Clinical Guideline CG3 from the National Institute for Health and Clinical Excellence (NICE) makes recommendations on appropriate clinical practice in preoperative testing for elective surgery. Unfortunately, there is minimal evidence on which the guidelines could be based and therefore they were constructed on the basis of professional opinion. This resulted in the construction of a decision matrix of Byzantine complexity built on foundations of sand: surgical risk is estimated using an unvalidated ad hoc risk estimation method; anaesthetic risk is estimated using the American Society of Anesthesiologists (ASA) risk method that has been demonstrated to be incapable of generating consistent risk assessments. The resultant matrix may be suitable for use as a template for future research, but is extremely complex and inadequately rigorous for routine use.
"Guidance issued in the United States and Canada is not binding on physicians or hospitals, as they are not tied to payment. However, payment in the United Kingdom is tied to adherence to certain guidelines (Reynolds, 2006). "
[Show abstract][Hide abstract] ABSTRACT: Health care institutions in many Western countries have developed preoperative testing and assessment guidelines to improve surgical outcomes and reduce cost of surgical care. The aims of this chapter are to (1) summarize the literature on the effect of preoperative testing on clinical outcomes, efficiency, and cost; and (2) to compare preoperative testing guidelines developed in the United States, the United Kingdom, and Canada.
We reviewed the literature from 1975 to 2014 for studies and preoperative testing guidelines.
We identified 29 empirical studies and 8 country-specific guidelines for review. Most studies indicate that preoperative testing is overused and comes at a high cost. Guidelines are tied to payment only in one country studied. This is the most recent review of the literature on preoperative testing and assessment with a focus on quality of care, efficiency, and cost outcomes. In addition, this chapter provides an international comparison of preoperative guidelines.
Advances in Health Care Management 05/2015; 17:161-94. DOI:10.1108/S1474-823120140000017010
[Show abstract][Hide abstract] ABSTRACT: To examine adherence to evidence-based recommendations for preoperative testing and health care costs associated with excessive testing.
An institutional review of women who underwent gynecologic surgery between 2005 and 2007 was performed. Data on the type of surgery, age, comorbidities, and perioperative testing was extracted. We noted the preoperative performance of chest X-ray, electrocardiogram, metabolic panel, complete blood count, coagulation studies, liver function tests, and urinalysis. Each test was classified as being guideline-based (appropriate) or non-guideline-based (inappropriate) as described by the National Institute of Clinical Excellence perioperative guidelines.
A total of 1,402 patients were identified. Ninety-five percent of patients underwent all of the guideline-recommended preoperative testing. Ninety percent of women underwent at least one nonindicated preoperative test. None of the 749 urinalyses, 407 liver function tests, or 1,046 coagulation studies performed was appropriate. Ninety-nine percent of the 427 chest X-rays ordered were inappropriate. Only 17% of metabolic panels, 36% of electrocardiograms, and 29% of complete blood counts were in accordance with evidence-based guidelines. Inappropriate perioperative tests led to a direct cost of more than $418,000. Of the inappropriate tests ordered, abnormalities were noted frequently but rarely changed management.
Adherence to evidence-based recommendations for preoperative testing is poor. Inappropriate preoperative tests represent a major health care expenditure.
Obstetrics and Gynecology 09/2010; 116(3):694-700. DOI:10.1097/AOG.0b013e3181ec448d · 5.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laryngeal dysplasia is a pre-malignant condition with wide variability in rates of malignant transformation reported in the literature. The management and follow-up strategies of these lesions vary widely.
To assess the risk of and interval to malignant transformation in patients with laryngeal dysplasia, the effect of different treatment modalities on malignant transformation and the effects that risk factors such as smoking, excessive alcohol intake and histological grade may have on this.
Systematic of observational studies with attempted meta-analysis.
A structured search of Medline (1966 to January 2010), EMBASE (1980 to January 2010), CINAHL (1981 to January 2010) and Cochrane databases (CENTRAL, Cochrane Library, 1995 to January 2010).
Nine hundred and forty cases from nine studies were included in the analysis. Overall malignant transformation rate was 14% (confidence interval 8, 22) and mean time to malignant transformation was 5.8 years. The malignant transformation rate is higher with increased severity of dysplasia grade - severe/CIS 30.4%versus mild/moderate 10.6% (P < 0.0002). Treatment modality did not show significant effects.
Laryngeal dysplasia carries a significant risk of malignant transformation. This risk triples with increasing severity of dysplasia. Transformation often occurs late and is not related to the grade of dysplasia. There is little evidence, therefore, to support the early discharge of patients with mild/moderate dysplasia, which is practised by some clinicians.
Clinical otolaryngology: official journal of ENT-UK; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery 10/2010; 35(5):364-72. DOI:10.1111/j.1749-4486.2010.02181.x · 2.11 Impact Factor
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