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Preoperative Testing ODG

The Official Disability Guidelines (December, 2013) recently updated the Low Back Chapter to include recommendations for preoperative testing. These recommendations have caused some concerns by our surgical specialty reviewers. Some have requested information on the position of the American Society of Anesthesiologists. Their web site includes a guideline entitled, “Statement on Routine Preoperative Laboratory and Diagnostic Screening.” This position paper states:

No routine* laboratory or diagnostic screening† test is necessary for the preanesthetic evaluation of patients. Appropriate indications for ordering tests include the identification of specific clinical indicators or risk factors (e.g., age, pre-existing disease, magnitude of the surgical procedure).

* Routine refers to a policy of performing a test or tests without regard to clinical indications in an individual patient.
† Screening means efforts to detect disease in unselected populations of asymptomatic patients.

Therefore, it would appear as though this Society would support that blanket terms such as “…Pre-op clearance, Pre-op labs, CXR and EKG…” should not be summarily authorized. Instead, the factors of each case must be considered.

One of the articles referenced by ODG (Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations) makes the following recommendations:

EKG:      Recommended before high risk surgeries (i.e. aortic & major vessel surgery, peripheral vascular
surgery)
Recommended before intermediate risk surgeries (i.e. intraperitoneal or intrathoracic surgery, carotid endarterectomy, head & neck surgery, orthopedic surgery, prostate surgery) with at least one of the following clinical risk factors: cerebrovascular disease, CHF, creatinine >2.0, DM – on insulin, or ischemic heart disease.

CXR:       Recommended if new or unstable cardiopulmonary signs or symptoms.
Recommended for patients at increased risk of pulmonary complications (i.e. CHF, COPD, age >60 yrs old, ASA score of 2 or >, hypoalbuminemia, prolonged procedures, and surgery to the upper abdomen, head or neck.

LABS:

Lytes/CRE: Recommended for history of hypertension, CHF, chronic renal disease, complicated DM, & liver disease
Recommended for claimants taking diuretics, angiotensin-converting enzyme inhibitors,              angiotensin receptor blockers, NSAID’s & digoxin.

GLU & HbA1c: Recommended for claimants at high risk of undiagnosed DM – based upon H&P.
Recommended for claimants taking glucocorticoids

CBC:       Recommended for claimants suspected of anemia (i.e. history of chronic inflammatory
condition, chronic kidney disease, chronic liver disease, clinic signs/symptoms of anemia)

PT/PTT: Recommended for history of liver disease, disease of hematopoiesis and those on anti-
coagulants
Recommended when H&P raises suspicion of underlying coagulopathy

An article from more than 20 years ago noted that $20 billion are spent on preoperative testing. Yet various articles note that the likelihood of detecting something which would alter the planned surgical course ranged only around 1-5%. We would appreciate your support in helping us educate requestors through the review process regarding this step in cost-containment.

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