The role of testing in the preoperative evaluation
ABSTRACT
Preoperative laboratory and electrocardiographic testing should be driven by the patient’s history and physical examination and the risk of the surgical procedure. A test is likely to be indicated only if it can correctly identify abnormalities and will change the diagnosis, the management plan, or the patient’s outcome. Needless testing is expensive, may unnecessarily delay the operation, and puts the patient at risk for unnecessary interventions. Preoperative evaluation centers can help hospitals standardize and optimize preoperative testing while fostering more consistent regulatory documentation and appropriate coding for reimbursement.
KEY POINTS
- Age-based criteria for preoperative testing are controversial because test abnormalities are common in older people but are not as predictive of complications as information gained from the history and physical exam.
- Pregnancy testing is an example of an appropriate preoperative test because pregnancy is often not detectable by the history and physical exam and a positive result would affect case management.
- Routine ordering of preoperative electrocardiograms is not recommended because they are unlikely to offer predictive value beyond the history and physical exam and are costly to an institution over time.
- Routine and aged-based preoperative tests are no longer reimbursed by the Centers for Medicare and Medicaid Services.
COST AND REGULATORY BENEFITS OF PREOPERATIVE CENTERS
Preoperative evaluation centers tend to be cost-effective, as they keep consultations and redundant provider interviews to a minimum, encourage more appropriate targeting of tests, and help to avoid last-minute operating room delays and cancellations.21,22 They also provide an efficient means of compiling the chart for the operating room.
The merits of standardization
Preoperative evaluation centers likewise encourage more standardized preoperative assessment, which can facilitate compliance with surgical quality measures such as those from the National Surgical Quality Improvement Program and the Leapfrog Group. Standardization also fosters more efficient and consistent regulatory documentation, making it easier to follow requirements from CMS (often linked to reimbursement) and the Joint Commission. It also tends to improve reimbursement by encouraging more appropriate coding under CMS’ diagnosis-related group (DRG) system to indicate that whatever testing is ordered is related to the surgical diagnosis or to relevant comorbidities.
No excessive dictates from Joint Commission or CMS
Contrary to what many believe, the Joint Commission does not require excessive preoperative testing. The Joint Commission has no mandate for routine diagnostic tests but requires only what is necessary for determining a patient’s health care needs.23
CMS provides no guidance as to what to do or not do in a preoperative assessment, but it does not reimburse for routine screening tests or for age-based testing.24 Reimbursement for a preoperative ECG, for example, requires documentation of the patient’s signs or symptoms; for an ECG that is indicated, reimbursement includes review and interpretation by the physician.25
A new partner for proper preoperative assessment
Appropriate preoperative evaluation and testing is one of the goals promoted by the recently formed Society for Perioperative Assessment and Quality Improvement (SPAQI). The mission of this international nonprofit organization is to optimize surgical outcomes by sharing best practices and promoting research and communication among health professionals across multiple disciplines. More information is available at www.spaqi.org.
DISCUSSION
Question from the audience: At my hospital, we teach residents about limiting the preoperative tests they order, but surgeons routinely expect many of these tests, including chest x-rays in patients with pulmonary conditions. Are any surgical societies involved in efforts to reduce preoperative testing? Or are surgical societies’ recommendations actually driving some of the unnecessary testing?
Dr. Hepner: I’m not aware of recommendations from surgical societies regarding preoperative testing. Many surgeons believe that the more testing that’s done, the likelier they are to uncover an occult disease. They also often want baseline information, which may actually be warranted in some cases.
Question from the audience: If you’re already ordering a “type and screen” or “type and hold” for a patient, isn’t it worthwhile to just add on a CBC? The patient is already getting the phlebotomy, so isn’t there a cost benefit to getting other routine tests done at the same time rather than calling the patient back for more tests if another indication arises?
Dr. Hepner: Charges are generally assessed for each individual test, not for drawing blood, so I would only get the tests that are indicated.
Question from the audience: In institutions without a preoperative clinic, sometimes the surgeons do the work-up without discussing the case with the primary doctor, and the surgeons want an ECG so that the case isn’t cancelled at the last minute. Can you give straightforward criteria in such cases, such as an age threshold, or would you not order an ECG for anyone?
Dr. Hepner: Based on our most recent data, 60 years seems to be a reasonable cutoff if you are going to use age as a criterion.
Question from the audience: What criteria do you use for preoperative screening with pregnancy tests?
Dr. Hepner: If you have an unreliable patient population, general screening should be done. We don’t have such a requirement, but we have a very low threshold. If a patient appears very reliable, knowing the exact date of her last menstrual period, we’ll go by that. If a patient is unsure, we’ll do a pregnancy test.
Question from the audience: My hospital doesn’t have a preoperative clinic, and until recently, the anesthesiology department has helped surgeons with ordering of preoperative tests. We followed a guideline protocol for about 20 years. Now the newer surgeons say they don’t want to be responsible for abnormal test results. Yet we anesthesiologists aren’t seeing the patients, so we can’t use clinical judgment; we can only go by the guidelines. The surgeons are the only physicians on the case who actually do the history and physical exam. So who should sign the test orders and be responsible for abnormal results?
Dr. Hepner: In our preoperative test center, we tell the surgical team that if they are uncertain about which tests to order, we will handle it. And if we order a test, we follow up on the results. You must ensure that orders are signed and not rubber-stamped; that way, the person who orders a test will get called with any abnormal results. If you order it, you own it.
Question from the audience: I agree that no testing is needed for the 72-year-old man you presented who was undergoing surgery for inguinal hernia, but it always worries me not to do an ECG since part of the standard of care for anesthesia is intraoperative ECG monitoring. If we see some sort of unusual arrhythmia when we take the patient in, we might cancel the case if we don’t know whether it was present at baseline. Surgeons will ask me, “Why didn’t you order a baseline if you’re going to monitor the ECG in the operating room? If you’re not going to order a baseline, then why monitor the ECG?” These are medicolegal issues that I haven’t seen addressed.
Dr. Hepner: A case like you describe will be addressed in the upcoming medicolegal session (see page S119). You make a good point that many times just having a baseline is helpful, but I would argue that it is more helpful for intermediate- or high-risk cases.
