Routine presurgical assessment of patients with a standard battery of tests not only is wasteful but can lead to more unnecessary expense, delay, and even risk to the patient and physician. Any abnormal tests results, even if likely to be clinically unimportant to the upcoming surgery, will need to be followed up to rule out a significant abnormality that may have later implications. This review will outline strategies for making decisions about which tests are clinically useful for preoperative assessment of a given patient and also discuss the value of preoperative evaluation centers in promoting appropriate preoperative testing.
PREOPERATIVE EVALUATION SHOULD BE CLEARLY DIRECTED
Most patients scheduled for surgery at Brigham and Women’s Hospital are assessed by the staff at our preoperative evaluation center. We take a medical history and conduct a physical examination, review the medical records, order laboratory tests or other studies as indicated, and determine which patients need further work-up or consultations. The goals are to evaluate patient readiness for anesthesia and surgery, optimize patient health before surgery, enhance the quality of perioperative care, reduce the morbidity of surgery and length of stay, and return the patient to normal functioning. 1,2
The above goals are generally achieved by directed laboratory testing, managing the patient’s medications, stabilizing disorders when possible, and creating plans for postoperative care and pain management. Communication among the surgeon, the anesthesiology team, and the preoperative medical consultant (if there is one) is critical. 1,2
In contrast, “clearing the patient for surgery” is not a legitimate goal of consultation. The real issues to be taken up in a consult are:
- What is the patient’s risk of complications (cardiac and noncardiac)?
- Would further risk stratification alter patient management?
- Can anything be done to reduce the patient’s risk?
If indicated, a consult should cover the entire perioperative period, offering opinions on operative risk and suggesting treatments that affect long-term patient outcomes. Rarely is preoperative intervention necessary just to lower the risk of surgery. Most interventions that are needed should be done regardless of the surgery.
Everyone on the medical team should have the goal of efficient resource utilization, including avoidance of unnecessary visits, laboratory testing, and consultations.
PREOPERATIVE TESTING: WHAT IS NEEDED?
Preoperative testing is extremely expensive: even more than 20 years ago, preoperative medical testing for all types of surgery accounted for approximately $30 billion in US health care costs annually. 3 The likelihood of abnormal test results increases with age, and the more tests performed, the more likely a false positive will occur, further driving up costs.
Preoperative testing should generally be directed by a targeted history and physical examination, and the relevance of any tests should be considered in light of the type of procedure that is planned, particularly the hemodynamic changes and blood loss involved. Before ordering a test, physicians should be sure that there is a good reason for the test, that it is consistent with established guidelines, and that the results will be useful (ie, have the potential to change management).