"Routine" preoperative studies. Which studies in which patients?

Marcello PW, Roberts PL.
Surg Clin North Am 1996 Feb;76(1):11-23.

This article emphasizes that 60% of routine tests conducted on patients in preparation of their surgery are unnecessary and add an extra $18 billion to the annual health care bill. In addition, unnecessary tests cause harm resulting from complications associated with the testing procedure, or with the unnecessary treatment of patients who receive a false positive test result.

Preoperative and postoperative medical evaluation of surgical patients.

Gluck R, Munoz E, Wise L.
Am J Surg 1988 Jun;155(6):730-4.

This article highlights that in low-risk patients, routine pre-operative and post-operative medical evaluations are of no proven benefits, and may therefore be unnecessary.

Preoperative testing for fecal occult blood: a questionable practice.

Sonnenberg A, Townsend WF.
Am J Gastroenterol 1992 Oct;87(10):1410-7.

This article shows that routine fecal occult blood testing has no benefits in patients hospitalized for elective major surgery. Although this test is associated with a small advantage, compared to non-testing, this benefit is overcome by the frequency of false positive results, leading to unnecessary diagnostic work-ups, higher procedural costs, and an overall adverse impact on the surgical procedure the patient was admitted to perform, by delaying it.

Unnecessary preoperative investigations: evaluation and cost analysis.

Allison JG, Bromley HR.
Am Surg 1996 Aug;62(8):686-9.

The results of this study indicate that two-thirds of the tests patients undergo in preparation of their surgery are unnecessary. The study evaluated prospectively the appropriateness of pre-operative testing in 60 randomly selected ambulatory surgery patients. Only one-third of tests had clinical indications and was therefore deemed appropriate. The cost of inappropriate tests was estimated at $47 to $80 per patient. The authors emphasize the need of changing obsolete practices.

Value of routine preoperative chest x-rays: a meta-analysis.

Archer C, Levy AR, McGregor M.
Can J Anaesth 1993 Nov;40(11):1022-7.

The results of this meta-analysis indicate that only 0.1% of pre-operative chest x-rays that are routinely performed on European and North American patients provide information that affects patient treatment. The study reviewed all relevant articles published in English, French and Spanish from 1966 to 1992, and selected 21 of them with enough data to perform a meta-analysis. On average, routine pre-operative chest x-rays detected abnormalities in 10% of patients. Only in 1.3% of films, though, the abnormality was unexpected, but its finding resulted in a change of treatment in only 0.1 of patients. The influence that the new information has on patient outcome is unknown. The authors concluded that the costs of routine chest x-rays are so high, and the likely benefits so small, that its use is no longer justified in patients who have received a careful anamnesis and clinical evaluation.

The impact of routine admission chest x-ray films on patient care.

Hubbell FA, Greenfield S, Tyler JL, Chetty K, Wyle FA.
N Engl J Med 1985 Jan 24;312(4):209-13.

This prospective study assessed the value of performing routine chest y-rays in a cohort of patients with high rates of cardiopulmonary diseases. Sixty percent of 491 patients admitted to the internal medicine wards of the Veteran Administration Medical Center, in Long Beach, California, had chest x-rays taken. The results of the test revealed abnormalities in 36% of patients, and the findings lead to modification of treatment in 12 (4%) patients. In only one patient, though, appropriate treatment would have probably been omitted if the test had not been performed, but the change in treatment did not result in improved outcome for the patient. These findings indicate that routine chest x-rays is of little value, even in a population with high rates of cardiopulmonary diseases.

Is admission chest radiography of any clinical value in acute stroke patients?

Sagar G, Riley P, Vohrah A.
Clin Radiol 1996 Jul;51(7):499-502.

This retrospective study assessed the value of performing routine chest x-rays in 435 patients hospitalized with acute stroke. Chest x-rays were taken in 86% of patients. Over three-quarters of films were judged to be technically unsatisfactory. The films revealed abnormalities in 16.4% of patients, but only 3.8% of patients underwent a change in management because of the test findings. The authors conclude that routine chest x-rays are not indicated in patients with acute stroke who don't have clinical indications for the test.

Evaluation of routine postoperative chest X-rays in the management of the cardiac surgical patient.

Rao PS, et al.
Eur J Cardiothorac Surg 1997 Nov;12(5):724-9.

The results of this study indicate that patients who have routine chest x-rays taken regularly after cardiac surgery fare no better than those who receive the test only when clinically indicated. The study was conducted on 300 consecutive patients who, after undergoing cardiac surgery, were divided in 3 groups of 100 individuals each. Group A received 3 routine chest x-rays, group B received 1 routine chest x-ray on the fourth day after the surgery, and group C received chest x-rays only if clinically indicated. Overall, groups A, B, and C received 304, 133 and 36 chest x-rays, respectively. The results of the tests lead to intervention in 5, 4 and 4 patients from groups A, B, and C, respectively. There was no increase in morbidity and mortality attributed to omission of the test in any patient. These findings indicate that routine postoperative chest x-ray is unnecessary in the management of cardiac surgical patients.

Routine preoperative testing: a systematic review of the evidence.

Munro J, Booth A, Nicholl J.
Health Technol Assess 1997;1(12):i-iv; 1-62.

This review evaluated all relevant articles retrieved through multiple search engines, assessing the value of different routine pre-operative tests. The authors define as routine tests those that are performed in apparently healthy individuals without indications from patient's clinical history and examination. No randomized controlled studies have ever tested the value of performing routine chest x-ray, electrocardiography, complete blood count, tests of haemostatic function, biochemical tests, and urine testing. The evidence reported, therefore, comes from the analysis of case-series studies. For chest x-rays, the available evidence shows that the results of performing routine pre-operative tests lead to a change in clinical patient management in 0% to 2.1% of patients. The influence that the new information has on patient outcome is unknown. For routine electrocardiography, the results of the test lead to a change of treatment in 0% to 2.2% of patients, with unknown effects on their health outcome. For complete blood count tests, the evidence shows that routine testing of hemoglobin levels results in changes in patient's management in 0.1% to 2.7% of patients, while platelet and white blood cells test values rarely, if ever, lead to changes in patient treatment. For tests of coagulation, the available evidence indicates that results of routine preoperative tests very rarely lead to change in treatment, and so is for routine serum biochemistry tests. Finally, routine urine test result in change of management in 0.1% to 2.8% of patients. These findings indicate that only in a very small percentage of patients, the results of several common routine pre-operative tests lead to a modification of management, and the effects on patient's health are unknown.

Preoperative laboratory testing: should any tests be "routine" before surgery?

Macpherson DS.
Med Clin North Am 1993 Mar;77(2):289-308.

The author of this article emphasizes that any routine test performed in patients admitted for elective surgery is unjustified, since the percentage of patients who will have abnormal test results is small, and there is little evidence indicating that the abnormality detected by the test will have an adverse impact on the surgery.

Accuracy of fecal occult blood screening for colorectal neoplasia

A prospective study using Hemoccult and HemoQuant tests.
Ahlquist DA, et al.
JAMA 1993 Mar 10;269(10):1262-7.

The results of this study, conducted on over 13,000 individuals, show that two of the most widely used tests for the detection of colorectal cancer, the Hemoocult and Hemoquant tests, whose job is to spot the presence of occult blood in the stools, miss approximately 70% of cancers that are later diagnosed by other methods, and 90% of polyps (pre-cancerous conditions) 1 cm or more in size.

Fecal occult blood testing: clinical value and limitations.

Simon JB.
Gastroenterologist 1998 Mar;6(1):66-78.

This article emphasizes that only 5% to 10% of patients who test positive at the fecal occult blood screening with the Hemoccult test have cancer. The low specificity of the test is an important problem, since patients who receive a false positive result will undergo unnecessary diagnostic work-up to ascertain the presence of the cancer.

An evaluation of the carcinoembryonic antigen (CEA) test for monitoring patients with resected colon cancer.

Moertel CG, Fleming TR, Macdonald JS, Haller DG, Laurie JA, Tangen C.
JAMA 1993 Aug 25;270(8):943-7.

The results of this study show that monitoring the levels of carcinoembryonic antigen (CEA) to detect the occurrence of a relapse in patients with a history of colon cancer has little, if any value, in improving their survival. In the study, 87% of 1216 patients who received surgery for colon cancer had CEA levels monitored. Survival rates more than a year after surgery were 2.3% in CEA-monitored patients, and 2% in non-monitored patients. The authors question the value of performing a test that is associated with substantial costs, that causes considerable psychological stress to the patients, and whose value in improving survival is, at best, minimal.

Screening of average-risk individuals for colorectal cancer and postoperative evaluation of patients with colorectal cancer.

Nelson RL.
Surg Clin North Am 1996 Feb;76(1):35-45.

This article emphasizes that screening patients with a history of colorectal cancer for recurrence of disease does not reduce morbidity and mortality from the disease, and is therefore unjustified.

Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome

Gausche, M. et al.
JAMA. 2000;283:783-790

The results of this study show that emergency intubation performed by paramedics does not improve survival or neurological outcome in children with severe breathing problems. Endotracheal intubation (ETI) is widely used by out-of-hospital providers, because of the belief that its use is associated with improved outcome in children with respiratory difficulties, compared to simple bag-valve-mask ventilation (BVM). This belief, however, has not been supported by any controlled trial. This study was conducted to determine the impact of ETI on survival and neurological outcome in children aged 12 years and younger, and to compare its effectiveness with that of BVM. Eight hundred-twenty consecutive children requiring airway management were randomly assigned to treatment in emergency, out-of-hospital settings, with bag-valve-mask ventilation or BVM followed by endotracheal intubation. No significant differences in survival or neurological status were observed between the two groups as a whole. Subgroup analyses, however, revealed that ETI was associated with significant detrimental outcome, compared to BVM, in 3 out of 10 subgroups of patients. In particular, children with respiratory arrest and with child abuse treated with ETI has significantly worse survival than those treated with BVM, and children with foreign body aspiration who underwent ETI had significantly worse neurological outcome, compared to those who received BVM. In addition ETI was associated with a high rate of fatal complications (approximately 8%). This is the first controlled study showing that ETI is not advantageous in pediatric patients in out-of-hospital settings. The authors report that in spite of the lack of research in support of this practice and the high rate of fatal and nonfatal complications, emergency intubation is thought in 97% of paramedic trainings, is considered to be the standard of care for children who require airway management, and is now being thought to emergency medical technicians, who are less-experienced that paramedics. These results strongly challenge the national consensus that ETI should be incorporated in routine emergency, out-of-hospital, medical services for children with breathing difficulties.

The medical appropriateness of tympanostomy tubes proposed for children younger than 16 years in the United States.

Kleinman LC, Kosecoff J, Dubois RW, Brook RH.
JAMA 1994 Apr 27;271(16):1250-5.

The results of this study indicate that 27% of the tympanostomy tubes placement proposed for the treatment of otitis media in children are inappropriate, and 32% have equivocal indications. The study was conducted on 6611 children younger than 16 years who were referred by their physician for a tympanostomy tube placement. In 97% of cases the reason for the procedure was the presence of recurrent otitis media or otitis media with effusion. The authors estimated, based on generous clinical assumptions, that only in 41% of cases the procedure was appropriate, and was equivocal and inappropriate in 32% and 27% of individuals, respectively.

Appropriateness of referrals for open-access endoscopy. How do physicians in different medical specialties do?

Mahajan RJ, Barthel JS, Marshall JB.
Arch Intern Med 1996 Oct 14;156(18):2065-9.

The results of this study show that 15% of esophagogastroduodenoscopy (EGD) and 33% of colonoscopy are scheduled for inappropriate reasons by internal medicine subspecialists and surgeons. The rates of inappropriate EGD and colonoscopy scheduled by family doctors and general internists, on the other hand, were significantly lower, being 3% and 19%, respectively.

Cost-Utility Analysis of Screening Intervals for Diabetic Retinopathy in Patients With Type 2 Diabetes Mellitus.

Vijan S; Hofer TP; Hayward RA.
JAMA 2000;283:889-896.

The results of this study show that screening for eye disease every other year or every three years can be as effective as screening annually to prevent blindness in patients with type 2 diabetes and no signs of eye deterioration. Current guidelines recommend yearly eye examination for diabetic patients on the basis of cost-effectiveness analyses demonstrating an economic benefit associated with this practice. The authors of the study used a computer model to assess the costs and effectiveness of yearly versus extended screening intervals. The results of the study indicate that a high-risk diabetic patient aged 45 years with poor glycemic control is expected to gain 21 days of sight by attending screening visits annually, rather than every third year. On the other hand, a 65-year old low-risk diabetic patient with moderately well glycemic control is expected to gain 3 days of sight by undergoing screening annually, rather than every third year. Screening low-risk patients annually rather than every other year results in an additional cost of $123,580 for each year of quality life gained. These estimates show that annual eye screening produces little benefits in low-risk diabetic patients, while substantially increasing health care costs. The authors emphasize that current guidelines calling for yearly screening in patients with type 2 diabetes should be re-evaluated, and recommendations should be tailored to patients clinical status.

Effects of preventive home visits to elderly people living in the community: systematic review.

van Haastregt, JCM et al.
BMJ 2000;320:754-758 ( 18 March ).

The results of this study show that preventive home visits are largely ineffective, the way they have been designed, in improving the health status of elderly individuals. The study, a systematic review of 15 trials, shows that preventive home visits where potential medical, psychosocial and environmental problems of elderly individuals are assessed and appropriate recommendations are given to reduce or treat the observed problems and to prevent future ones, have no clear beneficial impact on the health of senior citizens. The lack of efficacy of these measures, coupled with their high costs, questions their appropriateness in improving the health status of elderly individuals.

A prospective study of advance directives for life-sustaining care.

Danis M, et al.
N Engl J Med 1991 Mar 28;324(13):882-8.

This study evaluated the effectiveness of written advance directives in determining the type of medical care a patient will receive when he/she will be no longer competent to make decisions. In 25% of the cases advanced directives were inconsistent with provided end-of-life care such as hospitalization, intensive care, cardiopulmonary resuscitation, artificial ventilation, tube feeding.

Extraimmunization Among US Children.

Feikema SM et al.
JAMA. 2000;283:1311-1317.

The results of this study show that in the U.S., every year approximately 900,000 children aged 19-36 months (one fifth of all U.S. children in that age group) receive at least an extra immunization, leading to an excess cost of $26.5 billion. The investigators surveyed parents of 32,742 children and obtained information from 22,806 of them through their health care provider. They found that 21% of them had received at least one extra vaccination. Extra doses of vaccine, in addition to adding discomfort and stress to the baby, are associated with an increased risk of adverse reactions. The risk of adverse reactions is particularly high with extra doses of the diphtheria-tetanus vaccine, and there is evidence showing that extra doses of these vaccines can cause serious side effects. In addition extra immunizations add extra costs and labor to the health care system. This study estimated this excess cost at $26.5 billions. This estimate, however, is conservative, since it does not take in account the costs associated with vaccine handling and distribution, parent's travel time, treatment for adverse effects, or other indirect costs.

Inappropriate medication is a major cause of adverse drug reactions in elderly patients.

Lindley CM, et al.
Age Ageing 1992 Jul;21(4):294-300.

This study evaluated the rate of prescribing of drugs with absolute contraindications or unnecessary, in a sample population of 416 elderly patients consecutively admitted to a teaching hospital. On admission, 11.5% of patients were receiving drugs with absolute contraindications, and 27% were receiving drugs that were unnecessary. Adverse drug reactions (ADRs) occurred in 27% of patients on medication, and half of these reactions were due to drugs with absolute contraindications or unnecessary. ADRs were the cause of hospital admission in 6.3% of patients, and were due to inappropriate prescribing (and were therefore avoidable) in half of the cases.

Appropriateness of antibiotic therapy in long-term care facilities.

Jones SR, Parker DF, Liebow ES, Kimbrough RC 3d, Frear RS.
Am J Med 1987 Sep;83(3):499-502.

This study evaluated the appropriateness of antibiotic therapy in patients of two nursing homes in Portland, Oregon, over a 3-month period. One hundred twenty infections occurred during the study period. Antibiotic treatment was judged appropriate only in 49% of cases, and inappropriate and unjustified in 42% and 9% of cases, respectively.

Inappropriate medication prescribing for the elderly by office-based physicians.

Aparasu RR, et al.
Ann Pharmacother 1997 Jul-Aug;31(7-8):823-9.

This study evaluated prescribing patterns of 20 drugs that a panel of expert believed should never be given to the elderly. It is shown that in 1992, in the U.S., approximately 8.47 million visits resulted in physicians prescribing a minimum of one inappropriate medication. In 0.72 million visits, two inappropriate medications were prescribed. Overall, 7.6% of elderly who received a prescription had at least one inappropriate medication prescribed. Propoxyphene, amitriptyline, dipyridamole, diazepam, and chlorpropamide were among the most frequently inappropriate drugs prescribed.

Family practice and internal medicine office fees: an analysis of charge differences.

Julnes TE, Baker TA.
J Fam Pract 1993 Jul;37(1):35-43.

The results of this study show that general internists charge significantly more for office visits, compared to family physicians. These differences are not explainable by patient case mix.

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