Preoperative testing before low-risk surgical procedures
Preoperative testing before low-risk surgical procedures
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DOI：
10.1503/cmaj.150174
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发表时间：
2015-08-11
影响因子：
14.6
通讯作者：
Bhatia, R. Sacha
中科院分区：
文献类型：
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作者：
Kirkham, Kyle R.;Wijeysundera, Duminda N.;Bhatia, R. Sacha
背景：人们担心低价值医疗保健服务的使用率越来越高，包括对低风险外科手术的术前检测。我们调查了低风险程序前检测使用的时间趋势、解释因素以及机构和地区差异。方法：在这项回溯性队列研究中，我们访问了加拿大安大略省基于人口的行政数据库。从2008年4月1日到2013年3月31日，在14个健康地区的137个机构，1 546 223名18岁或18岁以上的患者总共接受了2224 070次低风险手术，包括内窥镜和眼科手术。结果：内窥镜检查、眼科手术和其他低风险手术分别占手术总数的40.1%、34.2%和25.7%。术前31.0%(95%可信区间30.9%~31.1%)和10.8%(95%可信区间10.8%~10.8%)前进行心电图和胸片检查，而超声心动图和负荷试验的发生率分别为2.9%(95%可信区间2.9%~2.9%)和2.1%(95%可信区间2.1%~2.1%)。不同机构之间存在显著差异，术前心电频率从3.4%到88.8%不等。术前接受心电图和X线片检查的患者年龄较大(在66-75岁患者中，心电图调整后的优势比[OR]18.3，95%CI为17.6~19.0；X线片调整后的OR为2.9，95%CI为2.8~3.0)、术前麻醉会诊(心电图调整后的OR为8.7，95%CI为8.5~8.8；X线检查调整OR 2.2，95%CI 2.1~2.2)和术前会诊(心电图调整OR 6.8，95%CI 6.7~6.9；X线检查调整OR 3.6，95%CI 3.5~3.6)。接受术前心电和胸片检查的中位OR值分别为2.3和1.6。解释：尽管指南建议限制低风险手术前的检查，但术前心电和胸片检查仍然频繁。在对患者和机构层面的因素进行调整后，各机构之间的差异仍然很大。
Background: There is concern about increasing utilization of low-value health care services, including preoperative testing for low-risk surgical procedures. We investigated temporal trends, explanatory factors, and institutional and regional variation in the utilization of testing before low-risk procedures.Methods: For this retrospective cohort study, we accessed linked population-based administrative databases from Ontario, Canada. A cohort of 1 546 223 patients 18 years or older underwent a total of 2 224 070 low-risk procedures, including endoscopy and ophthalmologic surgery, from Apr. 1, 2008, to Mar. 31, 2013, at 137 institutions in 14 health regions. We used hierarchical logistic regression models to assess patient- and institution-level factors associated with electrocardiography (ECG), transthoracic echocardiography, cardiac stress test or chest radiography within 60 days before the procedure.Results: Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. ECG and chest radiography were conducted before 31.0% (95% confidence interval [CI] 30.9%-31.1%) and 10.8% (95% CI 10.8%-10.8%) of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% (95% CI 2.9%-2.9%) and 2.1% (95% CI 2.1%-2.1%), respectively. Significant variation was present across institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. Receipt of preoperative ECG and radiography were associated with older age (among patients 66-75 years of age, for ECG, adjusted odds ratio [OR] 18.3, 95% CI 17.6-19.0; for radiography, adjusted OR 2.9, 95% CI 2.8-3.0), preoperative anesthesia consultation (for ECG, adjusted OR 8.7, 95% CI 8.5-8.8; for radiography, adjusted OR 2.2, 95% CI 2.1-2.2) and preoperative medical consultation (for ECG, adjusted OR 6.8, 95% CI 6.7-6.9; for radiography, adjusted OR 3.6, 95% CI 3.5-3.6). The median ORs for receipt of preoperative ECG and radiography were 2.3 and 1.6, respectively.Interpretation: Despite guideline recommendations to limit testing before low-risk surgical procedures, preoperative ECG and chest radiography were performed frequently. Significant variation across institutions remained after adjustment for patient- and institution-level factors.