Department of Anesthesiology, SUNY at Stony Brook, Stony Brook, NY 11794, USA.
Anesth Analg. 2011 Jan;112(1):207-12. doi: 10.1213/ANE.0b013e31820034f0. Epub 2010 Nov 16.
Nearly 20 years ago it was shown that patients are exposed to unnecessary preoperative testing that is both costly and has associated morbidity. To determine whether such unnecessary testing persists, we performed internal and external surveys to quantify the incidence of unnecessary preoperative testing and to identify strategies for reduction.
The medical records of 1000 consecutive patients scheduled for surgery at our institution were examined for testing outside of our approved guidelines. Subsequently, 4 scenarios were constructed to solicit physician views of appropriate testing: a 45-year-old woman for a laparoscopic ovarian cystectomy, a 23-year-old woman for right inguinal herniorrhaphy, a 50-year-old man for a hemithyroidectomy, and a 50-year-old man for a total hip replacement. One or more of these scenarios were sent to directors of preoperative clinics (all), United States anesthesiologists (all), gynecologists (cystectomy), general surgeons (herniorrhaphy), otolaryngologists (thyroidectomy), and orthopedists (hip replacement). Potential predictors of ordering and demographic information were collected.
More than half of our patients had at least 1 unnecessary test based on our testing guidelines (95% lower confidence limit = 52%). The 17 responding preoperative directors were unanimous for 36 of the 72 combinations of test or consult (henceforth "test") and scenario as being unnecessary. Among the 175 anesthesiologists responding to the survey, 46% ordered 1 or more of the tests unanimously considered unnecessary by the preoperative directors for the given scenario. Among 17 potential predictors of anesthesiologists' unnecessary ordering, only training completed before 1980 significantly increased the risk of ordering at least 1 unnecessary test (by 48%, 95% confidence limits >29%). Anesthesiologists were 53% less likely to order at least 1 unnecessary test relative to gynecologists for the cystectomy scenario, 64% less likely than general surgeons for the herniorrhaphy scenario, 66% less likely than otolaryngologists for the thyroidectomy scenario, and 67% less likely than orthopedists for the hip replacement scenario. The 95% lower confidence limits were all >40%.
The percentage of patients with at least 1 unnecessary test is a suitable end point for monitoring providers' ordering. The incidence can be high despite efforts at improvement, but may be reduced if anesthesiologists rather than surgeons order presurgical tests and consults. However, anesthesia groups should be cognizant of potential heterogeneity among them based on time since training.
近 20 年前，人们发现患者接受了不必要的术前检查，这些检查既昂贵又有相关的发病率。为了确定这种不必要的检查是否仍然存在，我们进行了内部和外部调查，以量化不必要的术前检查的发生率，并确定减少这种检查的策略。
对我院 1000 例连续手术患者的病历进行检查，以确定是否超出我们批准的指南进行了检查。随后，构建了 4 种情况来征求医生对适当检查的意见：一名 45 岁女性进行腹腔镜卵巢囊肿切除术，一名 23 岁女性进行右侧腹股沟疝修补术，一名 50 岁男性进行甲状腺部分切除术，以及一名 50 岁男性进行全髋关节置换术。这些情况中的一种或多种被发送给术前诊所主任（全部）、美国麻醉师（全部）、妇科医生（囊肿切除术）、普通外科医生（疝修补术）、耳鼻喉科医生（甲状腺切除术）和骨科医生（髋关节置换术）。收集了潜在的医嘱和人口统计学信息。
根据我们的检查指南，我们超过一半的患者至少有一项不必要的检查（95%置信下限=52%）。17 位回复的术前主任一致认为，72 种检查或咨询（以下简称“检查”）和方案中有 36 种是不必要的。在回复调查的 175 位麻醉师中，46%的人对至少一项被术前主任一致认为不必要的检查进行了医嘱。在 17 个可能影响麻醉师不必要医嘱的预测因素中，只有在 1980 年前完成的培训显著增加了至少一项不必要检查的医嘱风险（增加 48%，95%置信区间>29%）。与妇科医生对囊肿切除术方案相比，麻醉师进行至少一项不必要检查的可能性降低了 53%，与普通外科医生对疝修补术方案相比，降低了 64%，与耳鼻喉科医生对甲状腺切除术方案相比，降低了 66%，与骨科医生对髋关节置换术方案相比，降低了 67%。95%置信下限均>40%。
至少有一项不必要检查的患者比例是监测医生医嘱的合适终点。尽管已经努力进行改进，但发生率仍然很高，但如果由麻醉师而不是外科医生来进行术前检查和咨询，发生率可能会降低。然而，麻醉师群体应该意识到，基于培训时间的不同，他们之间可能存在潜在的异质性。
