From the 2018 HVPAA National Conference
NEIL KESHVANI (University of Texas Southwestern Medical Center, Dallas, TX;), Nemi Shah (University of Texas Southwestern Medical Center, Dallas, TX;), Sandeep Das (University of Texas Southwestern Medical Center, Dallas, TX; Parkland Center for Healthcare Innovations and Clinical Outcomes), Kimberly A. Kho (University of Texas Southwestern Medical Center, Dallas, TX; Parkland Center for Healthcare Innovations and Clinical Outcomes)
Preoperative electrocardiogram and chest x-ray are commonly utilized in the work up for benign hysterectomy. No single standard of care exists to guide surgeons in the use of preoperative studies to optimize patients for gynecologic surgery.
Our institution, like others in the United States, employs guidelines developed by our anesthesia department. The National Institute for Health and Care Excellence guidelines are used in the United Kingdom and several other European countries. Our objective was to assess concordance between our local practice pattern and these guidelines and to assess the utility of preoperative electrocardiogram and chest x-ray for benign hysterectomy.
The medical records of 587 women who underwent hysterectomy for benign indications at a single institution from January 1 through December 31, 2016 were reviewed. Each electrocardiogram and chest x-ray was analyzed for indication, concordance with institutional and National Institute for Health and Care Excellence guideline recommendations, result, effect on management, and association with perioperative complications.
Subjects had an average age of 44.8 years (range, 27-76), and were primarily of Hispanic (58.4%) and black (30%) race. For 587 benign hysterectomies performed, 182 electrocardiograms (31.0%) and 70 chest x-rays (11.9%) were ordered. Electrocardiogram was indicated in 166 (91.2%) patients according to institutional criteria and 177 (97.3%) patients per National Institute for Health and Care Excellence criteria, with local use in 91% institutional and 97% National Institute for Health and Care Excellence guideline concordance. Findings were normal in 101 (55%) and abnormal in 81 (45%) of 182 electrocardiograms. Further work up was pursued in 16 of 81 (20%) patients with abnormal electrocardiogram findings in the form of repeated electrocardiogram (6), additional cardiac testing such as echocardiogram or stress test (7), and/or specialist consult (7). These additional tests did not alter management. Two perioperative complications were noted. Surgery was aborted after post-induction nonspecific ST segment electrocardiogram changes in a patient with minimal ventricular hypertrophy voltage criteria on initial preoperative electrocardiogram. A second patient with airway edema failed extubation, with preoperative electrocardiogram having shown an old inferior infarct.
Of the 70 chest x-rays ordered, 17 (24.3%) were in concordance with institutional criteria. No preoperative chest x-rays were indicated per National Institute for Health and Care Excellence criteria. Results showed new abnormal findings in 10 of 70 (14.3%) chest x-rays. Known cardiomegaly and atelectasis were re-demonstrated in 2 patients. Anesthesia was consulted in 1 patient, and the surgery was subsequently continued as planned without management change. No cases were cancelled, nor were there any cardiopulmonary surgical or anesthetic complications in patients undergoing preoperative chest x-ray
Our data suggest that, regardless of guideline compliance, pre-operative electrocardiogram and chest x-ray offer little clinical utility in patients undergoing hysterectomy for benign indications
Implications for the Patient
Revision of indications for preoperative electrocardiogram and chest x-ray should be considered in order to avoid low-value testing for gynecologic procedures.