Preoperative routines

Purpose of Assessment

To assess the value of different preoperative investigations including preoperative chest radiography, electrocardiographic examination, and clinical laboratory tests based on evidence in the medical literature. Secondly, to describe the current practice in Sweden for routine investigations prior to elective surgery.

Methods

Narrative review, cost analysis, cost effectiveness

Primary Data Collection

Review of the scientific literature on preoperative chest radiography, electrocardiographic examinations, and clinical laboratory tests of patients with no history of illness. Questionnaire survey of all general and orthopaedic surgery and anaesthesiology clinics in Sweden (224 clinics in total) concerning the frequency of use, reasons for use, the organisation of, responsibility for, and the consequences of the results from preoperative investigations. Economic analysis of the costs of preoperative routines and potential savings associated with stricter indications for preoperative investigations in Sweden.

Review process for the publication

Internal review by project group, SBU Board and SBU Expert Group. Additional external review by experts in the field.

Content of Report

The literature search revealed no well controlled study that verified the benefit of preoperative investigation of healthy patients without previous history of illness. Several studies demonstrated benefits from performing preoperative chest radiography, electrocardiograms, and clinical laboratory tests on patients in high risk categories.

The survey (93% response rate) showed that the use of and selection criteria for preoperative investigations varies significantly in Sweden.

The cost of preoperative investigations in Sweden is SEK 726 million, including one inpatient day in 75% of all surgical cases.

Using more restrictive criteria for preoperative investigations, the potential savings are calculated as SEK 100-200 million per year (equivalent to about US$ 3 million per million population).

Impact of Assessment

A survey of seven hospitals was conducted on four occasions: before the report was published in 1989, in 1990, 1991 and 1994. All surgery patients from general surgery, orthopedics, and gynecology and for whom an anesthesia case record was kept were included for a total of 3,000 patients. Between the 1989 and 1994 surveys, there was a 9% decrease in the number of preoperative chest x-rays, an 11% decrease in the number of preoperative ECGs, a 16% decrease in the number of routine S-potassium laboratory tests taken and a 14% increase in the number of same day admissions for surgery.