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J Clin Anesth. 2019 Aug;55:92-99. doi: 10.1016/j.jclinane.2018.12.027. Epub 2018 Dec 29.

The impact of reduction of testing at a Preoperative Evaluation Clinic for elective cases: Value added without adverse outcomes.

Author information

1
Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South Medical Arts Building #708, Nashville, TN 37212, United States of America.
2
Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South Medical Arts Building #708, Nashville, TN 37212, United States of America. Electronic address: gen.li@vumc.org.
3
Vanderbilt University School of Medicine, 2301 Vanderbilt University Hospital, Nashville, TN 37232, United States of America.
4
Department of Anesthesiology, Vanderbilt University School of Medicine, 4648 Vanderbilt University Hospital, Nashville, TN 37232, United States of America; Department of Biomedical Informatics, Vanderbilt University School of Medicine, 4648 Vanderbilt University Hospital, Nashville, TN 37232, United States of America; Department of Surgery, Vanderbilt University School of Medicine, 4648 Vanderbilt University Hospital, Nashville, TN 37232, United States of America; Department of Health Policy, Vanderbilt University School of Medicine, 4648 Vanderbilt University Hospital, Nashville, TN 37232, United States of America.
5
Department of Anesthesiology, Vanderbilt University School of Medicine, 4648 Vanderbilt University Hospital, Nashville, TN 37232, United States of America; Department of Biomedical Informatics, Vanderbilt University School of Medicine, 4648 Vanderbilt University Hospital, Nashville, TN 37232, United States of America.

Abstract

STUDY OBJECTIVE:

Protocol changes at Vanderbilt have been adopted with the intention of reducing unnecessary preoperative testing. We sought to evaluate their success and association with clinical decisions.

DESIGN:

Retrospective Observational Study SETTING: Vanderbilt's Preoperative Evaluation Clinic MEASUREMENTS: We reviewed and identified a key interval of change on clinical workup protocols which led to a reduction in preoperative testing. We queried Data Warehouse for preoperative chemistry tests, complete blood counts, coagulation blood draws, electrocardiograms, and chest x-rays done before and after these intervals. Chi-square, univariate and mixed effect multivariable regressions were performed to determine the significance of testing reduction and tendency of readmission rates and length-of-stay; Welch's t-test with Freeman-Tukey transformation was conducted to identify the differences in case cancellation rates.

MAIN RESULTS:

We analyzed 56,425 anesthetic cases and there was a statistically significant downward trend in all preoperative testing performed: electrocardiograms (61.90% to 31.66% [OR 0.151; 95% CI 0.144 to 0.159]), coagulation blood draws (37.57% to 29.74% [OR 0.392; 95% CI 0.370 to 0.416]), basic metabolic panels (70.64% to 51.29% [OR 0.294; 95% CI 0.280 to 0.309]), blood cell counts (71.38% to 51.42% [OR 0.264; 95% CI 0.251 to 0.277]) and chest x-rays (11.80% to 6.04% [OR 0.417; 95% CI 0.384 to 0.452], to 3.13% [OR 0.473; 95% CI 0.431 to 0.519]) after protocol changed. The changes didn't induce a significant increase in case cancellations, length-of-stay, readmission or most DOS testing; except for BMPs (0.28% to 0.66% [OR 1.307; 95% CI 1.104 to 1.549]).

CONCLUSIONS:

A net reduction in preoperative testing was seen at our institution from 2012 to 2015 due to anesthesia protocol changes intended to limit routine ordering of labs and imaging. While there was a significant increase in DOS testing for BMPs, these increases were not enough to offset the decrease in testing observed preoperatively.

KEYWORDS:

Anesthesiology; Preoperative care; Quality improvement

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