Original Title: Valoración preoperatoria en cirugía programada

Authors' objectives: MAIN OBJECTIVE: To carry out a report synthesizing the evaluation papers published to date by INAHTA agencies on “Preoperative Evaluation in Elective Surgery”. ♦ SPECIFIC OBJECTIVES: - To sum up the state of scientific knowledge about “Preoperative Evaluation in Elective Surgery” in the published reports. - To describe habitual attitudes and practices among surgeons and anesthetists based on the surveys published in the assessment reports. - To summarize the economic and legal implications analyzed in the reports.

Authors' results and conclusions: Firstly, the aims of all the reports, except the one published in Catalonia, include an analysis of the scientific evidence available at the time of publication, in order to assess the suitability of indicating a number of diagnostic tests in the preoperative evaluation. This has been done by means of systematic reviews of the literature on the subject and by consensus methods such as the Dutch document and the Basque report. On many occasions, the conclusions obtained in these reports are similar or slightly differ in aspects such as the age limits as of which the tests are recommended. Nevertheless, in other cases, more important differences are shown, especially in reports in which consensus methods have been used. On the other hand, we should point out that the most recently published assessment report, made by the University of Sheffield (NCCHTA 97), based in available evidence and not in experts’ opinion, makes recommendations on the tests indicated in the preoperative stage for asymptomatic patients which are more restrictive than previous reports. Secondly, another aim included in several of the reports considered in this document has been to collect the opinions, attitudes and customary practices of professionals during the preoperative stage in elective surgery. This question has been analyzed through a survey carried out among the health service professionals involved, i.e., anesthetists and surgeons, by the Swedish, French and Catalonian agencies. Among the attitudes of doctors covered in the survey both in Sweden, France and Catalonia, it is interesting to note that most of these doctors express serious doubts about the existence of a valid scientific base for recommending an EKG or chest X-ray during the preoperative stage. This contrasts with the fact that in Catalonia, as a daily practice, 49% of anesthetists and 68% of surgeons request chest X-rays and that 55% and 70% respectively request an EKG to be carried out in patients to be submitted to elective surgery. According to the information gathered in Sweden in 1989, both anesthetists and surgeons requested the performance of analytical tests such as potassium (66% and 73% respectively), sodium (64% and 69%), creatinine (54% and 65%), albumin (30% and 41%) and white cell count (48% and 45%) “mainly in all those patients to be submitted to programmed surgery”. In 1998 in Catalonia, most of those surveyed declared that they request “always or almost always” glucose (87% anesthetists, 93% surgeons), platelet count (94% and 84% respectively), leukocyte counts (72% and 86% respectively), urea and creatinine (72% and 73%). There is a lack of concordance between the recommendations extracted from the assessment reports and customary practice of doctors, both in Sweden and in Catalonia 10 years later. It may prove interesting to discuss the causes that lead to this discrepancy between the information provided by scientific publications and customary medical practice. The French and Catalonian agencies asked the professionals surveyed about the obstacles to making changes in customary practice they consider relevant. The conclusion is in that most health services professionals point to problems of a legal nature (in France 62% of anesthetists and in Catalonia 87% of anesthetists and 74% of surgeons). 57% of French anesthetists also indicate difficulties of an organizational nature. In Catalonia, most doctors (91% of anesthetists and 87% of surgeons) consider that it is absolutely necessary to establish a selective protocol for preoperative tests by means of consensus among the different specialties involved and based on existing scientific knowledge. Thirdly, in relation with the economic considerations, it has been demonstrated in the reports published in Sweden and Basque Country, that in the case of following the general clinical practice recommendations, an important amount of resources could be liberated, in order to be devoted to improve other practices or cover other medical needs. Finally, as Civil law aspects stated in the French and Basque reports, following evidence recommendations, that could be considered as a kind of coded lex artis, would not liberate the responsibility of the physicians but will certainly attenuate or soften their responsibilities in case of legal procedures. On the other hand, it should not be forgotten that an appraisal of individual risk for each patient is needed in any case.

Authors' methods: An appraisal was made of the information contained in the aforementioned papers that comply with the following inclusion criteria: 1. The main subject of the document is “Preoperative Evaluation in Elective Surgery”. 2. The report has been published by an INAHTA member agency. No exclusion criteria have been considered. In accordance with these criteria, the following reports have been included in this paper: • “Preoperative routines” published by the Swedish Council on Technology Assessment in Health Care in May 1989 (SBU 89). • “Indication of preoperative tests” published by the Agence Nationale pour le Developpement de l’Evaluation Medicale in June 1992 (ANDEM 92). • “Healthy/Asymptomatic Patient Preoperative Evaluation” published by the Basque Office for HTA, OSTEBA, in June 1994 (OSTEBA 94). • “Preoperative Evaluation” published by the Health Council of the Netherlands in February 1997 (GR 97). • “Routine preoperative testing: a systematic review of the evidence” published by NCCHTA in December 1997 (NCCHTA 97). • “Survey of preoperative routines in Catalonia (Spain)” made by Catalan Agency for Health Technology Assessment in April 1999 (CAHTA 99). Preliminary report.

Project Status: Completed

Year Published: 1999

URL for published report: https://www.euskadi.eus/contenidos/informacion/1999_osteba_publicacion/es_def/adjuntos/1999/d_99_05_preoperative_evaluation.pdf

URL for additional information: https://www.euskadi.eus/contenidos/informacion/1999_osteba_publicacion/es_def/adjuntos/1999/d_99_05_valoracion_preoperatoria.pdf

English language abstract: There is no English language summary available

Publication Type: Not Assigned

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: Osteba (Basque Office for Health Technology Assessment), Health Department of the Basque Government