir Esp. 2016;94:280–286.
- ☆☆
Part of this study was used in 2 oral communications presented at the Spanish Society for Quality Healthcare Conference held in October 2014, in Madrid, under the title: Quality and efficiency of anaesthesia evaluations for major ambulatory surgery in ASA I and II patients.