术前实验室检查：低风险手术前的比例和可变性。

Preoperative Laboratory Investigations: Rates and Variability Prior to Low-risk Surgical Procedures.

机构信息

From the Department of Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada (K.R.K.); Department of Anesthesia, Women's College Hospital, Toronto, Ontario, Canada (K.R.K.); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (D.N.W.); Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada (D.N.W.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (D.N.W., J.V.T., J.T., M.J.S., R.S.B.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.N.W., R.N., J.V.T., M.J.S., R.S.B.); Institute for Health System Solutions, Women's College Hospital, Toronto, Ontario, Canada (C.P., R.S.B.); Department of Medicine, University of Toronto, Toronto, Ontario, Canada (J.V.T., M.J.S., W.L., R.S.B.); Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T.); Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts (A.S.B.); Health Quality Ontario, Toronto, Ontario, Canada (J.T.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (J.T.); Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.J.S.); and Department of Cardiology, Women's College Hospital, Toronto, Ontario, Canada (R.S.B.).

出版信息

Anesthesiology. 2016 Apr;124(4):804-14. doi: 10.1097/ALN.0000000000001013.

DOI:10.1097/ALN.0000000000001013

PMID:26825151

Abstract

BACKGROUND

Increasing attention has been focused on low-value healthcare services. Through Choosing Wisely campaigns, routine laboratory testing before low-risk surgery has been discouraged in the absence of clinical indications. The authors investigated rates, determinants, and institutional variation in laboratory testing before low-risk procedures.

METHODS

Patients who underwent ophthalmologic surgeries or predefined low-risk surgeries in Ontario, Canada, between April 1, 2008, and March 31, 2013, were identified from population-based administrative databases. Preoperative blood work was defined as a complete blood count, prothrombin time, partial thromboplastin, or basic metabolic panel within 60 days before an index procedure. Adjusted associations between patient and institutional factors and preoperative testing were assessed with hierarchical multivariable logistic regression. Institutional variation was characterized using the median odds ratio.

RESULTS

The cohort included 906,902 patients who underwent 1,330,466 procedures (57.1% ophthalmologic and 42.9% low-risk surgery) at 119 institutions. Preoperative blood work preceded 400,058 (30.1%) procedures. The unadjusted institutional rate of preoperative blood work varied widely (0.0 to 98.1%). In regression modeling, significant predictors of preoperative testing included atrial fibrillation (adjusted odds ratio [AOR], 2.58; 95% CI, 2.51 to 2.66), preoperative medical consultation (AOR, 1.68; 95% CI, 1.65 to 1.71), previous mitral valve replacement (AOR, 2.33; 95% CI, 2.10 to 2.58), and liver disease (AOR, 1.69; 95% CI, 1.55 to 1.84). The median odds ratio for interinstitutional variation was 2.43.

CONCLUSIONS

Results of this study suggest that testing is associated with a range of clinical covariates. However, an association was similarly identified with preoperative consultation, and significant variation between institutions exists across the jurisdiction.

摘要

背景

人们越来越关注低价值的医疗服务。通过明智选择运动，在没有临床指征的情况下，不鼓励在低风险手术前进行常规实验室检查。作者调查了低风险手术前实验室检查的发生率、决定因素和机构差异。

方法

从基于人群的行政数据库中确定了 2008 年 4 月 1 日至 2013 年 3 月 31 日期间在加拿大安大略省接受眼科手术或预先确定的低风险手术的患者。术前血液检查定义为在指数手术前 60 天内进行全血细胞计数、凝血酶原时间、部分凝血活酶时间或基本代谢小组。使用分层多变量逻辑回归评估患者和机构因素与术前检查之间的调整关联。使用中位数优势比来描述机构差异。

结果

该队列包括 906902 名患者，他们在 119 家机构接受了 1330466 次手术（57.1%为眼科手术，42.9%为低风险手术）。术前血液检查在 400058 次手术（30.1%）前进行。未调整的术前血液检查机构率差异很大（0.0 至 98.1%）。在回归模型中，术前检查的显著预测因素包括心房颤动（调整后的优势比 [AOR]，2.58；95%置信区间，2.51 至 2.66）、术前医疗咨询（AOR，1.68；95%置信区间，1.65 至 1.71）、先前的二尖瓣置换术（AOR，2.33；95%置信区间，2.10 至 2.58）和肝病（AOR，1.69；95%置信区间，1.55 至 1.84）。机构间变异的中位数优势比为 2.43。