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From Mandatory to Selective Preoperative Screening Evaluation in Patients for Thyroidectomy

A Model of Change Strategy towards Cost-effective Preoperative Screening

 

Reynaldo O. Joson, MD, FPCS

Vivian P. Enriquez, MD

Rolando V. de Guzman, MD

Anita O. So, MD, DPBA

Mercedes Rhandee M. Cruz, MD

Christia S. Padolina, MD, FPOGS

 

Introduction

 

There is a universal concern by medical insurers, hospital administrators, surgeons and anesthesiologists on the cost-effectiveness of routine preoperative screening investigations.  Search of the Medline reveals papers on this topic originating from almost all countries in the world [United States (1-7), United Kingdom (8), Germany (9,10), Spain (11-13), Italy (14,15), Belgium (16), Canada (17), France (18), Netherlands (19), Kuwait  (20), Thailand (21) and Pakistan (22)] and publications as early as the 70s and as recent as 2002 (8, 20).

 

In the Philippines, there exists a similar concern which was overtly expressed in a project conducted by the Philippine College of Surgeons in 1999 entitled “Evidence-based clinical guidelines on preoperative evaluation in noncardiac surgery” (23).  In the institution of the authors, prior to this study, the same situation and similar concern existed.

 

Despite the time immemorial concern, it seems that health care institutions are  having difficulty in coming out with a solution on how to shift from a routine practice of mandatory preoperative screening investigations to a selective approach.  The latter is the alternative practice that will promote cost-effective preoperative screening investigations.  The authors searched the Medline and found no published model of change strategy in this regard.

 

In 2001, the authors decided to institute a change in their institution that would promote a cost-effective preoperative screening investigations.  As of 2002, the change from a mandatory to selective preoperative screening investigations has been successfully effected and institutionalized in the authors’ institution.  The change process is hereby described which the authors think could be a model for other health care institutions to adopt or to get some idea from.

 

Methods

 

An action research methodology was utilized and facilitated by a surgeon-manager (the chairperson) with the goal of promoting a cost-effective preoperative screening investigations in the department of surgery of a city government hospital.  The chronological steps undertaken consisted of analysis of the situation and statement of the problem, formulation of strategies, implementation, evaluation, and institutionalization of solution.  All throughout the problem-solving activities, there was documentation and collaboration among the parties concerned. The documents were retrieved and synthesized to make a summative report of the action research.

 

Results

 

Setting

 

Ospital ng Maynila Medical Center (OMMC) is a 200-bed tertiary hospital owned by the government of the City of Manila.  It caters to the health needs of the residents of Manila, particularly the indigent ones. Just like other government hospitals in the Philippines, OMMC has meager resources and operational budget.

 

In 2001, a new chairperson (ROJ) was appointed by the hospital director (CSP) to resuscitate the department of surgery whose accreditation status with the Philippine College of Surgeons had been suspended primarily because of lack of surgical patients.  Project Optimal Surgical Services (POSS) was formulated as one of the major strategies to solve the problem of lack of surgical patients in the soonest time possible. Within the POSS was the Operasyon Pinoy program which in essence was an in-hospital surgical mission offering effective and efficient surgical operations to indigent Filipino patients for a minimal cost, and if not, for free.  It was intended to be an attraction for surgical patients to go to OMMC.

 

The first surgical mission to be launched was Operasyon Bosyo or Operation Goiter.  With the help of the hospital director, the new chair was able to find a donor to sponsor 60 patients for thyroidectomy to be done during the entire month of September, 2001.

 

Situational analysis and identification of problem prior to launching of Operasyon Bosyo

 

Beside other concerns associated with the usual preparation of surgical missions, ROJ was confronted with the challenges of cost-minimization and cost-effectiveness prior to launching Operasyon Bosyo.  He had to answer the donor’s query on how much money to put up for the 60 patients.  Data were gathered on the average expense of a thyroidectomy in OMMC which revealed PhP 10,000 for a charity patient and PhP 5,000 for a private patient (excluding the professional fees). ROJ decided to use PhP 5,000 as the target cost per patient with a resolve to promote cost-effectiveness during the implementation of the Operayson Bosyo.  Thus, a sum of PhP 300,000 was donated by the donor.

 

Analysis of the PhP 5,000 difference in the thyroidectomy expense between a charity and private patient showed that the main bulk of the difference lie in the preoperative screening evaluation, with the charity patients having a mandatory approach while the private patients, a selective approach.

 

Thus, the problem identified was how to shift from a mandatory to a selective approach in the preoperative screening evaluation of patients for thyroidectomy in the department of surgery of OMMC.

 

Formulation of strategies

 

ROJ decided to assume the role of a change facilitator and to use an action research methodology to effect the needed change.  Initially, he thought of the interventions to be made, then presented them to all the parties concerned, convincing them of the need for change, welcoming, understanding, and dealing reactions and suggestions with an open mind, tact, and allayance of fear with the end-goal of coming out with a shared mission and committed collaboration. 

 

From the very start, ROJ as a change facilitator had intended to use Operasyon Bosyo as a vehicle for change – to pilot test the change to be made and to institutionalize whatever change that would be effected by it.  Documentation of all activities was, therefore, decided upon at the outset.  Moreover, in the implementation of the planned changed, dialogues among the parties concerned and refinements were encouraged.

 

Implementation of planned change and outcome (with cyclical evaluation and institutionalization)

 

Planned change: Shift from mandatory to selective preoperative screening evaluation.   

 

Event 1: Conference with the staff of the department of surgery

 

1.1 Presentation of the need to shift from mandatory to selective preoperative screening evaluation in Operasyon Bosyo for cost-effectiveness reason and plan to use Operasyon Bosyo as a pilot and vehicle for change.

 

1.2 Presentation of policies and protocols on selective preoperative screening evaluation in patients for thyroidectomy.

 

1.                          NO routine cardiopulmonary, endocrine and pediatric clearances in patients for thyroidectomy.

2.                          Guidelines on when to refer to nonsurgical specialists for evaluation and treatment of associated nonthyroid conditions.

3.                          NO routine thyroid function tests - with guidelines on when to do thyroid function tests.

4.                          NO routine thyroid scan - with guidelines on when to do thyroid scan.

5.                          NO routine blood count, blood type, blood chemistries, urinalysis, chest x-ray, electrocardiogram and other diagnostic and laboratory tests traditionally being done – only if necessary as determined by findings in history and physical examination – with guidelines on when to do certain tests.

6.                          Electrocardiogram for all patients 70 and above.

 

1.3 Outcome: Approval by consensus of the proposed changes including the policies and protocols on selective preoperative screening evaluation approach but with concern whether the staff of department of anesthesia and hospital director would agree.

 

Event 2: Conference with the chairpersons of the departments of anesthesia and laboratory and the hospital director.

 

2.1 Presentation of the need to shift from mandatory to selective preoperative screening evaluation in Operasyon Bosyo for cost-effectiveness reason and plan to use Operasyon Bosyo as a pilot and vehicle for change.

 

2.2 Presentation of an additional reason to shift from mandatory to selective approach: to fulfill the requirement set by the General Surgery Accreditation Committee for all general surgery residency programs to implement the published “Evidence-based clinical practice guidelines on preoperative evaluation in noncardiac surgery.” (23)

 

2.3 Allayance of fear of medicolegal risk in selective approach: the published “Evidence-based clinical practice guidelines on preoperative evaluation in noncardiac surgery” could be used as a ground for defense.

 

2.4 Presentation of policies and protocols on selective preoperative screening evaluation in patients for thyroidectomy (see 1.2 above)

 

2.5 Outcome: Approval of the proposed changes including the policies and protocols on selective preoperative screening evaluation by chairpersons of the departments of anesthesia and laboratory and hospital director with the proviso that the changes would only be permitted on a trial basis for the duration of Operasyon Bosyo and that any problematic issue on preoperative screening should be discussed and settled during the regular weekly Surgery-Anesthesia Conference.

 

 

Event 3: Implementation of the Operasyon Bosyo during the month of September, 2001

 

3.1 A total of 63 patients with thyroid disorder was operated on.  There was no mortality reported.

 

3.2 A comparative study was made with the prior practice of mandatory work-ups done in 41 patients for thyroidectomy from January, 2000 to August, 2001.  The comparison revealed no significant difference in postoperative mortality, morbidity, and rate of cancellation of elective schedule of operation in both groups.  The selective group had advantages of decreased number of preoperative visits and lesser total patient-care cost.

 

3.3 The summative report on Operasyon Bosyo and the comparative study between mandatory and selective approach in preoperative work-ups were disseminated to the staff of the departments of surgery, anesthesia, and laboratory and to the hospital director.

 

Event 4: Memorandum of agreement between the departments of surgery and anesthesia on abolition of routine clearances in preoperative screening of surgical patients

 

On October 18, 2001, about 2 weeks after Operasyon Bosyo, the department of anesthesia initiated a meeting with the department of surgery.  Initially, the fear  was that the anesthesiologists would propose to go back to the mandatory approach of preoperative screening.  However, to the surprise of the surgeons, the anesthesiologists proposed to continue on with the practice of selective approach to cover all patients of the two departments.  A memorandum of agreement to this effect was, therefore, forged by the two departments (see appendix1).

 

Event 5: In a conference in July, 2002, the department of pediatric accepted the policies and protocol of the department of surgery on no routine preoperative pediatric clearance.

 

Event 6: Memorandum of agreement between the departments of surgery, anesthesia, and internal medicine on abolition of routine clearances in preoperative screening of surgical patients signed and approved by the hospital director in August, 2002 (See Appendix 2).

 

Event 7: Constant monitoring of implementation of memorandum of agreement and prevention of back-sliding during the weekly Surgery-Anesthesia Conference.

 

Event 8: Hospital director encouraging other surgical departments, particularly department of obstetrics-gynecology, to adopt the selective approach to preoperative screening evaluation.

 

 

Discussion

 

The estimate is that 60% of routine preoperative workups being done are not necessary (2,24) and that the routine approach is being done because of a perceived need for legal protection. As glimpsed from the literature, there has been a universal clamor for a shift from routine mandatory approach to a selective approach for reason of cost-effectiveness.  The question is how to change.

 

This paper reports on how a shift from a mandatory to selective preoperative screening evaluation was successfully effected and institutionalized from 2001 to 2002 in a city government hospital in the Philippines using an action research methodology.

 

The change process consisted of four essential chronological steps:

1) emergence of a surgeon-manager who acted as a change facilitator using an action research method; 2) development of a shared mission primarily between the staff of the departments of surgery and anesthesia and secondarily together with the staff of the nonsurgical departments and the hospital director; 3) pilot

testing with documentation to convince all parties concerned of the benefits of

the change; and 4) institutionalization of the change and constant monitoring

against back-sliding.

 

The generic change strategy utilized was an action research.  As a research methodology, action research can be described as a family of research methodologies which pursue action (or change) and research (or understanding) at the same time (25).  As a change methodology, action research as defined by Kurt Lewin, can be described as "proceeding in a spiral of steps, each of which is composed of planning, action and the evaluation of the result of action" (26).

Action research is known by several names with their corresponding definitions.  Within all these definitions there are four basic themes: empowerment of participants; collaboration through participation; acquisition of knowledge; and social change. The process that the researcher goes through to achieve these themes is a spiral of action research cycles consisting of four major phrases: planning, acting, observing and reflecting (27).

There is now a growing and renewed interest in action research in practically all fields and professions, health included, because of the participatory and collaborative approaches to research with both the researchers and practitioners participating together in the process; empowerment of participants; and impact of the research because of generation of solutions to practical problems.  All these elements were clearly seen in this action research promoting cost-effective preoperative screening evaluation.

Action research is identified as a style of research in which the researchers work explicitly with and for people rather than undertake research on them. (28)    In this particular project, although ROJ is the change facilitator and is the main researcher, it is considered that ROJ conducted the research together with the other surgical staff (VPE, RVG), the anesthesiologists (AOS, MRMC), and the hospital director (CSP), or so-called participants in the change process.  Thus, in consonance with the theme of an action research, the authorship of this paper included not only the change facilitator but also the main participants in the change process. Recognizing the participants as co-authors is actually another strategy to motivate and empower the participants to sustain the change.

Now that the authors have effected a shift from routine to selective preoperative screening evaluation in the department of surgery, the remaining task to be done in terms of a hospital-wide institutionalization will be to extend the change to the other surgical departments, such as obstetrics-gynecology, otorhinolaryngology, and ophthalmology.  With the hospital director (CSP) and the chair of the department of anesthesia (AOS) already convinced of the need for a cost-effective preoperative screening, the only people left to be convinced are the chairs of the abovementioned surgical department.  The same change strategy (action research) and change processes (4 steps as enumerated above – change facilitator, shared mission, pilot testing, and institutionalization) can be adopted.

For other centers in the Philippines and in the other countries in the world that may want to shift from routine mandatory to selective preoperative screening, the authors are sharing their experience and presenting it as a model of change strategy.

 

References


1. Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1997;1(12):i-iv; 1-62.

2. Marcello PW, Roberts PL. "Routine" preoperative studies. Which studies in which patients? Surg Clin North Am 1996 Feb;76(1):11-23.

3. Patel RI, DeWitt L, Hannallah RS. Preoperative laboratory testing in children undergoing elective surgery: analysis of current practice. J Clin Anesth 1997 Nov;9(7):569-75.
 

4. Vogt AW, Henson LC. Unindicated preoperative testing: ASA physical status and financial implications. J Clin Anesth 1997 Sep;9(6):437-41.

5. Tait AR, Parr HG, Tremper KK. Evaluation of the efficacy of routine preoperative electrocardiograms. J Cardiothorac Vasc Anesth 1997 Oct;11(6):752-5.

6. Mancuso CA. Impact of new guidelines on physicians' ordering of preoperative tests. J Gen Intern Med 1999 Mar;14(3):166-72.

7. Wattsman TA, Davies RS. The utility of preoperative laboratory testing in general surgery patients for outpatient procedures.  Am Surg 1997 Jan;63(1):81-90.

8. Johnson RK, Mortimer AJ. Routine pre-operative blood testing: is it necessary? Anaesthesia 2002 Sep;57(9):914-7.

9. Hesse S, Seebauer A, Schwender D.  Ambulatory anesthesia: which preoperative screening tests are required? Anaesthesist 1999 Feb;48(2):108-15.

 

10. Lingnau W, Strohmenger HU. Responsibility of the anaesthesiologist in the preoperative risk evaluation. Anaesthesist 2002 Sep;51(9):704-15.

11. Serrano Aguilar P, Lopez Bastida J, Duque Gonzalez B, Pino Capote J, Gonzalez Miranda F, Rodriguez Perez A, Erdocia Eguia J. Preoperative testing routines for healthy, asymptomatic patients in the Canary Islands (Spain). Rev Esp Anestesiol Reanim 2001 Aug-Sep;48(7):307-13.

12. Vilarasau Farre J, Martin-Baranera M, Oliva G. Survey on the preoperative evaluation in Catalonian surgical centers. I. What is the preoperative routine? Rev Esp Anestesiol Reanim 2001 Jan;48(1):4-10.

13. Oliva G, Vilarasau Farre J, Martin-Baranera M. Survey on the preoperative evaluation in Catalonian surgical centers. II. What is the attitude and opinion of the professionals involved? Rev Esp Anestesiol Reanim 2001 Jan;48(1):11-6.

14. Ricciardi G, Angelillo IF, Del Prete U, D'Errico MM, Grasso GM, Gregorio P, Schioppa FS, Triassi M, Boccia A.  Routine preoperative investigation. Results of a multicenter survey in Italy. Collaborator Group. Int J Technol Assess Health Care 1998 Summer;14(3):526-34.

15. Meneghini L, Zadra N, Zanette G, Baiocchi M, Giusti F. The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children. Paediatr Anaesth 1998;8(1):11-5.
Anesthesiology and Intensive Care Institute, University of Padua, Italy.

 

16. France FH, Lefebvre C.  Cost-effectiveness of preoperative examinations.
Acta Clin Belg 1997;52(5):275-86.

 

17. Is preoperative haemoglobin testing justified in children undergoing minor elective surgery? Roy WL, Lerman J, McIntyre BG. Can J Anaesth 1991 Sep;38(6):700-3.

18. Mignonsin D, Degui S, Kane M, Bondurand A. Value of selective prescription of preanesthetic laboratory tests.Cah Anesthesiol 1996;44(1):13-7.

19. de Vries TW, Harbers JS, Heymans HS, Harbers HS. Limited value of routine preoperative laboratory studies in children.  Ned Tijdschr Geneeskd 1992 Sep 12;136(37):1810-3.

20. Alsumait BM, Alhumood SA, Ivanova T, Mores M, Edeia M. A prospective evaluation of preoperative screening laboratory tests in general surgery patients.
Med Princ Pract 2002 Jan-Mar;11(1):42-5.

21. Bhuripanyo K, Khumsuk K, Sornpanya N, Wangsai W, Patoombal N. The impact of routine preoperative complete blood count (CBC) in elective operations in Srinagarind Hospital.  J Med Assoc Thai 1995 Jan;78(1):42-7. 

22. Pal KM, Khan IA, Safdar B. Preoperative work up: are the requirements different in a developing country? J Pak Med Assoc 1998 Nov;48(11):339-41.

23.  Roxas MFT, Dans DL, Laudico AV, Valera EDS, Gutierrez RR, Cruz CL.  Evidence-based clinical practice guidelines on seeking referral for preoperative cardiac evaluation for elective noncardiac surgery. Philipp J Surg Spec  l999; 54(4) 171-223.

 

24. Landais A.  Which preoperative tests in ambulatory surgery?  Cah Anesthesiol l993; 41(5) 511-9.

 

25. Dick, Bob (1999)  What is action research?  http://www.scu.edu.au/schools/gcm/ar/whatisar.html

 

26. Lewin, K. "Action Research and Minority Problems." Journal of Social Issues 1946; 2: 34-46.

27.  McNiff J. Action research: principles and practice. London: Macmillan Education Ltd, 1988.

28. Reason P, Rowan J. Human inquiry: a sourcebook of new paradigm research. Chichester: John Wiley and Sons, 1981.

 

 

 

 

 

 

Appendix 1

 

Memorandum of Agreement

 

Between Department of Surgery and Department of Anesthesia

on

 Abolition of Routine Clearances in Preoperative Screening of Surgical Patients

 

 

WHEREAS, the Department of Surgery and Department of Anesthesia of the Ospital ng Maynila Medical Center desire to improve the preoperative screening practices of surgical patients so as to make them more cost-effective, evidence-based, and above all, humane; and

 

WHEREAS, the Operasyon Bosyo on 60 patients with age ranging from 19 to 73 with a mean of 42,  held in September, 2001, has shown that routine preoperative cardiopulmonary clearance is NOT necessary and  selective use of laboratory examination for screening purposes is more cost-effective, evidence-based, and humane;

 

In a formal meeting between the Departments of Surgery and Anesthesia held on October 18, 2001, it is hereby resolved that starting October 18, 2001, the following policies will be adopted in the preoperative screening of surgical patients:

 

1.       The routine cardiopulmonary and pediatric clearances for adult and pediatric patients with surgical disorders who are to undergo anesthesia being practiced at present are hereby abolished.

 

2.       Any referral of surgical patients to internists and pediatricians and any other specialists for that matter will NOT be for reason of CLEARANCE but for further evaluation and assistance in the optimization of the surgical patients.

 

3.       Screening of surgical patients for operative and anesthetic risks will start with a complete history and complete and accurate physical examination by both the surgeons and anesthesiologists.

 

4.       The findings on history and physical examination will determine the need for laboratory exams.  Thus, request for laboratory exams will be selective and NOT routine.

 

5.       All patients 70 years old and above who are candidates for major and medium operation under general and regional anesthesia should have a screening ECG preoperatively.

 

6.       All pediatric patients 5 years old and below who are candidates for operation under general anesthesia should have a screening chest x-ray preoperatively.

 

7.       Clotting time, bleeding time, and complete blood count should NOT be done on a routine basis.

 

8.       The Departments of Surgery and Anesthesia agree to formulate more specific guidelines and protocols in the future so as to make the preoperative screening practices of surgical patients more cost-effective, evidence-based, and above all, humane.

 

__________________________                                                                                                               ____________________________

Reynaldo O. Joson, MD (sgd)                                                                                                               Anita O. So, MD (sgd)

Chair, Department of Surgery                                                                                                              Chair, Department of Anesthesia

 

 

Appendix 2

 

Memorandum of Agreement

 

Among Department of Surgery, Department of Anesthesia, and Department of Internal Medicine

on

 Abolition of Routine Clearances in Preoperative Screening of Surgical Patients

 

 

WHEREAS, the Department of Surgery, Department of Anesthesia, and Department of Internal Medicine of the Ospital ng Maynila Medical Center  (OMMC) desire to improve the preoperative screening practices of surgical patients so as to make them more cost-effective, evidence-based, and above all, humane;

 

WHEREAS, the Operasyon Bosyo on 60 patients with age ranging from 19 to 73 with a mean of 42,  held in September, 2001, has shown that routine preoperative cardiopulmonary clearance is NOT necessary and  selective use of laboratory examination for screening purposes is more cost-effective, evidence-based, and humane;

 

WHEREAS, there is already a published article in the Philippine Journal of Surgical Specialties entitled” Evidence-based clinical practice guidelines on seeking referral for preoperative cardiac evaluation for elective noncardiac surgery” (Philipp J Surg Spec 1999; 43(4): 172-223.) which seeks to rationalize the use of routine clearances in preoperative screening of surgical patients;

 

WHEREAS, all departments of surgery in the Philippines including the Department of Surgery of OMMC that are accredited by the Philippine College of Surgeons and Philippine Society of General Surgery are required to implement the evidence-based clinical practice guidelines as published in the Philippine Journal of Surgical Specialties 1999; 43(4):172-223;

 

WHEREAS, the Department of Surgery and Department of Anesthesia had since implemented a memorandum of agreement signed on October 18, 2001, abolishing routine preoperative cardiopulmonary clearances and had proven that routine preoperative cardiopulmonary clearance is really NOT necessary and selective use of laboratory examination for screening purposes is more cost-effective, evidence-based, and humane;

 

WHEREAS, the practice of selective use of laboratory examination for screening patients for operation has reduced the number of preop hospital visits from an average of 6 to 2 and has reduced the expense by PhP 5,000;

 

Resolved, therefore, that the following policies will be adopted by the Department of the Surgery, Department of Anesthesia, and Department of Internal Medicine of OMMC in the preoperative screening of surgical patients:

 

9.       There will be NO routine cardiopulmonary clearances for adult patients with surgical disorders who are to undergo anesthesia.

 

10.   Any referral of surgical patients to internists and any other specialists for that matter will NOT be for reason of CLEARANCE but for further evaluation and assistance in the optimization of the surgical patients.

 

11.   Screening of surgical patients for operative and anesthetic risks will start with a complete history and complete and accurate physical examination by both the surgeons and anesthesiologists.

 

12.   The findings on history and physical examination will determine the need for laboratory exams.  Thus, request for laboratory exams will be selective and NOT routine.

 

13.   All patients 70 years old and above who are candidates for major and medium operation under general and regional anesthesia should have a screening ECG preoperatively.

 

14.   Clotting time, bleeding time, and complete blood count should NOT be done on a routine basis.

 

15.   The Departments of Surgery and Anesthesia agree to formulate more specific guidelines and protocols in the future so as to make the preoperative screening practices of surgical patients more cost-effective, evidence-based, and above all, humane.  The Department of Internal Medicine will be consulted as needed.

 

 

 

 

Signature:

 

 

Signature:

Signature:

Reynaldo O. Joson, MD (sgd)

Anita O. So, MD (sgd)

Sonia Comia, MD (sgd)

Chair, Department of Surgery

Chair, Department of Anesthesia

Chair, Department of Medicine

Date:

Date:

Date:

 

                                                                                               

Approved:

 

 

Christia S. Padolina, MD (sgd)

Hospital Director

Date: