Preoperative Laboratory Screening in Healthy Mayo Patients: Cost-Effective Elimination of Tests and Unchanged Outcomes

Narr, Bradly J.; Hansen, Todd R.; Warner, Mark A.

doi:10.1016/s0025-6196(12)60487-x

Cited by 145 publications

(81 citation statements)

References 4 publications

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“…To the best of our knowledge, ours is the only study to examine separate and unique clinical practice guidelines for ordering PT or PTT tests. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] The use of two distinct guidelines in practice may help reinforce differences between indications for these tests and minimize the routine pairing of orders observed by McKinley and Wrenn 29 and confirmed in this study.…”

Section: Discussionmentioning

confidence: 65%

“…Most studies validated PT and PTT guidelines for use in preoperative, general medical, and surgical patient cohorts that are unrepresentative of the broad mix of patients treated in the hospital ED. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Studies specific to ED patients used retrospective cohort designs that may have missed clinical indications that were present but undocumented. 28,29 Indeed, McKinley and Wrenn 29 found that even among patients hospitalized from the ED for initiation of coagulation therapy, emergency physicians rarely documented important coagulopathy screening questions.…”

Section: Discussionmentioning

confidence: 99%

“…Both tests are routinely ordered for surgical and other patients admitted to the hospital even though studies consistently demonstrate the low diagnostic utility of this practice. [1][2][3][4] Additionally, preoperative PT and PTT test results are poor predictors of abnormal bleeding during and after surgery, 2,[5][6][7][8][9][10][11][12][13][14][15][16][17][18] and abnormal blood coagulation tests are often not acted upon. 2,4 Evidence suggests that readily available historical and physical examination variables can accurately identify preoperative surgical and other admitted patients at low risk for inpatient bleeding complications.…”

mentioning

confidence: 99%

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Evaluation of Guidelines for Ordering Prothrombin and Partial Thromboplastin Times

Auble

Taylor

Hsu

et al. 2002

Academic Emergency Medicine

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Objectives: Existing clinical practice guidelines for ordering prothrombin time (PT) and partial thromboplastin time (PTT) tests in the emergency department (ED) include physician expectation of an invasive procedure as a criterion. This study sought to determine whether this criterion accurately identifies patients who undergo an invasive procedure and whether an amalgam of these guidelines identifies patients at low risk of an adverse medical outcome. Methods: A prospective observational cohort study of adults treated in a university medical center ED between July 1997 and March 1998. Physicians were surveyed at order placement to determine the presence of guideline criteria. Adverse clinical outcomes defined as an International Normalized Ratio [INR] > 1.3 or PTT > 39.9 seconds combined with consequent directed medical therapy were abstracted from ED and the first 24 hours of inpatient medical records. Results: The sensitivity of ED physician expectation of an invasive procedure was 60.0%; therefore, it was excluded from both the PT and PTT guidelines. There were 553 patients with a PT test order; test order indications were absent in 190 (34.4%), of which one (0.5%, 95% CI = 0.1% to 2.9%) had adverse outcomes. There were 547 patients with a PTT test; test order indications were absent in 226 (41.3%), of which three (1.3%, 95% CI = 0.4 to 3.8%) had adverse outcomes. All three were taking warfarin when they presented to the ED. Conclusions: Emergency department physician expectation of an invasive procedure for patients with PT or PTT test orders is an insensitive predictor of patients who undergo such procedures. Clinical practice guidelines that exclude this criterion identify ED patients at the time of ED presentation at low risk for adverse medical outcomes in the ED or shortly after admission. Key words: prothrombin time; partial thromboplastin time; guidelines; bleeding; emergency department. ACADEMIC EMERGENCY MEDI-CINE 2002; 9:567-574.Prothrombin time (PT) and partial thromboplastin time (PTT) tests are widely used global screening tests for blood coagulation. Both tests are routinely ordered for surgical and other patients admitted to the hospital even though studies consistently demonstrate the low diagnostic utility of this practice.1-4 Additionally, preoperative PT and PTT test results are poor predictors of abnormal bleeding during and after surgery, 2,5-18 and abnormal blood coagulation tests are often not acted upon. 2,4 Evidence suggests that readily available historical and physical examination variables can accurately identify preoperative surgical and other admitted patients at low risk for inpatient bleeding complications.1,3,12 Implementation of these criteria could safely reduce the proportion of PT and PTT test orders for these patients by 50% to 85%. ever, the validity of these or similar high-yield criteria 19,20,21 has not been examined in an acute care setting where disposition and treatment decisions must be made within a narrow time interval.Clinical practice guidelines exi...

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Section: Discussionmentioning

confidence: 65%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Evaluation of Guidelines for Ordering Prothrombin and Partial Thromboplastin Times

Auble

Taylor

Hsu

et al. 2002

Academic Emergency Medicine

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“…1 The group recommended against routinely ordering complete blood cell counts, basic or comprehensive metabolic panels, and coagulation tests in low-risk patients for 3 reasons: (1) these studies are typically normal before low-risk surgery, (2) abnormal results lead to a change in management in as few as 3% of patients, and (3) randomized trials demonstrated no difference in intraoperative or postoperative patient outcomes when preoperative testing is performed. [2][3][4][5][6][7] Despite these efforts, gynecologists heuristically order routine preoperative laboratory testing in low-and high-risk patients before surgery even when many of these laboratory results are already present in the medical record. One major reason for this testing is to identify medically high-risk patients, optimize them before surgery, and lower their risk.…”

Section: Introductionmentioning

confidence: 99%

A model to predict risk of blood transfusion after gynecologic surgery

Stanhiser

Chagin

Jelovsek

2017

American Journal of Obstetrics and Gynecology

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BACKGROUND:A model that predicts a patient's risk of receiving a blood transfusion may facilitate selective preoperative testing and more efficient perioperative blood management utilization. OBJECTIVE: We sought to construct and validate a model that predicts a patient's risk of receiving a blood transfusion after gynecologic surgery. STUDY DESIGN: In all, 18,319 women who underwent gynecologic surgery at 10 institutions in a single health system by 116 surgeons from January 2010 through June 2014 were analyzed. The data set was split into a model training cohort of 12,219 surgeries performed from January 2010 through December 2012 and a separate validation cohort of 6100 surgeries performed from January 2013 through June 2014. In all, 47 candidate risk factors for transfusion were collected. Multiple logistic models were fit onto the training cohort to predict transfusion within 30 days of surgery. Variables were removed using stepwise backward reduction to find the best parsimonious model. Model discrimination was measured using the concordance index. The model was internally validated using 1000 bootstrapped samples and temporally validated by testing the model's performance in the validation cohort. Calibration and decision curves were plotted to inform clinicians about the accuracy of predicted probabilities and whether the model adds clinical benefit when making decisions. RESULTS: The transfusion rate in the training cohort was 2% (95% confidence interval, 1.72e2.22). The model had excellent discrimination and calibration during internal validation (bias-corrected concordance index, 0.906; 95% confidence interval, 0.890e0.928) and maintained accuracy during temporal validation using the separate validation cohort (concordance index, 0.915; 95% confidence interval, 0.872e0.954). Calibration curves demonstrated the model was accurate up to 40% then it began to overpredict risk. The model provides superior net benefit when clinical decision thresholds are between 0-50% predicted risk. CONCLUSION: This model accurately predicts a patient's risk of transfusion after gynecologic surgery facilitating selective preoperative testing and more efficient perioperative blood management utilization.

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“…URRENT literature has consistently demonstrated that 'routine' preoperative testing has little, if any, impact on perioperative outcomes particularly in asymptomatic patients undergoing low-risk ambulatory surgery. [1][2][3][4][5][6][7][8][9] Many suggest that such 'routine' testing can be completely eliminated while others advocate a 'selected' or 'indicated' testing based upon the patient's medical status. Different jurisdictions have developed different institutional policies regarding preoperative evaluation.…”

mentioning

confidence: 99%

Current preoperative testing practices in ambulatory surgery are widely disparate: a survey of CAS members

Yuan

Chung

Wong

et al. 2005

Can J Anesth/J Can Anesth

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Preoperative Laboratory Screening in Healthy Mayo Patients: Cost-Effective Elimination of Tests and Unchanged Outcomes

Cited by 145 publications

References 4 publications

Evaluation of Guidelines for Ordering Prothrombin and Partial Thromboplastin Times

Evaluation of Guidelines for Ordering Prothrombin and Partial Thromboplastin Times

A model to predict risk of blood transfusion after gynecologic surgery

Current preoperative testing practices in ambulatory surgery are widely disparate: a survey of CAS members

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