International Journal for Quality in Health Care Advance Access originally published online on April 14, 2005
International Journal for Quality in Health Care 2005 17(4):323-329; doi:10.1093/intqhc/mzi039
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Guidelines for preoperative assessment: impact on clinical practice and costs
1 ASO San Giovanni Battista, Università di Torino and CPO Piemonte, Unit of Cancer Epidemiology, Torino, Italy, 2 ASO San Giovanni Battista, 7th Unit of Anaesthesiology and Reanimation, Torino, Italy, 3 ASO San Giovanni Battista, 1st School of Anaesthesiology and Reanimation, Torino, Italy, 4 ASO San Giovanni Battista, Hospital Director, Torino, Italy
Objective. To describe preoperative evaluation in the San Giovanni Battista Hospital in Turin and to forecast the economic impact when preoperative assessment guidelines are implemented.
Design. We enrolled, in a month, 702 consecutive patients, excluding cardiac, thoracic, neuro- and vascular surgery, as well as emergency operations. Preoperative assessment data were collected individually, followed by simulating various applications of guidelines based on: (i) preoperative tests relying on full medical history and physical examination to discriminate preoperative risk patients; (ii) organization of a preoperative evaluation unit and tests before patient hospitalization.
Main measures. Mean number of tests prescribed, preoperative assessment cost per patient.
Results. The application of preoperative guidelines would decrease the mean number of tests prescribed from 20 laboratory and 1.9 instrumental to, respectively, 3 and 1.4 per patient. Tests deemed inappropriate by guidelines did not add any relevant clinical information to our study. Economic analysis estimates a reduction of 63% in cost per patient for preoperative tests by introducing guideline criteria (from 
69 to 26). As regards the cost per patient for preoperative evaluation and hospital stay (115 considering only variable costs, 580 including all costs), the application of the guidelines would reduce costs by 41–52% according to different cost evaluation approaches for hospital stay.
Conclusion. Preoperative guidelines fully introduced in practice could notably increase efficiency without affecting the quality of care.
Keywords: anaesthesiology, ASA classification, cost and cost analysis, hospital economics, practice guidelines, preoperative tests
Address reprint requests to Alberto Ferrando, Universita di Torino, Epidemiologia dei Tumori, Via Santena 7, 10126 Torino, Italy. E-mail: aferrando{at}molinette.piemonte.it
Accepted for publication March 6, 2005.
 |
Introduction |
|---|
 Top Introduction MethodsResultsDiscussionAcknowledgementsReferences |
|---|
Preoperative medical assessment is an important component of the anaesthetic care of patients and contributes to the estimate of the resources that may be needed after surgery. Preoperative patient risk should be identified from anamnesis, clinical data, physical examination, and laboratory and instrumental tests [such as electrocardiogram (ECG) and chest X-ray]. Evidence-based guidelines have been issued to rationalize the use of preoperative tests [1–8], and the use of such guidelines has been reported to lead to a reduction in the number of preoperative tests, with no impairment of patient safety [9–13]. The cost reduction achieved by applying these guidelines has been quantified at both individual [10–12] and health system level [14]; however, only two studies [8,15] included the costs of organization, such as for personnel and preoperative hospitalization.
The guidelines on preoperative evaluation and laboratory and istrumental tests used in the present study were defined in 1996 by an Italian multidisciplinary group at a consensus conference organized by the Niguarda Hospital in Milan [16]. The guidelines address the preoperative tests for patients undergoing programmed surgical interventions. They also provide recommendations for the organizational aspects. The first part is in substantial agreement with corresponding guidelines in other countries [2–8]; however, the organizational aspects have, to our knowledge, been considered only by the Swedish Council of Technology Assessment [8]. Contrary to current preoperative practice in Italian hospitals, the guidelines recommend that the anaesthetist should assess patients before they are admitted to hospital, in an ad hoc unit [17], and that the information collected during the assessment should be detailed enough to discriminate between high- and low-preoperative-risk patients, so that additional tests are recommended only to those at high risk.
The guidelines include appropriateness criteria for the application of the following tests: ECG, chest X-ray, complete blood count, glycaemia, electrolytes, transaminase, coagulation tests, creatinaemia, creatine kinase, and cholinesterase. In particular, they recommend ECG for men older than 45 years of age, on women older than 55 years of age (unless a valid test is available from within 6 months) and on patients who suffer from cardiac diseases. Chest X-ray is recommended for smokers, patients over 60, and people affected by pulmonary or cardiac diseases (unless a valid test is available from within 6 months). Patients mainly affected by these guidelines are those classified as ASA I or II. All recommendations in the guidelines are based on three levels of strength: level A, when relying on randomized clinical trials or meta-analyses; level B, when relying on well-conducted observational studies; level C, when based merely on the jury’s agreement.
Since 1996, attempt to implement these guidelines has been made in several hospitals in Italy and in Ticino Canton, Switzerland, within the TRiPSS project [18], a pilot study for promoting the use of evidence-based medicine in health services. Results for hospitals in Ticino Canton have been reported elsewhere [19]; however, they cover only preoperative tests and not hospitalization cost. The San Giovanni Battista Hospital in Turin participated as a working group of anaesthetists, surgeons, and laboratory physicians. Organizational change was introduced progressively (in terms of a growth in outpatient care and a reduction in preoperative hospitalization) even though there was never full implementation of the guidelines due to medico-legal implications and the uncertainty about the economic impact. This suggests that a formal economic evaluation would be an important step in changing current practice [20]. We report here on the experience in the hospital and compare the costs of traditional preoperative assessment with those to be expected after various applications of the guidelines.
|
Methods |
|---|
|
TopIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
A survey was carried out during May 1997 on all patients undergoing programmed surgical interventions in general surgery, excluding cardiac, thoracic, neuro- and vascular surgery, and emergency operations. Thirty-one anaesthetists participated in the study. They collected the following data on 702 consecutive patients:
- age, sex, weight, clinical history, smoking habit, intake of alcohol and other drugs, type of programmed surgery, ASA class, date of anaesthesiological assessment, date of surgery, number of days in hospital before surgery, delays due to requests for additional tests;
- type and results of routine laboratory and instrumental tests performed;
- reports from neurologists, cardiologists, or pneumologists, if any;
- type of anaesthesia;
- postoperative complications attributable to anaesthesia, if any.
The anaesthetists identified the tests that they considered useful for clinical decisions and those that they considered useful only for medico-legal purposes. On this basis, each patient’s profile of risk and routing through the organizational framework of the hospital was reconstructed, and the procedures that had been carried out in practice, according to established routines, were compared with those corresponding to the following three hypotheses of rationalization:
Hypothesis 1: performance only of those tests considered to be useful (for clinical or medico-legal reasons) by the anaesthetist in charge of the patient;
Hypothesis 2: performance only of the tests recommended by the Italian guidelines (Table 1) according to preoperative patient risk, with no change in the patient’s routing through the organizational framework of the hospital;
|
Hypothesis 3: application of all the indications in the guidelines, with prescription only of appropriate specific tests as well as individual routing through the organizational framework of the hospital.
In hypotheses 2 and 3, adoption of the clinical guidelines and their consequences were simulated a posteriori by applying algorithms to data on individual patients. We then evaluated the number of diagnoses of relevant conditions (i.e. conditions that would have led to changes in programmed anaesthesia) that would have been missed by blind application of the guidelines to each of the 702 patients. The confidence intervals of these numbers were estimated by the exact method, with CIA software [21].
The background situation and hypotheses were then analysed in terms of economics, by defining the required resources, their cost and use. The resources were broken down into four categories, as indicated below.
Laboratory and instrumental tests
(Line A in Table 2): the tariffs set by the Piedmont Region were used (Table 1). For each test, the tariff was multiplied by:
|
- the number of tests conducted during the 1997 survey (background situation);
- the number of cases in which the anaesthetists considered the test appropriate for the patient on the basis of clinical or medico-legal considerations (hypothesis 1);
- the number of cases in which the test is considered appropriate in the guidelines (hypotheses 2 and 3).
Preoperative hospitalization
(Line B in Table 2): the cost of the days spent in hospital for the visit to the anaesthetist and for preoperative laboratory and instrumental tests was estimated by two approaches. In the first approach (line B1 in Table 2), only the ‘hotel’ expenses (meals and laundry) were considered; the cost per day was obtained by dividing the annual (2002) cost by the total number of days in hospital (weighted according to in-patient or outpatient hospitalization) [22,23]. In the second approach (line B2 in Table 2), all costs (variable and fixed) of the hospitalization, including the general expenses of the hospital, were considered.
In the survey, the median length of stay in hospital before surgery was 2 days. This figure was used in estimating the costs in hypotheses 1 and 2 (i.e. with no changes in the routing of patients through the organizational framework of the hospital). It was assumed that application of hypothesis 3 would correspond to a median hospital stay of 1 day. We chose the median instead of the mean length of stay in order to smooth the effect of extreme values.
Organizational aspects
(Line C in Table 2): this item included only the resources required by the drastic change foreseen in hypothesis 3, i.e.
- professional nurses for reception, booking anaesthesiological visits and preoperative tests for patients and collecting general data on patients in an outpatient unit;
- anaesthetists’ time, which was assumed in hypothesis 3 to increase by 50% over that currently required;
- administrative staff for reserving hospital beds, with thecost estimated on the basis of the current organization.
The personnel costs were computed from hospital figures for 2003, and the amount of work needed for each activity was estimated from discussions with nurses and anaesthetists.
Postponement of surgery
(Line D in Table 2): the cost of additional hospital days was calculated from the proportion of cases in which surgery was postponed and the average length of the additional hospital stay, on the basis of the results of the survey.
We assumed that there would be no need for new premises for the ad hoc unit for preoperative assessment and that postponement of surgery would not entail cancellation of use of the surgical room. Patients’ costs related to hospitalization, such as loss of work days, were also excluded, as well as the costs of unnecessary tests giving wrong results (usually false-positive results). The latter choice was due to the incompleteness of available data.
|
Results |
|---|
|
TopIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Clinical findings
Table 3 describes the characteristics of the 702 patients included in the survey.
|
In the survey, an average of 20 preoperative laboratory tests and 1.9 instrumental tests were performed per patient. The anaesthetists evaluated 52% of the tests performed as useful (for clinical or medico-legal reasons), corresponding to an average of 12 laboratory and 1.4 instrumental tests per patient. The application of the guidelines would further reduce the average number of laboratory tests to 3.
In 67% of cases, the anaesthetist interview took place on the day before surgery, resulting in unnecessary occupation of hospital beds by patients whose surgery was postponed because of circumstances identified during the interview (3% of cases). The interview lasted an average of 20 min and included collection of the results of anamnesis, examination and completion of the survey form.
Estimation of the loss of potentially useful clinical information that would have derived from application of the guideline criteria showed that 128 patients (19.2%) underwent an ECG which was not required by the guidelines, and none had unexpected findings requiring changes in the anaesthesiological decisions [95% confidence interval (CI) 0–2.84%]. Besides, 182 patients (27.8%) had a chest X-ray under conditions that the guidelines consider inappropriate, and the results modified the estimated surgical risk on only two occasions (1.1%; 95% CI 0.13–3.91%), with no change in the programme for anaesthesia. The surgical risk was increased in one case, and the other changed from ASA class I to II.
Economic analyses
Table1 shows the number of preoperative tests performed and the cost per patient in the background situation. It also describes, for each alternative hypothesis, the proportion of patients who would need a given test and the corresponding cost. The cost per patient would be reduced by 63% by application of the guidelines (hypotheses 2 and 3) and by 36% by elimination of tests considered unnecessary by the anaesthetists (hypothesis 1), corresponding to about 43 and 25, respectively. In Table 4 we report the total costs and savings by subgroups of patients, broken down by ASA class and age. The largest difference from the background situation refers to patients under 15 years of age. A relevant aspect is that hypotheses 2 and 3 show a wider difference between subgroups (6–42 in total cost) than background situation (59–71) and hypothesis 1 (31–49).
|
Table 2 summarizes the results for all the resources considered, broken down by category, for the background situation and for each of the three hypotheses. In addition to the 63% reduction in the cost of preoperative tests, full application of the guidelines (hypothesis 3) would entail a 50% reduction in costs by reducing preoperative days in hospital [(12.89/25.77)–1 = –0.5] and the elimination of the costs associated with postponement of the surgical intervention. The savings would greatly exceed the increased cost due to organizational changes. The saving implied by hypotheses 1 and 2, albeit limited to preoperative tests, would still be substantial.
Table 2 also shows the results obtained with the two methods of quantifying the cost of preoperative hospitalization. The estimated reduction in total costs resulting from full application of the guidelines (hypothesis 3) would be 41% with method 1 (only variable costs) and 52% with method 2 (all costs), corresponding to 47 and 302, respectively. In a hospital like ours, where about 10 000 patients are hospitalized annually for programmed surgery and classified as ASA I or II, adoption of hypothesis 3 would result in an annual saving of 0.47 million or 3 million, depending on whether estimates are based on method 1 or method 2. Hypothesis 3 assumes a median stay of 1 day, as compared with 2 days in the background situation, corresponding to a saving of 10 000 days in hospital.
|
Discussion |
|---|
|
TopIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Our results indicate that unnecessary procedures could be reduced drastically by application of the Italian guidelines on preoperative evaluation of patients, with no loss of clinically relevant information. The crucial aspect appears to be timely identification by the anaesthetist of each patient’s requirements and risk factors. In fact, the guidelines seem to allow for a more appropriate approach to the patient’s risk profile, as shown by the results reported in Table 4. As expected, patients at low preoperative risk (ASA I or II) would be the major contributors to the reduction in the number of preoperative tests and costs.
The estimated annual saving (in costs or in days of hospitalization) that we calculated refers to the unrealistic hypothesis that the guidelines apply to all relevant cases; the percentage of those for whom the guidelines would not be applied is yet to be determined. Each hypothetical situation considered entails potential sources of bias. In the background situation and hypothesis 1, the 31 anaesthetists participating in the survey probably differed to a certain extent with regard to both the prescription and the assessment of the appropriateness of tests performed on their patients. Such heterogeneity was not quantified. In the construction of hypothesis 3 (full application of the guidelines), some parameters were estimated pragmatically (e.g. staff working time), in the absence of previous investigations, and others were omitted (e.g. cost of premises for an ad hoc unit).
Nevertheless, the extent of the reduction in testing achieved by application of the guidelines and the corresponding estimated reduction in costs are consistent with the findings of similar studies [9–15,19]. Consistency was found not only with the study of Barazzoni et al. [19], who used the same guidelines, but also with studies in other countries [9–15], despite differences in the tests considered and in the criteria defined by the different guidelines. The consistency is not surprising, as the Italian and the other guidelines were based on the same scientific findings. The comparability of the financial estimates is limited because of contextual differences: further information would be required. The quantitative aspect is, however, of marginal importance, as all the studies indicate an economic advantage.
An original feature of our study is that we addressed not only laboratory and instrumental tests but also other more neglected aspects of preoperative assessment due to difficult evaluation, including the organizational changes that would result from full application of the guidelines. Assessing the comparability of these results is particularly difficult, because similar estimates have been reported only by the Swedish Council on Technology Assessment in Health Care [8] and, more recently, in a study in Spain [15]. The estimates reported were similar to ours.
The cost of laboratory and instrumental tests included both a ‘variable’ and a ‘fixed’ component (corresponding respectively to the consumption of goods and to staff and equipment) [24]. In the short term, savings could be made only on the ‘variable’ component. Thus, a 63% reduction in the number of tests would not lead to a corresponding reduction in cost, as in the short term the costs of staff and equipment would not fall proportionately. In the long run, the reductions in the number of tests and days of hospital stay would create an excess of resources (e.g. equipment, staff, premises), and this aspect is covered by our second approach, about all costs related to hospitalization.
The indirect (social) costs to patients were not considered in the present analysis. Although difficult to quantify, they must be considered when decisions are taken by hospital management and other public health authorities. The same applies to ‘intangible’ costs, such as the emotional consequences to patients of a long hospital stay before surgery and a large number of laboratory tests. Unnecessary preoperative tests would lead to a large number of false-positive results, causing unnecessary anxiety and additional costs [13,25].
Anaesthetists’ fear of the medico-legal consequences of omitting traditional routine tests is a major obstacle to implementation of the guidelines and this has been mentioned in previous studies [1,19,26]. If complications arise during or after surgery, it might be necessary to demonstrate that all predictable risks had been taken into consideration. Nevertheless, in our study the anaesthetists considered 48% of the routinely prescribed tests to be useless. This contradiction could be overcome by official recognition by national health authorities and scientific societies of the scientific basis of the guidelines. In Italy, this issue has been raised as a goal of all guidelines [27].Another requirement—at both national and local level—is the need for consensus among professionals (anaesthetists, surgeons, nurses) about the advantages of changes in work practices. This implies training and the use of techniques to favour changes in attitude [28].
|
Acknowledgements |
|---|
|
TopIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
We wish to thank the anaesthetists participating in the survey: Bergoglio, Bertino, Buttiglieri, Cerutti, De Cento, De Siena, Donadio, Fagiano, Franco, Gambino, Guarnaccia, Illengo, Mabilia, Maritano, Martino, Massano, Occella, Orecchia, Orlando, Pattono, Perani, Piazza, Previtera, Roberti, Roggino, Salamino, Sansalvadore, Sciuto, Tempia, Tirone, Urcioli. We thank Nerina Dirindin, Andrea Turolla, and Paola Alaria for their important contribution to the cost analysis in this study. Special thanks to Benedetto Terracini for his unique contribution to this paper. We also acknowledge the fundamental role of the national coordinators of the TRiPSS project: A. Liberati, R. Grilli, and A. Penna. The study was partially supported by a grant from the Compagnia San Paolo/FIRMS, Special Project Oncology. Finally, we acknowledge the constant support of AIRC to our Unit.
|
References |
|---|
|
TopIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
- Garcia-Miguel FJ, Serrano-Aguilar PG, Lopez-Bastida J. Preoperative assessment. Lancet 2003; 362: 1749–1757.[Medline]
- National Institute for Clinical Excellence. Guidance on the Use of Preoperative Tests for Elective Surgery. NICE Clinical Guideline No. 3. London: NICE, 2003.
- Guidelines and Protocols Advisory Committee (GPAC), Medical Services Commission, and British Columbia Medical Association. Guideline for Routine Pre-Operative Testing. Victoria BC: Ministry of Health, 2000.
- Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1997; 1: 1–63.
- Health Council of The Netherlands, Gezondheidsraad (GR). Preoperative Evaluation. Den Haag: Gezondheidsraad, 1997.
- Office for Health Technology Assessment (OSTEBA). Healthy/Asymptomatic Patient Preoperative Evaluation. Victoria-Gasteiz: Health Department, 1994.
- Agence Nationale pour le Development de l’Evaluation Medicale (ANDEM). Indication of Preoperative Tests. Paris: ANDEM, 1992.
- Swedish Council on Technology Assessment in Health Care (SBU). Preoperative Routines. Stockholm: SBU, 1989.
- Larocque BJ, Maykut RJ. Implementation of guidelines for preoperative laboratory investigations in patients scheduled to undergo elective surgery. Can J Surg 1994; 37: 397–401.[Medline]
- Mancuso CA. Impact of new guidelines on physicians’ ordering of preoperative tests. J Gen Intern Med 1999; 14: 166–172.[Medline]
- Nardella A, Pechet L, Snyder LM. Continuous improvement, quality control, and cost containment in clinical laboratory testing. Effects of establishing and implementing guidelines for preoperative tests. Arch Pathol Lab Med 1995; 119: 518–522.[ISI][Medline]
- Power LM, Thackray NM. Reduction of preoperative investigation with the introduction of an anaesthetist-led preoperative assessment clinic. Anaesth Intensive Care 1999; 27: 481–488.[ISI][Medline]
- Roizen MF. Cost-effective preoperative laboratory testing. JAMA 1994; 271: 319–320.[Medline]
- France FH, Lefebvre C. Cost-effectiveness of preoperative examinations. Acta Clin Belg 1997; 52: 275–286.[Medline]
- Lopez-Bastida J, Serrano-Aguilar PG, Duque-Gonzàlez B, Talavera-Déniz A. Cost analysis and potential cost savings related to the use of preoperative tests in hospitals of the Canary Islands (in Spanish). Gac Sanit 2003; 17: 131–136.[Medline]
- Bevilacqua L, Minella C, Consensus Conference Group. Guidelines on anaesthesiological evaluation and preoperative tests (in Italian). Qual Assur 1996; 7: 109–131.
- Fischer SP. Cost-effective preoperative evaluation. Chest 1999; 115: 96S–100S.
[Abstract/Free Full Text] - Penna A, Barazzoni F. The TRiPSS project. A pilot study for promoting the use of evidence based medicine in health services (in Italian). Eff Health Care Italian Edition 1998; 1: 1–4.
- Barazzoni F, Grilli R, Amicosante AMVet al. Impact of end user involvement in implementing guidelines on routine pre-operative tests. Int J Qual Health Care 2002; 14: 321–327.
[Abstract/Free Full Text] - Grimshaw JM, Thomas RE, MacLennan G et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004; 8: 1–72.[Medline]
- Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with Confidence. 2nd Edn. London: BMJ Books, 2001.
- Dirindin N, Vineis P. Health Economics: An Introduction (in Italian). Bologna: Il Mulino Editore, 1999.
- Vanara F. Health Economics. Exercises and Case Study (in Italian). Milano: F. Angeli Editore – Collana Cresa, 1993.
- Turolla A. Cost Determination and Auditing in Hospitals (in Italian). Milano: Giuffrè Editore, 1997.
- Roizen MF. More preoperative assessment by physicians and less by laboratory tests. N Engl J Med 2000; 342: 204–205.
[Free Full Text] - Hurwitz B. Legal and political considerations of clinical practice guidelines. BMJ 1999; 318: 661–664.
[Free Full Text] - Agency for Regional Health Services, Italy. http://www.assr.it/plg.htm Accessed 2 November 2004.
- NHS Center for Review and Dissemination, University of York. Getting evidence into practice. Eff Health Care 1999; 5: 1–15.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||