Abstracts of Posters Presented at the International Anesthesia Research Society; 72nd Clinical and Scientific Congress; Orlando, FL; March 7-11, 1998: Anesthesia/OR Economics
Introduction: Traditional routine preoperative testing ordered by surgeons/anesthesiologists is being questioned since its usefulness is not clear. [1,2] Many anesthesia departments are developing PACs to improve the perioperative management of surgical patients and broaden the scope of anesthetic practice as perioperative medicine.  In order to demonstrate the benefits of a PAC by applying case by case preoperative testing we prospectively analyzed the economic aspects of preoperative testing in a general hospital between that ordered by surgeons vs. that ordered by anesthesiologists based on protocols/ and clinical findings at the PAC.
Methods: As soon as the PAC was established, the anesthesia department jointly with medicine and surgery developed guidelines/ protocols for routine preoperative testing in patients with and without medical problems. We prospectively designed a database to record all the preanesthetic evaluations of the PAC. From this database a report form is generated and printed to be annexed to the patient's chart. In the form, specific questions regarding the tests' usefulness and the physician who ordered the tests are included.
In period of 30 months 16890 patients were evaluated at the PAC by attending anesthesiologists. Excluded were all obstetric patients (ob=4561) and all patients who had testing ordered for non perioperative reasons (nonperi=3360). The 8969 patients analyzed were young patients (36.4 +/- 16.7 y) with 82.4% ASA I, 16.0% ASA II and 1.6% ASA III. Two major groups were defined: Group A (n=3486) if they had tests ordered prior to the PAC assessment, and Group B (n=5483) all those who had all necessary tests ordered at the PAC. Group A was subdivided in A1 including only healthy patients without any medical problems (n=2227) and A2 any other patient in this group (n=1259).
We compared the number of tests ordered and the costs per patient between the groups. Unnecessary tests were defined as those not recommended by either the protocols, by clinical findings or by the medical history of the patient. Data was analyzed using t-tests with p<0.05 considered significant.
Results: There were no anesthetic deaths nor any major cardiovascular or neurological complications in the 8969 patients. No procedure was postponed or canceled for any reason other than common colds.
(Table 1) illustrates the number of pre-PAC tests the patients had been ordered; the tests ordered at the PAC and the total of the two. With the above definition the number of unnecessary tests and % of total ordered was determined. The cost in $ of tests/patient was calculated in each group.
In group B there were 3400 patients (62.0%) who underwent anesthesia without any test performed and did not develop any major perioperative complication.
The "excess" in preoperative testing by surgeons (= # unnecessary tests * cost/test) calculated is of $63,727 in Group A1; and $36,330 in Group A2 for a total of $100,057 in Group A.
Conclusions: 1) The PAC can effectively diminish perioperative costs by the identification of individual patient's needs of preoperative testing. 2) In this population of surgical patients the use of protocols to minimize preoperative testing was not associated with any major anesthetic complication. 3) A property designed database can help address economic issues in the preoperative setting.
1. Can J Anaesth 35;214-8;1988
2. Mayo Clin Proc 72;505-9;1997
3. Anesthesiology 85;196-206;1996