Abstract
Background: Preoperative testing for surgery is estimated to cost $30 billion annually. The goal of this study was to determine the relative influence of access to a guideline reference for preoperative test ordering appropriateness by resident physicians in simulated case scenarios. Methods: At a single teaching hospital, 80 PGY (Post Medical School Graduation Year) 2-5 residents from anesthesiology, surgery, internal medicine, and obstetrics/gynecology were recruited to review simulated case scenarios. Participants within each specialty were randomized with half receiving supplemental ASA preoperative testing guidelines during completion of the questionnaire. Participants indicated which preoperative tests they believed appropriate for each scenario. Correct responses were set by an expert panel and results were reported as relative probabilities and 95% CI. Results: 66 surveys were analyzed. In the entire cohort, the group receiving supplemental guidelines achieved a greater percentage of correct answers (x=84.2%) compared to the group without guidelines (x=78.6%) (relprob =1.07 [CI 1.01-1.12], p=0.011). Correct answers improved to 1.07 [1.01-1.12] with a guideline across specialties and experience levels. Without a guideline, correct answer rates were greater for anesthesia vs surgery residents (1.19 [1.08, 1.31]) and anesthesia vs internal medicine residents (1.16 [1.04, 1.31]). With guidelines, these differences were maintained. Without a guideline, significant differences were noted between PGY 3 vs PGY 2 residents (1.12 [1.03, 1.23]) and PGY 4 vs PGY 2 residents (1.11 [1.03, 1.20]), but these differences were not present with guidelines. Surgery residents did not improve with the guideline. Conclusions: In a set of simulated clinical scenarios, reference to ASA-adapted guidelines improved test ordering by the majority of resident physicians. While anesthesia residents performed better than others independent of the guideline, the guideline negated the effect of experience in non-anesthesia trainees. Given the financial burden of inappropriate preoperative test ordering, further validation of the benefits of guideline implementation is warranted.
Highlights
The evolution of surgical practice over the last two decades has altered the practice of preoperative evaluation such that preoperative assessments occur in multiple, completely different settings
Many patients are not evaluated by an attending anesthesiologist at all prior to surgery
The study was limited to resident physicians in the PGY
Summary
The evolution of surgical practice over the last two decades has altered the practice of preoperative evaluation such that preoperative assessments occur in multiple, completely different settings. It has been estimated that greater than 50% of patients do not visit a preadmission testing center, even though these have been showed to be efficient and costeffective [1,2,3,4,5,6,7,8,9]. Preoperative testing for surgery is estimated to account for approximately $30 billion in health care costs annually in the US and a majority of these tests may be unnecessary [10,11,12]. While it is impractical to evaluate all patients in dedicated preoperative centers, there still exists a need to curtail the ordering of unnecessary and expensive tests in the preoperative period [13]. Preoperative testing for surgery is estimated to cost $30 billion annually. The goal of this study was to determine the relative influence of access to a guideline reference for preoperative test ordering appropriateness by resident physicians in simulated case scenarios
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