Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Key Questions

1. Does routine preoperative testing compared to no testing or alternative testing strategies improve outcomes (such as surgical complications, other morbidity, and mortality) among patients undergoing elective surgery?
2. What are the harms of routine preoperative testing compared to no testing or to an alternative testing regimen?
3. Do the benefits or harms of routine preoperative tests vary by the risk of the surgical procedure (low vs. medium vs. high risk)? Do the benefits or harms of routine preoperative tests vary by the clinical conditions, comorbidities or risks of the particular patient? (e.g. potassium in patients on diuretics, pregnancy test in women of child-bearing age)
4. Do routine preoperative tests change patient management decisions?

We proposed the following set of Key Questions. The population in question is assumed to be patients who have had a thorough history and physical examination during which no suspected clinical abnormalities are identified which might require further evaluation. In this set of Key Questions, “routine preoperative tests” refers to any combination of the following: electrocardiogram, chest x-ray, complete blood count, prothrombin time/partial promboplastin time basic or complete metabolic panel, urinalysis, and urine pregnancy test.

This proposed evidence review would not include perioperative cardiovascular evaluation which is discussed in a 2007 ACC/AHA guideline.18

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

1. routine preoperative testing compared to no testing or alternative testing.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

All pre-surgical evaluations. The population in question is assumed to be patients who have had a thorough history and physical examination during which no suspected clinical abnormalities are identified which might require further evaluation

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

In addition to savings of at least $10 billion annually in the United States,7 the elimination of unneeded preoperative testing could improve patient safety,1 eliminate delays,15 limit harm from unnecessary follow-up of abnormal tests,7,14 improve system efficiency,14,15 decrease postponement of surgery,7,14,15 and improve the patient experience.14,15 A large proportion of the cost savings would be among patients enrolled in federal healthcare programs.

Describe any health-related risks, side effects, or harms that you are concerned about.

It is unclear why routine preoperative testing is still widespread. Reasons for continued use of routine preoperative tests are poorly understood. Possible factors include the following: institutional policies and procedures,4,6,12,16 medicolegal worries 4,6,9,12 concern about surgical delays,4,15 complex healthcare environments,14 the difficulty of changing ingrained behavior,6,7 and a belief among physicians that other physicians want the tests performed.2,12

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Arthritis and nontraumatic joint disorders
• Cancer
• Cardiovascular disease, including stroke and hypertension
• Dementia, including Alzheimer's disease
• Depression and other mental health disorders
• Developmental delays, attention-deficit hyperactivity disorder, and autism
• Diabetes mellitus
• Functional limitations and disability
• Infectious diseases, including HIV/AIDS
• Obesity
• Peptic ulcer disease and dyspepsia
• Pregnancy, including preterm birth
• Pulmonary disease/asthma
• Substance abuse

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare
• State Children's Health Insurance Program (SCHIP)
• Other

Importance

Describe why this topic is important.

Numerous experts have called for an end to routine preoperative testing, including the ASA and the Institute for Clinical Systems Improvement. 1,3,4,13,14 The ASA published a 2002 practice advisory3 noting that "preoperative tests should not be ordered routinely," and it outlines indications for commonly used tests. The United Kingdom’s National Institute for Health and Clinical Excellence has published a guideline on the use of routine preoperative tests for elective surgery.19

In addition to savings of at least $10 billion annually in the United States,7 the elimination of unneeded preoperative testing could improve patient safety,1 eliminate delays,15 limit harm from unnecessary follow-up of abnormal tests,7,14 improve system efficiency,14,15 decrease postponement of surgery,7,14,15 and improve the patient experience.14,15 A large proportion of the cost savings would be among patients enrolled in federal healthcare programs.

It is unclear why routine preoperative testing is still widespread. Reasons for continued use of routine preoperative tests are poorly understood. Possible factors include the following: institutional policies and procedures,4,6,12,16 medicolegal worries 4,6,9,12 concern about surgical delays,4,15 complex healthcare environments,14 the difficulty of changing ingrained behavior,6,7 and a belief among physicians that other physicians want the tests performed.2,12

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

The American Society of Anesthesiologists (ASA), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP) co-nominate “preoperative evaluation and testing” as a topic for an AHRQ evidence-based practice center (EPC) evidence review.

During pre-surgical evaluations, physicians frequently order a battery of tests. Tests often considered part of a routine preoperative evaluation include: complete blood count, electrocardiogram, chest radiograph, electrolytes, renal function tests, glucose, hepatic tests, urinalysis, pregnancy testing, and coagulation tests.3,4 Preoperative laboratory testing in the United States costs at least $18 billion annually.1,2

The value of routine preoperative testing has been challenged. In fact, preoperative tests rarely change management 3-6 and may cause harm to patients.6-9 Up to 93% of preoperative tests may not be indicated.7,10 Two recent randomized controlled trials demonstrated no benefit to preoperative testing2,11 and many physicians feel these tests are unnecessary.12

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Numerous experts have called for an end to routine preoperative testing, including the ASA and the Institute for Clinical Systems Improvement. 1,3,4,13,14 The ASA published a 2002 practice advisory3 noting that "preoperative tests should not be ordered routinely," and it outlines indications for commonly used tests. The United Kingdom’s National Institute for Health and Clinical Excellence has published a guideline on the use of routine p Recent editorials have emphasized the need for leadership to reduce unnecessary preoperative testing.1,14 Physicians in several specialties and numerous other healthcare professionals are involved in preoperative decision making. Therefore, any attempt to eliminate routine testing will require a solution that is acceptable across disciplines.

The 2002 ASA practice advisory is not widely used,17 is now 8 years old, and an explicitly evidence-based methodology was not employed to support this practice advisory. An updated consensus guideline based on an EPC evidence report and widely disseminated by the nominating organizations has the potential to help minimize practice variation in preoperative testing, decrease costs, maximize quality, improve physician confidence with test ordering, and improve the patient experience.

This proposed evidence review would not include perioperative cardiovascular evaluation which is discussed in a 2007 ACC/AHA guideline.18 reoperative tests for elective surgery.19

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

It is the intent to develop a clinical practice guideline if the evidence review is sufficent to do so.

Describe the timeframe in which an answer to your question is needed.

As soon as possible, hopefully in 2011.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

This topic impacts all pre-surgical patients.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

It is the intent to develop a clinical practice guideline if the evidence review is sufficent to do so.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

Have worked closely with AHRQ for many years.