National Institute for Health and Clinical Excellence guidelines on preoperative tests: The use of routine preoperative tests for elective surgery

Clinical Chemistry Department, Queen's Hospital, Belvedere Road, Burton-on-Trent, Staffordshire DE13 0RB, UK.
Annals of Clinical Biochemistry (Impact Factor: 2.34). 02/2006; 43(Pt 1):13-6. DOI: 10.1258/000456306775141623
Source: PubMed


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.

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Available from: Tim M Reynolds, Nov 23, 2015
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    • "The fear of delaying treatment and habitual requesting of routine bloods due to lack of guidance for junior doctors appear to be significant contributing factors anecdotally, which needed to be addressed. NICE have published guidelines on best practice for blood requesting in full blood count, renal function tests, and coagulation screens in scheduled patients[1]for all ASA grades and types of surgery. The general consensus is that a full blood count and renal function tests are required for patients who are ASA 3 and 4 who are to have Grade 3 or Grade 4 surgery, for example a joint replacement. "
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    ABSTRACT: In a recently published report from the Academy of Medical Royal Colleges, around 20% of clinical practice which encompasses blood science investigations is considered wasteful. Blood tests including liver function tests (LFTs), C-reactive protein (CRP), coagulation screens, and international normalising ratios (INR) are frequently requested for patients who undergo emergency hospital admission. The paucity of guidance available for blood requesting in acute trauma and orthopaedic admissions can lead to inappropriate requesting practices and over investigation.Acute admissions over a period of one month were audited retrospectively for the frequency and clinical indications of requests for LFTs, coagulation screens/INR, and CRP. The total number of blood tests requested for the duration of the patient's admission was recorded. Initial auditing of 216 admissions in January 2014 demonstrated a striking amount of over-investigation. Clinical guidelines were developed with multidisciplinary expert input and implemented within the department. Re-audit of 233 admissions was carried out in September 2014.Total no. of LFTs requested: January 895, September 336 (-62.5%); coagulation screens/INR requested: January 307, September 210 (-31.6%); CRPs requested: January 894, September 317 (-64.5%). No. of blood requests per patient: January (M = 4.81, SD 4.75), September (M = 3.60, SD = 4.70). Approximate combined total cost of LFT, coagulation/INR, CRP in January £2674.14 and September £1236.19 (-£1437.95, -53.77%).A large decrease was observed in admission requesting and subsequent monitoring (p <. 0.01) following the implementation. This both significantly reduced cost and venepuncture rates.
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    • "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). "
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    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.
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    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. III.
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