SELECTIVE VERSUS MANDATORY PREOPERATIVE WORK UPS IN PATIENTS FOR THYROIDECTOMY
Vivian P. Enriquez, MD
Rolando V. de Guzman, MD
Redomir P. Roque, MD
Janix M. de Guzman, MD
Harry Go, MD, FPCS
Alfonso Nunez, MD, FPCS
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
2002
SELECTIVE VERSUS MANDATORY PREOPERATIVE WORK UPS IN PATIENTS FOR THYROIDECTOMY
ABSTRACT
Mandatory routine preoperative work-ups is widely practiced both locally and internationally. This paper reports on the use of selective preoperative work-ups in 63 patients for thyroidectomy. Comparison was made with the prior practice of mandatory work-ups done in 41 patients for the same kind of operation. 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.
Keywords: preoperative work-ups; preoperative screening; thyroidectomy
SELECTIVE VERSUS MANDATORY PREOPERATIVE WORK UPS IN PATIENTS FOR THYROIDECTOMY
INTRODUCTION
Preoperative evaluation of surgical patients is necessary to assess health status in order to optimize condition before surgery and to plan the most appropriate protective management(1). However, the content of preoperative examination remains the object of discussion. Routine preoperative evaluation often includes more tests than are necessary for patients with no risk factors(2). Hence, questions on the appropriateness of the battery of tests routinely requested preoperatively have been raised. Worldwide, billions of dollars is spent annually for routine screening tests and many studies conclude that 60% of which are of no value(3,4). It is argued that a thorough patient history and physical examination should be the cornerstone in assessing patient's operative risk, so that routine preoperative tests should be abandoned and replaced with judicious selection and utilization of preoperative testing(5 - 7). In fact, a more individualized utilization of preoperative testing was recommended in 1989 by the Swedish Council on Technology Assessment and by the Swedish Consensus Conference on Preoperative Routines8. Despite the clamor for selective approach, the practice of ordering routine preoperative test is still prevalent worldwide and surveys showed that this practice is influenced mainly by perceived need of legal protection(9, 10).
In the Department of Surgery of Ospital ng Maynial Medical Center (OMMC), prior to September, 2001, it had been the practice to request for mandatory preoperative cardiopulmonary clearance and other non-surgical specialist referrals and the routine laboratory procedures that went with it, for all patients 35 years old and above. It could be presumed to be a hand-down habit of both surgeons and anesthesiologists since there are no hospital policies to support this practice. In an attempt to establish a more judicious approach to our patients in the present climate of cost-consciousness, a memorandum of agreement between Department of Surgery and Department of Anesthesia was formulated stating that selective pre-operative screening tests and non-surgical specialty referral should be practiced. This approach of selective screening was tried and implemented in all patients who were included in the month-long thyroid surgical mission in September, 2001.
The general objective of this study is to determine the safety and cost-effectiveness of selective preoperative work-ups. The specific objective is to compare selective and mandatory routine preoperative work-ups in patients who had undergone thyroidectomy in terms of operative outcome (mortality and morbidity), operation cancellation rates, number of preoperative visits, and patient-care cost.
METHODOLOGY
Two groups of post-thyroidectomy subjects were identified for comparison. The first group was categorized as the mandatory or M group operated from January 2000 to August 2001. This group consisted of patients regardless of signs and symptoms indicating surgical risks were subjected to a battery of tests and non-surgical specialists' clearance, which included:
a) Routine laboratory work-ups (CBC, CT, BT, blood typing, urinalysis, FT3, FT4, TSH, ECG, CXR)
b) Cardio-pulmonary clearance
c) Endocrine clearance
Absence of one requirement means no clearance for thyroid surgery by the anesthesiologists.
The second group was categorized as the selective or S group operated during the thyroid surgical mission in September to October, 2001. In this group, laboratory procedures and referral to non-surgical specialists were done only when there were signs and symptoms suggesting or indicating surgical risks which needed further evaluation and preoperative preparation.
For the purpose of comparison, only patients who were 35 to 70 years old and those without co-morbid problems were included in the study.
The charts of all patients included in the two groups were reviewed and data gathered to be used in the comparison based on the following variables: mortality rate, morbidity rate related to screening, schedule of operation cancellation rate, number of preoperative visits and patient-care cost.
RESULTS
There were 134 patients who underwent thyroid surgery at the Department of Surgery of OMMC from January 2000 to October 2001. A total of 104 patients were included in this study, 96 females (93%) and 8 males (8%).
Forty-one patients were categorized into the mandatory group while 63 patients were categorized into the selective group. The age range of patients in the M group was 35 to 62 years old with a mean age of 46, while that in the S group was 35 to 67 years old with a mean age of 45.
Of the 63 patients in the S group, only 9 patients had selective laboratory work ups, mostly thyroid hormone assay.
The number of preoperative hospital visits ranged from 4 to 6 for the M group and 2-4 for the S group (Table 1). Majority of patients in M group had 4 visits (88%), while majority of patients in S group had 2 visits (89%). With the selective approach, the total number of preoperative hospital visits was reduced by 50%.
Table 2 shows the total cost of preoperative laboratory tests in M group as compared to that in the M group. There was 93% reduction in cost with about PhP 30,000 savings in the S group. Laboratory costs were based on the price list of OMMC laboratory. About 86% (54/63) of patients in S group had no laboratory tests done. Since the professional fee for cardiac/pulmonary clearance and endocrine clearance were variable, this was excluded from the computation of the total cost.
Table 3 shows the schedule of operation cancellation rates in the 2 groups. There was no significant difference. The cause of the one case of cancellation in the M group was uncontrolled hypertension, while that for the two cases in the S group were tachycardia and uncontrolled hypertension.
There was no mortality in the two groups.
Table 4 shows the morbidity rates in the 2 groups. Focusing on complications that preoperative screening tries to avoid, there were no cardio-pulmonary complications and thyroid storms recorded in the 2 groups. The rest of the complications listed in the table have no direct relation with a preoperative screening. Nevertheless, the overall morbidity rates in the 2 groups did not show any statistical difference using a Chi square test.
Table 1. Number of preoperative visits.
n
2 VISITS
3 VISITS
4 VISITS
5 VISITS
6 VISITS
MANDATORY
41
0
0
36 (88%)
2 (5%)
3 (7%)
SELECTIVE
63
56 (89%)
5 (8%)
2 (3%)
0
0
*Data are given as number of patients
Table 2. Cost of preoperative tests.
COST(MEAN)
COST(TOTAL)
MANDATORY
P 785*
P32,185
SELECTIVE
P 55+
P3,465
* 8 patients in mandatory group had additional laboratory tests which were not included in the costing because they were not routinely requested.
+ 9 patients on the selective group had laboratory tests done, 54 patients had no laboratory tests done.
Table 3. Schedule of operation cancellation rate.
n
NUMBER OF CANCELLATIONS
CANCELLATION RATE
MANDATORY
41
1
2.4%
SELECTIVE
63
2
3.1%
Table 4. Morbidity rate.
MANDATORY
SELECTIVE
TOTAL
Cardio-pulmonary complications
0
0
0
Thyroid Storm
0
0
0
Hypocalcemia
1
1
2
Hoarseness
3
2
5
Hematoma
1
1
2
Seroma
1
3
4
Wound Infection
0
1
1
TOTAL
6
8
14
MORBIDITY RATE
14.6%
12.7%
13.5%
DISCUSSION
Mandatory and routine preoperative work-ups is still widely practiced both locally and abroad. In the Philippines, the practice of mandatory and routine preoperative cardiopulmonary clearance is still prevalent.10 So is the practice of routine endocrine clearance and routine thyroid function tests prior to thyroid surgery.
Both here and abroad, the main reason for such practice is the perceived need for legal protection.9,10 Habit is also another factor for perpetuation of such practice despite the clamor in the literature for selective preoperative work-ups. During their training years, surgical and anesthesia residents, because of some hospital or departmental policies, usually acquire the habit of requesting for routine preoperative work-ups. This habit, they carry in their post-graduation practice. Still, another reason, especially in the charity sections of government hospitals, is the lack of agreement between surgeons and anesthesiologists on such an issue. The usual scenario is that surgeons who want to practice a selective approach are being discouraged or prevented to do so because of resistance coming from anesthesiologists who insist on the routine approach. The root cause of this conflict is the absence of a good working relationship between the surgeons and the anesthesiologists.
The literature is abound with studies advocating the selective approach in preoperative work-ups. There are a lot of papers saying that routine complete blood count is not necessary prior to operation; that a routine bleeding and clotting time is not necessary; etc. What is not reported in the literature is a strategy on how to change the routine practice.
This particular paper could very well be another paper showing that routine preoperative work-ups is not necessary because of its explicit objective to compare selective versus mandatory preoperative work-ups. It could just be another paper without any impact in the literature. However, beside showing the safety and cost-effectiveness of selective preoperative work-ups, this paper has, though not in detail, shown how the routine preoperative practice could be changed. The memorandum of agreement between surgeons and anesthesiologists was the crucial strategy and most effective solution. The memo implies good working relationship between anesthesiologists and surgeons. The memo implies shared objective, shared vision, and shared mission. With cooperation and collaboration between surgeons and anesthesiologists, selective approach to preoperative work-ups can be done not only to improve efficiency but also to pave way for cost-effectiveness and an enhanced quality of patient care leading to patient satisfaction that will eventually negate worries for medico-legal problems.
References
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