This article is accompanied by the following Invited Commentary:
Wijeysundera DN, Johnson SR. Surveys, samplings and botched US presidential election predictions. Eur J Anaesthesiol 2012; 29:462–464.
Preoperative evaluation of elective surgical patients is a basic part of anaesthesia care. Its role in reducing perioperative morbidity and mortality through identification of those at risk for adverse cardiac events, and in applying risk reduction strategies is accepted.1 Medical history, specifically cardiac symptoms and exercise tolerance, together with physical examination are key instruments in screening for cardiovascular co-morbidity.2 Various additional investigations such as laboratory screening and 12-lead electrocardiography can assist cardiovascular risk stratification.1,3,4 It is, however, questionable whether the latter has more to offer than a thorough history and physical examination. Routine preoperative testing has been criticised for its failure to predict perioperative events or improve patient outcomes, but it does increase healthcare costs.5–11
Several guidelines offer a rational approach to decision making in this area. The 2007 guideline of the American College of Cardiology (ACC) and American Heart Association (AHA)3 recommends screening elective surgical patients for active cardiac conditions using specific clinical risk factors, like a history of ischaemic heart disease. The Practice Advisory on Preanaesthesia Evaluation of the American Society of Anesthesiologists clearly distinguishes ‘routine’ testing from ‘selective’ or ‘indicated’ testing; an indicated test being the one that is required only in the case of certain clinical criteria or preexisting medical conditions.1
However, daily clinical practice frequently does not follow guideline recommendations.12,13 Previous surveys of preoperative evaluation in Canada and the USA have shown a marked disparity in practice between different hospitals and a low guideline adherence.14,15 This study aims to assess the spectrum of current pre-anaesthetic evaluation of patients scheduled for noncardiac surgery in Europe. Additionally, the opinion of the participating anaesthesiologists on the practice of routine testing and its possible elimination was assessed.
We created a short, Web-based survey in English (Fig. 1), aimed at members of different national anaesthesiology societies throughout Europe that were registered with the European Society of Anaesthesiology (ESA). The survey investigated three different aspects of preoperative practice: first, the organisation of preoperative evaluation, for example the presence of an outpatient clinic and who had responsibility for preoperative testing; second, the practice of preoperative testing including tests used, indications for additional testing and guideline adherence; and third, the opinion of the participating anaesthesiologists on the elimination of routine preoperative testing. Between May and July 2009, the representatives of all 36 national anaesthesiology societies registered with ESA were asked by a letter to distribute the link to this Web-based survey to their members by e-mail. We sent a reminder to the representatives of countries without any responders a few weeks later.
The online questionnaires were collected over 3 months. The questions regarding general test-ordering and indications used were collated and analysed using frequency tables. The difference in practice of routine testing between countries was compared using cross-tabulation.
The questionnaire was distributed in 17 different countries. The anaesthesiology societies undertook further distribution of the questionnaire in various ways; it was sent to all members, or to an unknown number of members, to a group of heads of anaesthesiology departments, or placed on the society Web site. In total, 369 questionnaires were returned. When void questionnaires and those from cardiac surgery centres were excluded, 354 completed questionnaires all from different hospitals were available for analysis. Because of the low response rate from certain countries, we grouped those countries together on the basis of geographical location (Table 1).
A preoperative assessment clinic was available to 340 centres (95%). In 294 (83%), the anaesthesiologist had the final responsibility for preoperative evaluation, whereas in 49 (14%) the surgical specialist was responsible (mostly Baltic states).
A standardised questionnaire was used by 311 respondents (89%). The practice of ordering additional tests varied widely, both within countries as well as between countries. Laboratory tests (N = 203, 57%) and a chest radiograph (N = 165, 46%) were often performed in a selection of patients, but 102 respondents (28%) and 21 respondents (6%), respectively, ordered these tests in all patients (Fig. 2). Respondents from Spain, Hungary, Bulgaria, Ukraine, Serbia and Montenegro most frequently ordered routine tests (Table 2). Most anaesthesiologists ordered a routine ECG; 49 (14%) in all and 275 (79%) in a selection. A history of cardiovascular disease and age were the most frequently reported indications for a preoperative ECG. Other indications mentioned were obesity, smoking, pacemaker in situ and patient request. Despite the fact that routine tests are frequently ordered, only seven (2%) respondents reported that preoperative management was changed ‘quite often’ in light of the ECG findings (Table 3).
Preoperative test-ordering in accordance with (published) guidelines was reported by 174 (50%) respondents. The most frequently mentioned guidelines were the DGAI guideline of the German Society for Anaesthesiology and Intensive care, and the National Institute for Health and Clinical Excellence (NICE) guideline (UK). A minority of respondents (N = 39, 11%) adhere to North American guidelines such as the ASA practice advisory and the ACC/AHA guidelines.
The majority of the respondents (N = 300, 86%) indicated that they would support a move towards reducing preoperative testing and almost 70% would support the elimination of routine ECG. Sixty-six respondents (19%) would have no concerns if routine preoperative testing was eliminated. Concerns cited against elimination were the lack of a baseline or reference ECG in the case of perioperative cardiac complications, teaching aspects for young colleagues, organisational aspects and a perceived high incidence of coronary artery disease among young patients. The most frequently mentioned concern in the elimination of all routine testing was patient safety (N = 157, 45%), followed by legal aspects (N = 57, 16%) and financial aspects (N = 37, 11%).
The present study shows that there is huge variation between both European hospitals and countries in the practice of preoperative evaluation. Despite recent evidence to the contrary, routine testing in the majority of elective surgical patients is still commonplace.5–11
Guidelines are intended to improve practices related to preoperative evaluation, mainly through the application of evidence-based criteria to clinical practice.2,3,16 The Practice Advisory on Preanaesthesia Evaluation of the ASA clearly distinguishes ‘routine’ testing from ‘selective’ or ‘indicated’ testing; an indicated test being one that is required only in the case of certain clinical criteria or preexisting medical conditions.1 Although the trend towards more selective testing is confirmed in the present survey, our results are in accordance with previous studies in Canada, the USA and Spain, showing that routine testing is still commonplace and that adherence to guidelines is low.14,15,17 The translation of guidelines into clinical practice is known to be challenging, largely due to the difficulty of changing established behaviour of clinicians.13,18
Over the years, there have been some changes in preoperative medicine; one of the most important developments being the formation of preoperative outpatient clinics by anaesthesiologists. The mantra of preoperative medicine used to be ‘the more information available, the better’. This approach gave rise to problems such as excessive costs, delayed operations and frequent abnormal test results with limited clinical importance. The situation is now evolving into a more rational, selective way of ordering tests with elimination of routine investigations. It seems this development has not yet been taken up throughout Europe and in some countries preoperative evaluation is still largely the territory of surgical specialists.
The question whether certain routine tests, such as preoperative laboratory screening and ECG, can be completely eliminated in all patient categories remains controversial. It appears that there is still some ambiguity towards this subject, because current evidence is incomplete and clear evidence from randomised clinical trials is lacking. The respondents of our survey mentioned ‘patient safety’ as the most important concern in eliminating routine ECG. The value of a preoperative ECG as a baseline reference in the case of postoperative cardiac complications is mentioned by some respondents and has some recent support.19
The present study is limited first by an uncertain response rate. A minority of the addressed representatives of the different national anaesthesiology societies indicated how the survey was distributed in their country. The response rate from certain countries was low, hampering the comparisons between countries. However, all questionnaires came from different hospitals.
The country with the most respondents was Germany, with respondents from 214 different hospitals. As this was such a large group, it would have been interesting to investigate the nature of these practices, for instance to determine how representative the response was for the situation in Germany overall. However, subjecting just one country to an in-depth examination was beyond the aim of the present study.
Furthermore, the way the study was conducted could have lead to selection bias. By choosing the national representatives of the national societies, we were exposed to any potential idiosyncrasies of their mailing lists. It may also be that our respondents were chiefly those who had sufficient concern to take our questionnaire seriously. Finally, some questions might reflect our perceptions rather than the opinions of the respondents and their practices.
In conclusion, our study demonstrated that routine preoperative testing is still commonplace and that clinical practice is often not in accordance with guidelines and recommendations, nor with recent evidence. However, the majority of the respondents support moves towards reducing preoperative testing.
Assistance with the study: we would like to thank all the representatives of the anaesthesiology societies who participated in our study.
Sources of funding: none declared.
Conflicts of interest: none declared.
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