Will you ID diseases or waste time, money on routine pre-op tests on elderly?
Will you ID diseases or waste time, money on routine pre-op tests on elderly?
New research opens door for no routine testing with some procedures
Your 80-year-old cataract patient has shown up for the preoperative evaluation on the day of surgery. She has a long history of diseases and medical conditions, but you don’t have a lot of time for the interview. She’s had some preoperative tests conducted by her internist in recent days, but you don’t have the results yet. You’re concerned that you might miss something if your rush the assessment because elderly patients often have atypical presentations of diseases.
So what’s a same-day surgery manager to do? Order a battery of preoperative tests? Postpone surgery? Go bang his head against a wall?
According to research published this year in The New England Journal of Medicine, many physicians routinely order preoperative tests for cataract patients, who usually are older.1 Those tests include complete blood counts, measurements of serum electrolytes, electrocardiograms, chest radiography, blood-clotting studies, and urinalysis.
"Many physicians believed the tests were unnecessary but ordered them anyway because of institutional requirements, legal concerns, or a belief that another physician wanted them performed," says Oliver D. Schein, MD, MPH, professor of ophthalmology at the Wilmer Eye Institute at Johns Hopkins University in Baltimore. Schein was the lead author of the research published in The New England Journal of Medicine, which indicated that patients who did not have routine preoperative tests before cataract surgery fared as well as patients who did have the tests. Routine pre-op testing before cataract surgery costs the Medicare program $150 million each year, he estimates. And with the number of elderly persons rising, that amount could increase dramatically in coming years.
In response to this research, the Wilmer Eye Institute eliminated routine pre-op testing for cataract patients this year. Other providers who are considering making a change to their pre-op testing guidelines might gain some support next year from the American Society of Anesthesiologists (ASA), which is developing a practice advisory on the topic.
"After reviewing [more than] hundreds of articles, there was no evidence-based data to support that a particular test would have a direct impact on outcome," says Rebecca S. Twersky, MD, a member of the ASA task force developing the advisory, and the medical director of the Ambulatory Surgery Unit at Long Island College Hospital in Brooklyn, NY. "The advisory will be based on responses of consultants and ASA members who were surveyed as to their practices."
Lee Fleisher, MD, FACC, associate professor of anesthesiology at Johns Hopkins School of Medicine, and clinical director of the OR at Johns Hopkins Hospital, says, "We’ve almost come to the basic conclusion: There’s almost no routine testing for anything, although EKGs are a major issue."
Consider these suggestions
To help you solve the dilemma presented by pre-op testing in the elderly, here are some tips from experts in the field:
• Consider pre-op tests for cataract and similar procedures only when the history and physical reveals a new or worsening medical condition that warrants such a test.
The New England Journal of Medicine study involved 19,000 patients at nine medical centers. Researchers randomly assigned cataract procedures to be preceded or not preceded by a standard battery of tests. The researchers recorded any medical complications on the day of surgery or during the following seven days. The most frequent complications in both groups were rises in blood pressure and slowed heart rates. The overall rate of complications was the same in both groups: 31.3 events per 1,000 operations. Researchers observed no benefit of routine preoperative medical testing when analyzing the results by the patient’s age, sex, race, or coexisting medical conditions.
So what do these researchers recommend in terms of pre-op tests before cataract procedures? Such tests should be conducted for "anyone with a new or worsening medical problem that under any circumstances, a medical tests would be of benefit to the patient, but not simply because the patient’s cataract surgery has been scheduled," Schein says.
The $6 million dollar question is whether the results of the cataract study can be applied to similar outpatient procedures. They can, according to Schein. "When one considers outpatient procedures in the elderly, where similar kinds of agents are used, you have monitored anesthetic care, the length of procedures is similar — 20 minutes to one hour — and where anticipated blood loss is minimal, a reasonable extrapolation could be made by reasonable people."
• Perform a complete cardiac work-up in selective cases.
The leading cause of death in elective survey is for cardiac complications, says Jeffrey Leppo, MD, professor of medicine at the University of Massachusetts in Worcester. Still, elderly patients (typically defined as older than 65 or 70) don’t need routine pre-op testing, he adds. "Assuming that patients have stable cardiac conditions, which means they are not Class III or IV angina, don’t have congestive heart failure, and don’t have significant sustained arrhythmias, they don’t require a complete work-up unless they have two of the following three conditions":
— poor functional capacity, which is defined as less than four metabolic equivalent units (METs);
— intermediate-risk factors, which are mild angina pectoris (Canadian Class I or II), prior myocardial infarction by history or pathological Q waves, compensated or prior congestive heart failure, and diabetes mellitus.2 (Those risk factors are being revised by the guidelines from the Bethesda, MD-based American College of Cardiology and the Dallas-based American Heart Association and will be published in early 2001 in the Journal of the American College of Cardiology and Circulation, according to Leppo);
— high-risk surgery, which is defined in the guidelines as vascular surgery and any major abdominal, thoracic, or orthopedic surgery that involves long procedures with high amount of fluid shifts.
"There’s a lot of fluid management issues, which impacts mostly orthopedic procedures because of there’s a lot of blood loss and transfusion," Leppo says.
• Consider EKGs.
EKGs still present a diagnostic dilemma, Fleisher points out. At Johns Hopkins, the anesthesiologists find it useful to have a baseline EKG, even if the EKG was performed years ago. The EKG doesn’t help as much with the decision about whether to delay surgery as it helps determine who should safely go home, he says.
"You should only do diagnostic tests that will affect patient management," he acknowledges. "But part of patient management is [asking], Is it safe to send them home if they’re not medically stable or not in optimal condition?’"
Many providers, including Johns Hopkins, perform routine EKGs at age 65 for men and age 75 for women, but the test is somewhat dependent on risk factors, Fleisher says. "The benefits are that you save the money and inconvenience of getting a new EKG." The risk is that if you take the patients to surgery, connect monitors, and providers see a complication that they didn’t expect, they have to decide whether to cancel the case or admit the patient after surgery, he says. "That’s the downside."
Identifying silent’ comorbidities
Therein lies the crux of the debate of eliminating routine pre-op tests for the elderly: Those patients might have nondiagnosed diseases that could have postponed surgery if they had been detected.
There will always be situations in which a particular lab test happens to find an abnormality that subsequently ends up being important, Schein points out. For example, if providers performed a chest X-ray on every cataract patients, it would be possible to find some lung cancer that had previously been undiagnosed. "However, no one would argue that people who undergo cataract surgery should be the only ones who get adequate preventive health care," he says.
Because the incident of undiagnosed medical comorbidities increases with age, some providers think it’s important to identify what are essentially "silent" comorbidities. Should you do that with routine pre-op testing?
"You do that with selective, pre-op testing," Fleisher emphasizes.
References
1. Schein OD, Katz J, Bass EB. The value of routine preoperative medical testing before cataract surgery. N Engl J Med 2000; 342:168-175.
2. Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Circulation 1996; 93:1,278-1,317.
For more information on routine preoperative testing for elderly patients, contact:
• Lee Fleisher, MD, FACC, Associate Professor of Anesthesiology, Johns Hopkins School of Medicine, Clinical Director of the OR, Johns Hopkins Hospital, Baltimore. E-mail: [email protected].
• Jeffrey Leppo, MD, Professor of Medicine, University of Massachusetts, 55 Lake Ave. N., Worcester, MA 01655. Telephone: (508) 856-3711. Fax: (508) 856-1016. E-mail: [email protected].
• Oliver D. Schein, MD, MPH, Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, 600 N. Wolfe St., 116 Wilmer Building, Baltimore, MD 21287-9019.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.