Preoperative Tests The use of routine preoperative tests for elective surgery Appendices

237 Pages·2003·0.97 MB·English

by  Scanning Station

National Institute for
Clinical Excellence
Preoperative Tests
The use of routine preoperative
tests for elective surgery
Appendices, Guidelines
& Information
EVIDENCE, METHODS & GUIDANCE
JUNE 2003
Developed by the National Collaborating Centre
for Acute Care
Preoperative Tests
The use of routine preoperative
tests for elective surgery
Appendices, Guidelines
& Information
EVIDENCE, METHODS & GUIDANCE
2
PREOPERATIVE TESTS
Contents
Appendices
Appendix 1 Results of a Systematic Review of the
Literaturefor Routine Preoperative Testing 3
Appendix 2 Examples of Surgical Procedures
bySeverityofGrading 93
Appendix 3 Phase A consensus questionnaire (results) 95
Appendix 4 Phase B consensus questionnaire (results) 147
Appendix 5 Economics of routine preoperative testing 201
Full guideline “Preoperative tests: the use of routine tests
forelective surgery. Evidence, Methods & Guidance
NICE guideline
Information for the Public
3
APPENDIX 1
Appendix 1: Results of a Systematic Review of
the Literature for Routine Preoperative Testing
The methods used for this systematic review are preoperative chest radiographs. Nine of these
presented in Chapter 2 of the full NICE guideline papersreported abnormal outcome data, eight
forpreoperative testing. The search strategy and reported changes in clinical management and
dataextraction forms used are appended to this fivereported postoperative complications. In
results section. combination with the 28 papers identified in the
Health Technology Assessment (HTA) report, this
1 Preoperative chest radiographs review includes 38 papers that studied preoperative
chest radiographs. The characteristics of the 38
1.1 Characteristics of the studies papers are summarised in Table 1.1. All the studies
In our search of the literature from 1995 to 2001, identified were case series.
weidentified a total of ten papers that studied
TABLE 1.1 Characteristics of the eligible studies of preoperative chest radiographs
First author and Country Study sample Type of surgery Abnormal test Change in clinical Postoperative
year of publication (age) management complications
Krupski USA 161 Major vascular surgery ✓ ✓ ✓
20001 (46 to 81years)
Silvestri Italy 6111 General, orthopaedics, ✓
19992 (not stated) ophthalmology,
gynaecology, urology
Pal Karachi 320 General ✓ ✓
19983 (not stated)
Ishaq Karachi 477 General, urology, ✓ ✓
19974 (>40years) gynaecology, obstetrics
Wattsman USA 142 Ambulatory surgery ✓ ✓ ✓
19975 (17 to 76years)
Bouillot France 3959 General, gastrointestinal ✓ ✓
19966 (15 to 99years)
Clelland USA 238 Orthopaedic ✓ ✓ ✓
19967 (37 to 94years)
Khong Hong Kong 203 Orthopaedic ✓ ✓ ✓
19968 (21 to 98years)
Ranparia USA 236 Prostatectomy ✓
19969 (33 to 84years)
Boland USA 100 Internal medicine ✓ ✓
199510 (43 to 75years)
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PREOPERATIVE TESTS
TABLE 1.1 Characteristics of the eligible studies of preoperative chest radiographs continued
First author and Country Study sample Type of surgery Abnormal test Change in clinical Postoperative
year of publication (age) management complications
Perez* Spain 3131 General, trauma, ✓ ✓
199511 (0 to 98years) gynaecology, paediatric
Adams* USA 169 (adults) General ✓ ✓
199212
MacDonald* UK 147 Orthopaedic ✓
199213 (>60years)
Sommerville* South Africa 797 General, obstetrics and ✓ ✓
199214 (0 to 80years) gynaecology, ear, nose and
throat (ENT), orthopaedics,
urology, ophthalmology,
plastic surgery, maxillofacial
Bhuripanyo* Thailand 1013 ENT, general, gynaecology, ✓ ✓ ✓
199015 (>15years) obstetrics, ophthalmology,
orthopaedics
Gagner* Canada 1000 Not stated ✓ ✓
199016 (0 to 70years)
McCleane* UK 687 Not stated ✓
198917 (0 to 81years)
Charpak* France 866 General, orthopaedic, ✓ ✓ ✓
198818 (not stated) gynaecology, obstetrics
Ogunseyinde* Nigeria 203 Not stated ✓
198819 (1 to 79years)
Tape* USA 318 Vascular ✓ ✓
198820 (24 to 90years)
Umbach* Germany 1175 Gynaecology ✓ ✓ ✓
198821 (0 to >80years)
Boghosian* USA 136 General, ophthalmology, ✓ ✓
198722 (60 to 93years) orthopaedics, urology
McKee* UK 397 Genera ✓ ✓ ✓
198723 (not stated)
Mendelson* USA 369 General ✓
198724 (not stated)
Turnbull* Canada 1010 General ✓ ✓ ✓
198725 (adults)
Weibman* USA 734 Not stated ✓ ✓
198726 (adults)
Wiencek* USA 403 Not stated ✓ ✓
198727 (mean 54years)
Muskett* USA 200 Cardiothoracic, ENT, general, ✓ ✓
198628 (mean 56years) neurosurgery, ophthalmology,
orthopaedics, plastic surgery,
urology
5
APPENDIX 1
TABLE 1.1 Characteristics of the eligible studies of preoperative chest radiographs continued
First author and Country Study sample Type of surgery Abnormal test Change in clinical Postoperative
year of publication (age) management complications
Rucker* USA 905 Plastic surgery, ✓ ✓
198329 (not stated) gynaecology, general
ophthalmology, ENT,
orthopaedics
Seymour* UK 233 Not stated ✓ ✓
198230 (> 60years)
Törnebrant* Sweden 100 General, orthopaedics, urology ✓
198231 (>70years)
Wood* USA 1924 ENT, general, ophthalmology, ✓ ✓
198132 (0 to 19years) orthopaedics, urology
Farnsworth* USA 350 Not stated ✓
198033 (0 to 14years)
Rossello* Peurto Rico 690 Not stated ✓ ✓
198034 (<14years)
Loder* UK 1000 Dental, gynaecology, ENT, ✓
197835 (not stated) ophthalmology, general,
orthopaedics
Petterson* USA 1530 Dental, ENT, gastrointestinal, ✓ ✓
197736 (adult + children) ophthalmology, orthopaedics,
urology
Sane* USA 1500 Not stated ✓ ✓
197737 (0 to 19years)
Rees* UK 667 Not stated ✓
197638 (not stated)
* Papers included in the HTA review
The results of the 38 studies, which documented the
findings from a total of 27,432 preoperative chest
radiographs, are summarised in Table1.2.
6
PREOPERATIVE TESTS
S
SA GRADE STATED x ASA I to V x x ASA I to III x x ASA I to II x x ASA I to II x x ASA I to IV x x ASA I to V x x x x
A
E T
V N
UTI ME
EC UIT ✓ x x ✓ ✓ ✓ x ✓ x x x x x x ✓ x x x ✓ x ✓
NS CR
O E
C R
)
s
t
s
d te CTIVE A
ate SPE DAT x ✓ x x ✓ ✓ ✓ x x x x x ✓ x ✓ x ✓ ✓ x x x
dic PRO
n
i
d
n d d d d d
es routine a ROUTINE Not stated Routine only Routine only Routine only Routine & indicate Routine only Not stated Routine only Not stated Routine only Routine only Routine only Routine only Routine & indicate Routine only Not stated Routine & indicate Routine & indicate Routine only Routine only Routine & indicate
d
u
l
c
n E S
h results (i POSTOPERATIV COMPLICATION N (%) 8 (5.0) 0 2 (0.1) 1.4 (5.0) 3 (1.5) 0 193 (34.0) 12 (3.6) 14 (1.2)
p
a
gr NT
o ME
di N E
hest ra HANGES I AL MANAG N (%) 8 (5.0) 313 (5.1) 1 (0.3) 1 (0.2) 0 1 (0.4) 3 (1.5) 1(1.6) 45 (2.1) 0 4 (1.3) 34 (3.6) 0 51 (4.6) (13.3) 15 (1.3)
c C C
e NI
tiv CLI
a
r
f preope ABNORMAL RESULTS N (%) 42 (28.1) 1116 (18.3) 192 (60) 203 (44.9) 3 (13.6) 125 (6.0) Not stated 93 (45.8) 28 (11.9) 4 (6.6) 485 (22.6) 6 (4.5) 7 (4.8) 48 (15.0) 181 (19.4) 74 (7.4) 127 (43.3) 568 (52.0) 122 (60.1) 116 (34.5) 118 (10.0)
o
y
r
a
m
m F
O
Su MBER ESTS# (N) 161 6111 320 452 22 2092 238 203 236 61 2151 133 145 319 933 1000 297 1101 203 336 1175
U T
N
TABLE 1.2 FIRST AUTHOR 1Krupski 2Silvestri 3Pal 4Ishaq 5Wattsman 6Bouillot 7Clelland 8Khong 9Ranparia 10Boland 11Perez* 12Adams* 13MacDonald* 14Sommerville* 15Bhuripanyo* 16Gagner* 17McCleane* 18Charpak* 19Ogunseyinde* 20Tape* 21Umbach*
7
APPENDIX 1
S e
E h
ASA GRAD STATED x x x x x x x x x x x x x x x x x patients in t
of
all
E T ot
V N n
UTI ME use
) continued CONSEC RECRUIT x x x x ✓ ✓ ✓ x x ✓ x x x ✓ ✓ ✓ ✓ ve tests beca
ndicated tests PROSPECTIVE DATA x ✓ x x x ✓ x x ✓ x x x x x x ✓ x of multiple preoperati
d i ults
des routine an ROUTINE Routine only Routine & indicated Routine only Routine only Routine only Routine & indicated Routine & indicated Routine only Routine only Routine & indicated Routine only Routine & indicated Routine & indicated Routine only Routine only Routine only Routine only apers reporting the res
u p
aph results (incl POSTOPERATIVE COMPLICATIONS N (%) 12 (8.8) 27(8.3) 3(0.4) 0 10 (5.8) 0 me studies. This occurs in
hest radiogr HANGES IN AL MANAGEMENT N (%) 1 (0.3) 8 (1.2) 38 (5.2) 10 (4.0) 6 (5.0) 0 3 (0.4) 2 (2.4) 2(0.01) 57(3.8) e sample size in so ailed in the paper.
y of preoperative c ABNORMALC RESULTSCLINIC N (%) 88 (64.7) 121 (37) 62 (18.7) 38 (5.5) 213 (29.0) 101 (42.6) 35 (29.4) 1 (0.3) 134 (57.5) 43 (47.3) 35 (4.7) 31 (8.9) 20 (2.9) 97 (9.7) 134 (8.8) 111 (7.4) 299 (44.8) e HTA review arried out may differ from th all thepreoperative tests det
Summar NUMBER OF TESTS# (N) 136 327 332 691 734 237 119 368 233 91 749 350 682 1000 1527 1500 667 *Papers included in th #The number of tests c study sample received
TABLE 1.2 FIRST AUTHOR 22Boghosian* 23McKee* 24Mendelson* 25Turnbull* 26Weibman* 27Wiencek* 28Muskett* 29Rucker* 30Seymour* 31Törnebrandt* 32Wood* 33Farnsworth* 34Rossello* 35Loder* 36Petterson* 37Sane* 38Rees*
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PREOPERATIVE TESTS
Table 1.2 shows that the proportion of abnormal patient inclusion is not associated with differences in
preoperative chest radiographs varied greatly across the study populations. Although this assumption may
studies and ranged from 0.3%29to 64.7%.22The not be true, there were too few data (insufficient
proportion of patients who had had a preoperative number of papers within strata of different aspects
chest radiograph and who subsequently underwent ofheterogeneity) or inadequate information (papers
achange in clinical management ranged from did not report data in sufficient detail) to explore
0%infour studies5,12,16,29to 13.3% in a further heterogeneity in a multivariate manner. However,
study.19The proportion of patients who had had a wewere able to explore variation both between
preoperative chest radiograph and who suffered studies, where confounding from different aspects of
postoperative complications ranged from 0% in four heterogeneity that are not independent of each other
studies5,15,29,34to 34.0% in a further study.18 is likely to have existed, and within studies, where
confounding of this kind is controlled to some extent.
The wide variation in the results may be explained
atleast in part by heterogeneity in the study
1.2 Heterogeneity in the quality of the
populations and outcome measures. The impact of
studydesign
four major sources of heterogeneity on the outcome
Studies in which data are collected prospectively or in
of the studies was explored in this review. The quality
which patients are recruited consecutively are more
of the study design was the first source of variation.
likely to be representative and have complete data
For example the quality of the study design was
and, therefore, are less likely to be susceptible to
regarded as highest in papers where data had been
biasthan studies in which data are collected
collected prospectively and where patients had
retrospectively or where patients are recruited
beenrecruited consecutively. The second source
selectively. We hypothesised that the proportions of
ofvariation was the composition of the study
abnormal preoperative chest radiographs, changes in
population. Variation arose for example, from
clinical management and postoperative complications
differences in the age range of study participants
may differ between the studies with high (prospective
and their American Society of Anesthesiologists
studies with consecutive recruitment of patients) and
(ASA) grades. The third source of variation
low (retrospective studies with nonconsecutive
considered arose from differences in the criteria
recruitment of patients) quality designs.
thateach study used as a basis for testing. For
example, some studies included patients having We investigated the effects of variations in the quality
routine preoperative chest radiographs only, whereas of the study design on the proportions of abnormal
other studies included patients who had either preoperative chest radiographs, changes in clinical
routine or indicated preoperative tests. Finally, the management and postoperative complications
fourth important source of variation arose from acrossthe identified studies. Five studies collected
differences in the definitions of the outcome data prospectively and recruited consecutive
variables. Differences occurred between studies patients,5,6,15,27,37and seven studies collected data
in,for example, the definitions used to determine prospectively but did not state that the sample of
abnormal test results, in what was considered patients was consecutive.2,7,13,17,18,23,30Eleven
achange in clinical management and in the studiescollected data retrospectively for a sample
postoperative complications that were reported. ofconsecutive patients,1,4;8,19,21,27,28,31,35,36,38
while15studies collected data retrospectively
These four major sources of heterogeneity are
anddidnotstate that the sample patients was
considered separately in the following sections.
consecutive.3,9-12,14,16,20,22,24,25,29,32-34The results
Ineach section, we have tried to identify the effect
ofthese studies are summarised in Table 1.3.
of variations in a particular feature across all studies
and, where possible, the effect of variations in that There was little difference in the average proportion
feature within each of the studies. This univariate of postoperative complications, the proportions
approach assumes that different aspects of ofabnormal preoperative chest radiographs and
heterogeneity are independent of each other, changes in clinical management by quality of
forexample that the choice of different criteria for studydesign.
9
APPENDIX 1
TABLE 1.3 Summary of abnormal chest radiographs and changes in clinical
management or postoperative complications in study populations
according to study quality indicators
QUALITY % ABNORMAL TEST % CHANGE IN CLINICAL % POSTOPERATIVE
INDICATOR (Number of Studies) MANAGEMENT COMPLICATIONS
(Number of Studies) (Number of Studies)
Mean* Maximum Minimum Mean* Maximum Minimum Mean* Maximum Minimum
P C 12.0 (5 42.6 6.0 2.2 (4) 4.0 0 0 (3) 0.1 0
P N 35.5 (6) 57.5 4.8 2.6 (4) 5.1 0.3 13.1 (4) 34.0 5.0
R C 21.9 (11) 60.1 9.6 6.9 (8) 13.3 0.2 0.4 (3) 5.0 1.2
R N 14.8 (15) 64.7 0.3 0.9 (10) 2.4 0 0.3 (5) 8.8 0
P = prospective data collection; R = retrospective data collection; C = consecutive recruitment of patients; N=nonconsecutive
recruitment of patients; *weighted means were produced to reflect the different numbers of patients in each study. It was not
possible to produce a distributional statistic reflecting this weight.
1.3 Heterogeneity in the composition of clinical management and postoperative complications
thestudy population across the identified studies. Twenty of the studies
included adults only1,4-10,12,15,18,20,25-28with four
1.3.1 Age range ofthese studies including adults over 60 years
Given that the prevalence of cardiopulmonary only.13,22,30,31Ten studies included both adults
disease increases with age, we hypothesised that the andchildren2,11,14,16,17,19,21,24,29,36and four studies
proportion of patients with abnormal preoperative included children only.32-34,37The remaining four
chest radiographs would be higher in studies of studies did not specify the age range of their study
olderpatient populations. population.3,23,35,38The proportions of abnormal
chest radiographs, changes in clinical management
We investigated the effects of variations in the age and postoperative complications in the study
range of the study population on the proportions of populations according to age group are summarised
abnormal preoperative chest radiographs, changes in in Table1.4.
TABLE 1.4 Summary of abnormal chest radiographs and changes in clinical
management or postoperative complications in study populations
according to age group
AGE % ABNORMAL TEST % CHANGE IN CLINICAL % POSTOPERATIVE
RANGE (Number of Studies) MANAGEMENT COMPLICATIONS
(Number of Studies) (Number of Studies)
Mean* Maximum Minimum Mean* Maximum Minimum Mean* Maximum Minimum
Adults
>60years 43.6 (4) 64.7 4.8 (0) (0) (0) 7.3 (2) 8.8 5.8
Adults only 24.9 (15) 52.0 5.5 2.5 (13) 5.2 0 5.5 (9) 34.0 0
Children
& adults 20.5 (10) 60.1 0.3 1.4 (7) 5.1 0 0.6 (2) 1.2 0
Children only 6.0 (4) 8.9 2.9 2.2 (3) 3.8 0.4 0 (2) 0 0
Not stated 37.9 (4) 60.0 9.7 0.3 (2) 0.3 0.3 8.3 (1)
*weighted means