From the 2021 HVPAA National Conference
Nina D’Amiano (Johns Hopkins University School of Medicine), Matt Stewart, Rosalyn Stewart,
Background
Prior to surgery, patients undergo a preoperative assessment to determine their medical readiness for surgery. Preoperative evaluations can be performed by a variety of providers in different settings, such as in a primary care provider’s (PCP) clinic or a preoperative evaluation center. The purpose of a preoperative evaluation center is to medically optimize patients for surgery, as well as streamline the process of medical evaluation and appropriate preoperative testing. Some studies suggest that routine preoperative assessment tends to include excessive testing, which imposes unnecessary burdens on both individual patients and the U.S. healthcare system. Despite evidence-based professional guidelines, little is known about whether preoperative testing varies based on setting.
Objective
This project assessed whether there was a difference in guideline concordance for preoperative testing between PCPs and preoperative evaluation center providers.
Methods
We retrospectively reviewed medical records of patients who obtained an outpatient preoperative assessment and underwent surgery in the Johns Hopkins Department of Otolaryngology Head and Neck Surgery (OHNS) during the first two weeks of January 2019 (N=94). We referred to the 2014 American College of Cardiology/American Heart Association Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. We collected data on patients’ demographics, preoperative health status, procedure, and preoperative testing. We used the National Surgical Quality Improvement Program (NSQIP) Risk Calculator to compute the preoperative risk of a major adverse cardiac event (MACE score). Together, this data was used to determine what preoperative testing was indicated according to professional guidelines. Standard descriptive statistics were used to determine the appropriateness of the preoperative evaluation. Chi-square test was used to compare excessive preoperative testing between PCPs and preoperative evaluation center providers, who included anesthesiologists, nurse practitioners, and physician assistants at the Johns Hopkins Center for Perioperative Optimization. In addition to the quantitative analysis, the professional guidelines were compared to the departmental OHNS preoperative testing recommendations to PCPs.
Results
Overall, in 45.2% of the preoperative evaluations, tests were ordered in excess of professional guidelines. When stratified by setting, there was a statistically significant difference in the proportion of preoperative evaluations with excessive testing; excessive preoperative testing occurred in 56.5% of the evaluations performed by PCPs compared to 20.7% of those performed by preoperative evaluation center providers (p-value = 0.001). Furthermore, we found that the departmental OHNS recommendations conflicted with professional guidelines; for example, OHNS advises obtaining an ECG on any patient over the age of 50, although guidelines do not endorse routine age-based preoperative ECG testing.
Conclusions
Preliminary evidence demonstrates that preoperative testing exceeds professional guidelines and excessive preoperative testing is more commonly performed by PCPs compared to preoperative evaluation center providers. Next steps include reconciling departmental OHNS recommendations with professional guidelines, identifying the reasons for differential guideline discordance across settings, and then intervening accordingly.
Clinical Implications
Our study findings inspired the OHNS Quality and Safety Committee to revise its departmental preoperative testing recommendations to PCPs based on professional guidelines. This will affect the preoperative testing decisions of many providers. In addition, it would be prudent for all surgical departments to review their preoperative evaluation recommendations in order to minimize unnecessary testing. With regard to high-value healthcare, although PCPs traditionally perform preoperative assessments, our results suggest that a potential shift in this clinical responsibility from PCPs to preoperative evaluation center providers could reduce healthcare costs.
