Survey Study of Anesthesiologists and Surgeons

Ordering of Unnecessary Preoperative

Laboratory Tests
Robert I. Katz, MD,* Franklin Dexter, MD, PhD, Kenneth Rosenfeld, MD,* Laura Wolf
e, BA,*
Valerie Redmond, BA,* Deepti Agarwal, MD,* Irim Salik, MD,* Karen Goldsteen, PhD
,
Melody Goodman, PhD,§ and Peter S. A. Glass, MB*
BACKGROUND: Nearly 20 years ago it was shown that patients are exposed to unnece
ssary
preoperative testing that is both costly and has associated morbidity. To determ
ine whether such
unnecessary testing persists, we performed internal and external surveys to quan
tify the
incidence of unnecessary preoperative testing and to identify strategies for red
uction.
METHODS: The medical records of 1000 consecutive patients scheduled for surgery
at our
institution were examined for testing outside of our approved guidelines. Subseq
uently, 4
scenarios were constructed to solicit physician views of appropriate testing: a
45-year-old woman
for a laparoscopic ovarian cystectomy, a 23-year-old woman for right inguinal he
rniorrhaphy, a
50-year-old man for a hemithyroidectomy, and a 50-year-old man for a total hip r
eplacement. One
or more of these scenarios were sent to directors of preoperative clinics (all),
United States
anesthesiologists (all), gynecologists (cystectomy), general surgeons (herniorrh
aphy), otolaryngologists
(thyroidectomy), and orthopedists (hip replacement). Potential predictors of ord
ering
and demographic information were collected.
RESULTS: More than half of our patients had at least 1 unnecessary test based on
our testing
guidelines (95% lower confidence limit .
52%). The 17 responding preoperative directors were
unanimous for 36 of the 72 combinations of test or consult (henceforth test ) and s
cenario as
being unnecessary. Among the 175 anesthesiologists responding to the survey, 46%
ordered 1
or more of the tests unanimously considered unnecessary by the preoperative dire
ctors for the
given scenario. Among 17 potential predictors of anesthesiologists unnecessary or
dering, only
training completed before 1980 significantly increased the risk of ordering at l
east 1 unnecessary
test (by 48%, 95% confidence limits 29%). Anesthesiologists were 53% less likely
to order
at least 1 unnecessary test relative to gynecologists for the cystectomy scenari
o, 64% less likely
than general surgeons for the herniorrhaphy scenario, 66% less likely than otola
ryngologists for
the thyroidectomy scenario, and 67% less likely than orthopedists for the hip re
placement
scenario. The 95% lower confidence limits were all 40%.
CONCLUSIONS: The percentage of patients with at least 1 unnecessary test is a su
itable end
point for monitoring providers ordering. The incidence can be high despite effort
s at improvement,
but may be reduced if anesthesiologists rather than surgeons order presurgical t
ests and
consults. However, anesthesia groups should be cognizant of potential heterogene
ity among
them based on time since training. (Anesth Analg 2011;112:207 12)
R
R
outine
screening
laboratory
testing
for
surgery
persists
even
though
it
is
generally
unnecessary1
4
and
adds
considerably
to
the
cost
of
health
care.
Up
to
80%
of
surgeons,
consulting
internists,
and
anesthesiologists
order
testing
that
they
themselves

From
the
Departments
of
*Anesthesiology,
Health
Policy
and
Management,
and
§Preventive
Medicine,
State
University
of
New
York
at
Stony
Brook,
Stony
Brook,
New
York;
and
Department
of
Anesthesia,
University
of
Iowa,
Iowa
City,
Iowa.

Accepted
for
publication
September
9,
2010.

Study
Funding:
No
funding
was
received
or
accepted
by
any
of
the
authors,
either
for
conducting
this
study
or
preparing
the
manuscript.

The
authors
declare
no
conflicts
of
interest.

Laura
Wolfe
is
currently
affiliated
with
Lake
Erie
College
of
Osteopathic
Medicine,
Deepti
Agarwal
is
currently
affiliated
with
Northwestern
University
School
of
Medicine,
and
Irim
Salik
is
currently
affiliated
with
St.
Luke s
and
Roosevelt
Hospitals.

Address
correspondence
and
reprint
requests
to
Robert
I.
Katz,
MD,
Department
of
Anesthesiology,
SUNY
at
Stony
Brook,
Stony
Brook,
NY
11794.
Address
e-mail
to
rikatz@aol.com.

Copyright
©
2010
International
Anesthesia
Research
Society
DOI:
10.1213/ANE.0b013e31820034f0

think
unnecessary
in
the
belief
that
medical-legal
considerations,
institutional
rules,
or
a
physician
other
than
themselves
will
require
it.5
Institutional
guidelines
on
preoperative
testing
can
reduce
the
number
of
unnecessary
tests.6 8
However,
the
incidence
and
effectiveness
of
use
of
such
guidelines
nationwide
are
unknown.
When
one
service
(in
this
case,
the
Department
of
Anesthesiology)
was
given
responsibility
for
preparing
the
patient
for
surgery,
with
sole
authority
to
order
laboratory
testing
and
medical
consultation,
the
number
of
both
decreased
by
50%.9
Whether
the
more
important
factor
was
one
service
or
anesthesia
is
unknown.

Our
institution
has
had
guidelines
in
place
for
preoperative
laboratory
testing
for
5
years.
These
guidelines
were
developed
by
a
committee
composed
of
surgeons
and
anesthesiologists.
They
had
been
distributed
to
all
surgeons
and
were
posted
in
our
presurgical
evaluation
unit.
We
performed
an
internal
analysis
that
revealed
considerable
unnecessary
testing.
We
subsequently
performed
a
nationwide
survey
to
determine
factors
influencing
surgeons
and
anesthesiologists
ordering
of
unnecessary
preoperative

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207
Decisions
Regarding
Preoperative
Laboratory
Testing

Figure 1. Preoperative testing guidelines at Stony Brook. None of the internally

recommended tests was one for which the preoperative
directors were unanimous in considering to be unnecessary (Table 2). The survey
study observed that 59% of patients had at least 1
unnecessary test (95% confidence limit .
52%). The most common was a bleeding test (prothrombin time, partial thromboplas
tin time, and/or
international normalized ratio) in 37% of patients. A bleeding test and/or gluco
se check contributed to 49% of patients. Hb/Hct .
hemoglobin/hematocrit; Lytes .
electrolytes; Bun Creat .
blood-urea-nitrogen plus creatinine; Gluc .
glucose; LFT s .
liver function tests;
ECG .
electrocardiogram; CXR .
chest radiograph; Pulm .
pulmonary disease; BP .
blood pressure.
laboratory
tests
and
consultations.
Differences
among
specialties
were
predicted.

METHODS

With
permission
from
the
IRB,
2
undergraduate
volunteers
surveyed
the
charts
of
1000
consecutive
patients
scheduled
for
surgery
at
our
institution
between
July
and
August
2006.
After
laboratory
testing
had
been
completed,
tests
outside
of
our
institutional
guidelines
were
counted
as
unnecessary
(Fig.
1).
The
end
point
analyzed
was
the
number
of
patients
with
zero
versus
at
least
one
unnecessary
test
(see
Results)
among
each
successive
batch
of
100
patients.
The
Freeman-Tukey
transformation10
was
applied
to
each
of
the
n
.
10
batches,
the
Student
1-sample
t
test
was
applied
among
batches
to
calculate
the
lower
confidence
level,
and
then
the
inverse
transformation
was
taken.11
For
reliability,
each
student
received
instruction
and
surveyed
10
randomly
selected
charts
before
data

collection.
Concordance
between
the
students
was
98%.
After
500
charts
were
surveyed,
the
students
were
again
tested
on
10
randomly
selected
charts,
and
concordance
was
again
98%.

The
subsequent
United
States
national
survey
was
designed
by
4
of
the
authors.
The
survey
authors
prepared
4
standardized
clinical
scenarios
with
increasingly
complex
medical
histories:
a
23-year-old
woman
for
inguinal
herniorrhaphy
(general
surgery),
a
45-year-old
woman
for
laparoscopic
ovarian
cystectomy
(gynecology),
a
50-year-old
man
for
total
hip
replacement
(orthopedics),
and
a
50-year-old
man
for
hemithyroidectomy
(otolaryngology),
as
shown
in
Table
1.
The
20
surveyed
anesthesiologist
directors
of
preoperative
evaluation
units
at
academic
medical
centers
(85%
response
rate)
and
the
400
anesthesiologists
(44%
response
rate)
were
each
sent
the
same
4
clinical
scenarios.
The
surveys
sent
to
400
general
surgeons
(43%
response
rate),
400
gynecologists
(37%
response
rate),

208
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ANESTHESIA
&
ANALGESIA
Table 1. Preoperative Laboratory Testing Scenarios Table 1. Preoperative Laborat
ory Testing Scenarios
Scenario 1 (anesthesiologists and general surgeons):
A 23-y-old woman who often plays soccer on the weekend and has
no medical history is scheduled for repair of a right inguinal
hernia. According to the patient s statement, there is no
possibility of her being pregnant.
Scenario 2 (anesthesiologists and gynecologists):
A 45-y-old woman is scheduled for a laparoscopic ovarian
cystectomy. She has a history of vague chest pains. She plays
golf twice a week, walking the course and carrying her own golf
clubs. She has no other medical history.
Scenario 3 (anesthesiologists and orthopedic surgeons):
A 50-y-old man is scheduled for a total hip replacement. He has a
history of hypertension and coronary artery disease. Two years
ago, he had 3 stents placed in his coronary arteries. His
medications are aspirin, metoprolol, and enalapril. A stress test
18 mo ago was negative for ischemia. He has neither chest
pain nor shortness of breath. He has no other medical history.
Scenario 4 (anesthesiologists and otolaryngologists):
A 50-y-old man with a thyroid nodule is scheduled for a
hemithyroidectomy. The patient has smoked 1 1/2 packs of
cigarettes per day for 30 y. He has a hoarse voice and becomes
short of breath after walking approximately 1 block. He denies
any other symptoms and has no other medical history.
400
orthopedists
(28%
response
rate),
and
400
otolaryngologists
(27%
response
rate)
each
shared
the
specialty s
scenario
with
that
of
the
anesthesiologists.
The
survey
also
asked
the
respondent s
age,
specialty,
and
gender,
and
contained
questions
regarding
factors
that
influenced
the
respondent
to
order
a
particular
test.
Before
being
mailed,
the
survey
was
tested
by
3
members
of
the
Department
of
Anesthesiology
not
otherwise
associated
with
the
study
and
at
least
1
member
of
each
of
the
4
surgical
specialties,
and
suggestions
for
improvement
were
incorporated.
A

wide
range
of
tests,
from
routine
tests
to
obviously
unnecessary
tests,
was
included
(Table
2).12

Members
of
the
American
College
of
Surgeons
were
selected
randomly.
The
physicians
chosen
were
the
first
physician
in
each
state
whose
surname
began
with
B,
D,
F,
H,
J,
L,
and
so
on.
Anesthesiologists
to
whom
the
survey
was
sent
were
selected
randomly
from
members
of
the
American
Society
of
Anesthesiologists.
Again,
the
chosen
physicians
were
the
first
listed
in
each
state
whose
last
name
began
with,
B,
D,
etc.
Ten
physicians
of
each
specialty
were
identified
per
state
to
obtain
a
national
distribution.
The
survey
was
initially
mailed
to
the
first
8
physicians
identified
in
each
state.
If
a
survey
was
returned
as
undeliverable,
then
it
was
sent
to
an
additional
physician
in
the
same
specialty,
from
the
same
state.
The
surveys
were
sent
by
mail
with
a
self-addressed
stamped
envelope.
They
were
mailed
3
times
over
a
1-year
period.

An
e-mail
query
was
sent
to
national
organizations
in
each
surgical
specialty,
inquiring
whether
their
organization
had
published
guidelines
with
recommended
preoperative
laboratory
testing.

Statistical
analysis
of
the
survey
was
performed
using
StatXact-9
(Cytel
Inc.,
Cambridge,
MA).
Because
response
rates
were
50%
for
all
specialties,
analyses
focused
on
relationships
among
responses.
Monte
Carlo
simulation
to
accuracy
within
0.1%
was
used
to
calculate
95%
lower
confidence
limits
(CLs)
and
P
values
for
the
relative
risks
of
different
groups
of
physicians
to
order
at
least
1
unnecessary
test.
Association
of
this
end
point
with
the
abovedescribed
factors
potentially
influencing
preoperative
test
ordering
(Table
3)
was
assessed
using
Wilcoxon-Mann-
Whitney
test
for
ranked
variables
and
Fisher
exact
test
for
binary
variables.
Effect
sizes
(and
corresponding
adequacy

Table 2. Unnecessary Tests and Consultations ( X ) for the Four Scenarios, Based on
Unanimous
Consensus of Anesthesiologist Directors of Preoperative Clinics
Scenario: #1 #2 #3 #4
Age (y): 23 45 50 50
Gender: Woman Woman Man Man
Procedure: Inguinal Ovarian Total hip Hemiherniorrhaphy
cystectomy replacement thyroidectomy
CXR X
ECG X
CBC X
PT/PTT X X
INR X X X
SMA-8 X
Hepatic panel X X X X
Lipid panel X X
Comprehensive metabolic panel X X
Pregnancy test
Urine culture X X X
Urinalysis X X X
Pulmonary function tests X X X
Stress test X X
Echocardiogram X X X
Type and screen X
Other (specify): response of Hct and/or X X
Hb was analyzed
Medical or cardiology consult X X
The laboratory tests and consultations are listed in the sequence presented belo
w each scenario. There were no tests or consults for which the 17 responding

preoperative clinic directors were unanimous in all ordering (i.e., there was on
ly full agreement on what not to order).
CXR .
chest radiograph; ECG .
echocardiogram; CBC .
complete blood count; PT .
prothrombin time; PTT .
partial thromboplastin time; INR .
international
normalized ratio; SMA .
sequential multichannel analysis; Hct .
hematocrit; Hb .
hemoglobin.

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209
Decisions
Regarding
Preoperative
Laboratory
Testing

Table 3. Potential Predictors of Responding Anesthesiologists Ordering of Unneces

sary Laboratory Tests
For the above scenarios, how important were the following reasons for your order
ing decisions?
For each reason, circle a number between 1 and 5,
where 1 not at all important and 5 extremely important.
% of respondents ratings
Responses of anesthesiologists
ordering at least 1 versus no
unnecessary tests
Reason 1 2 3 4 5 n95% confidence interval
for median difference Pvalue
A physician other than yourself might want it 33% 30% 21% 13% 4% 172 0 to 1 0.64
The patient s ability to pay 81% 13% 6% 0% 1% 173 0 to 0 0.58
Patient s described preoperative medical condition 0% 0% 2% 23% 75% 173 0 to 0 0.3
5
The patient s insurance status 85% 11% 3% 0% 1% 173 0 to 0 0.33
Nature of this surgical procedure 2% 1% 13% 44% 40% 172 0 to 0 0.31
Your institution s policy 26% 16% 24% 25% 9% 173 0 to 1 0.18
Result is very likely to affect perioperative
management
2% 2% 17% 35% 43% 173 0 to 0 0.18
Medical-legal considerations 16% 21% 32% 24% 8% 173 0 to 1 0.17
Patient s age 4% 7% 37% 37% 15% 172 0 to 1 0.11
Result may affect perioperative management 0% 1% 14% 44% 41% 173 0 to 0 0.048
Kendall with number of unnecessary tests 0.07, 95% confidence interval 0.01 to 0.15
, P0.11.
Responding Anesthesiologists Demographic Information
Question Yes nAt least 1 unnecessary
test (the yes s vs no s) Pvalue
Man (or woman) 75% 169 44% vs 50% 0.59
Practice is primarily private practice (or academic practice) 67% 175 43% vs 53%
0.26
Know of institutional written guidelines regarding
laboratory tests ordered before surgery
64% 169 45% vs 46% 0.99
Know of departmental written guidelines regarding
laboratory tests ordered before surgery
79% 161 47% vs 43% 0.70
Know of departmental preoperative evaluation service 74% 170 50% vs 33% 0.080
Kendall presence increases number of unnecessary tests 0.06, 95% confidence inter
val 0.02 to 0.13, P0.13.
Residency or fellowship training completed: 168
1967 1969 1.2% 100% vs 46% 0.21
1967 1979 12% 80% vs 42% 0.002
1970 1979 11% 78% vs 43% 0.006
1980 1989 27% 48% vs 46% 0.86
1990 1999 33% 33% vs 53% 0.014
2000 2006 20% 48% vs 46% 0.85
Currently in training 8% 43% vs 47% 0.99
Kendall each year reduces number of unnecessary tests 0.10, 95% confidence interva
l (CI)
0 .21 to 0.01, P0.026. By point estimate, lower, and upper limit, the relationship w
as
the strongest for gynecology, with 0.25, 95% CI 0.35 to 0.14, P0.0001, n141. It
was weakest for otolaryngology with 0.07, 95% CI 0.17 to 0.03, P0.22, n99.
of
sample
sizes
to
test
associations)
were
assessed
by
Hodges-Lehmann
confidence
intervals
for
differences
between
groups.
A
Kendall
.
was
used
to
test
for
association
between
numbers
of
unnecessary
tests
ordered
by
each
physician
and
predictive
factors.
Additionally,
qualitative
methods
were
used
to
understand
predictive
factors,
including
sending
e-mails
to
professional
organizations
for
the
surgical
specialties
included
in
our
survey
looking
for
recommendations
regarding
preoperative
testing.

RESULTS

More
than
half
of
the
1000
surveyed
records
had
at
least
1
unnecessary
test
based
on
our
institutional
guidelines
(Fig.
1,
95%
lower
CL
.
52%).
The
finding
motivated
our
national
survey.

The
17
preoperative
directors
unanimously
considered
36
of
the
72
combinations
of
test
or
consult
( test )
and
scenario
to
be
unnecessary
(Table
2).
These
36
tests
were
designated
the
unnecessary
tests
for
analysis
of
the
following
survey
results.

Among
the
175
anesthesiologists
responding,
54%
did
not
order
an
unnecessary
test,
and
24%
ordered
just
one.
The
maximum
was
10
unnecessary
tests.
The
probability
distribution
of
the
number
of
unnecessary
tests
was
geometric
(2
test
of
fit
P
.
0.323),
with
the
proportion
unnecessary
tests
p
.
50%.
This
finding
is
important
because
p
is
the
geometric
distribution s
sole
parameter.
Thus,
knowing
the
percentage
of
the
physicians
ordering
at
least
1
unnecessary
test
provides
just
as
much
information
as
the
number
of
such
tests.
This
is
the
basis
for
our
subsequent
analysis.

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ANESTHESIA
&
ANALGESIA
Table 4. Surveyed Surgeons Versus
Anesthesiologists Ordering of Unnecessary Tests
Scenario nTests that were considered
unnecessary by all 17 directors of
preoperative evaluation
clinics/all 17 or 16 of the 17
(i.e., sensitivity analysis)
Reduction in relative risk
(95% lower CL)
#1
General surgeons 173 46%/46% 64% (51%)/64% (51%)
Anesthesiologists 175 17%/17%
Tests and
consults
compared
17/17
#2
Gynecologists 146 79%/86% 53% (44%)/48% (40%)
Anesthesiologists 175 37%/45%
Tests and
consults
compared
12/14
#3
Orthopedists 110 21%/27% 67% (44%)/64% (44%)
Anesthesiologists 175 6.9%/9.7%
Tests and
consults
compared
3/5
#4
Otolaryngologists 108 31%/50% 66% (48%)/65% (52%)
Anesthesiologists 175 10%/18%
Tests and
consults
compared
4/6
Table 4. Surveyed Surgeons Versus
Anesthesiologists Ordering of Unnecessary Tests
Scenario nTests that were considered
unnecessary by all 17 directors of
preoperative evaluation
clinics/all 17 or 16 of the 17
(i.e., sensitivity analysis)
Reduction in relative risk
(95% lower CL)
#1
General surgeons 173 46%/46% 64% (51%)/64% (51%)
Anesthesiologists 175 17%/17%
Tests and
consults
compared
17/17
#2
Gynecologists 146 79%/86% 53% (44%)/48% (40%)
Anesthesiologists 175 37%/45%
Tests and
consults
compared
12/14
#3
Orthopedists 110 21%/27% 67% (44%)/64% (44%)
Anesthesiologists 175 6.9%/9.7%
Tests and
consults
compared
3/5
#4
Otolaryngologists 108 31%/50% 66% (48%)/65% (52%)
Anesthesiologists 175 10%/18%
Tests and
consults
compared
4/6
For example, scenario #4 (column 1) was viewed by otolaryngologists and
anesthesiologists (column 2). There were 4 tests and consults that every
preoperative clinic director considered to be unnecessary for that scenario
(column 4, last row). Among the 108 otolaryngologists (column 3, row 10),
31% ordered at least 1 of those 4 tests (column 4, row 10). In contrast,
among the 175 anesthesiologists (column 3, row 11), 10% ordered at least
1 of those tests. Comparing the 31% and 10%, 66% equals the reduction in
relative risk of ordering at least 1 of those tests (95% confidence limit CL.

48%) (column 5, row 10). There were 6 tests and consults that all but one
of the preoperative clinic directors considered to be unnecessary for the
scenario (column 4, last row). Given 50% of otolaryngologists ordering at least
1 of those 6 tests, versus 18% for anesthesiologists, the relative risk
reduction with anesthesiologist ordering was 65%.
Comparison
was
made
between
anesthesiologists
and
gynecologists
for
the
gynecology
case,
anesthesiologists
and
otolaryngologists
for
the
otolaryngology
case,
etc
(Tables
1
and
4).
Anesthesiologists
were
53%
less
likely
to
order
at
least
1
unnecessary
test
relative
to
gynecologists
for
the
cystectomy
scenario,
64%
less
likely
than
general
surgeons
for
the
herniorrhaphy
scenario,
66%
less
likely
than
otolaryngologists
for
the
thyroidectomy
scenario,
and
67%
less
likely
than
orthopedists
for
the
hip
replacement
scenario.
The
95%
lower
CLs
were
all
40%.

Of
the
specialty
organizations
queried,
only
the
American
College
of
Surgeons
and
the
American
Association
of
Orthopedic
Surgeons
responded.
Both
reported
no
guidelines
regarding
preoperative
laboratory
testing.

Because
these
results
suggest
value
to
anesthesiologists
being
engaged
institutionally
in
preoperative
testing,
we
explored
how
anesthesia
departments
can
achieve
consistent
performance.
Among
17
potential
predictors
studied,
only
year
of
training
was
statistically
significant
(Table
3).
Anesthesiologists
trained
after
1979
were
48%
less
likely
to

order
at
least
1
unnecessary
test
than
those
completing
training
in
or
before
1979
(95%
CL
29%).

DISCUSSION

More
than
half
of
our
patients
had
at
least
1
unnecessary
test
despite
repeated
dissemination
of
testing
guidelines
within
the
institution.
This
adds
to
the
cost
of
health
care,
without
appreciable
benefit.
Similarly,
the
national
survey
showed
not
even
a
suggestion
of
a
benefit
in
reducing
unnecessary
tests
from
institutional
or
anesthesia
department
guidelines.
Tests
can
become
simply
part
of
an
expected
routine.13
We
recommend
other
facilities
screen
for
unnecessary
tests.

Our
data
suggest
that
institutions
can
reduce
costs
by
having
anesthesiologists
order
the
preoperative
tests,
which
is
itself
a
function
of
anesthesiologists
institutional
engagement.14
However,
anesthesia
groups
should
be
cognizant
of
potential
heterogeneity
within
groups
based
on
time
since
training,
because
their
younger
physicians
may
be
more
cognizant
of
what
are
unnecessary
tests.

The
number
of
unnecessary
tests
per
simulated
patient
followed
a
geometric
distribution.
This
result
reveals
that
the
percentage
of
an
anesthesiologist s
patients
with
at
least
1
unnecessary
test
may
provide
just
as
much
information
over
a
long
period
as
the
number
of
unnecessary
tests
per
patient.
Feedback
on
adherence
to
guidelines
could
be
done
simply
by
reporting
to
each
anesthesiologist
the
percentage
of
his
or
her
patients
with
any
unnecessary
tests.
We
recommend
that
future
multicenter
observational
studies
aim
to
confirm
this
result
using
real
data
from
many
hospitals,
because
guidelines
alone
have
far
less
influence
on
anesthesiologists
behavior
influencing
costs15
than
guidelines
combined
with
individualized
feedback.16 19

Many
studies
have
demonstrated
that
routine
preoperative
testing
rarely
changes
management
or
improves
surgical
outcome.1 4
History
and
physical
examination,
not
laboratory
testing,
may
be
the
most
important
components
of
a
preoperative
evaluation.20,21
The
American
Society
of
Anesthesiologists
has
stated
that
routine
laboratory
and
diagnostic
screening
testing
is
unnecessary
for
asymptomatic
patients.22
Chung
et
al.3
recently
concluded
that
no
laboratory
tests
are
needed
for
healthy,
ambulatory
patients.
We
are
unaware
of
any
nationally
accepted
guidelines
on
preoperative
testing.
Strikingly,
there
was
not
a
single
test
in
Table
2
that
the
anesthesiologist
directors
of
preoperative
clinics
unanimously
agreed
was
necessary.
In
contrast,
Table
2
shows
consensus
for
many
tests
and
labs
for
what
is
unnecessary.
We
considered
the
extremes
of
complete
agreement
as
to
what
was
unnecessary
to
enhance
validity
of
our
results,
and
followed
up
with
sensitivity
analysis
as
well
(Table
4).
Future
studies
should
focus
on
mechanisms
to
establish
more
uniformly
accepted
guidelines
for
preoperative
laboratory
testing.

AUTHOR
CONTRIBUTIONS

Robert
I.
Katz,
MD,
helped
design
the
study,
conduct
the
study,
analyze
the
data,
and
write
the
manuscript.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
approved
the
final
manuscript,
and
is
the
author
responsible
for
archiving
the
study
files.
Franklin
Dexter,
MD,
PhD,
helped
analyze
the
data
and
write
the
manuscript.
This
author

January
2011
Volume
112
Number
1
www.anesthesia-analgesia.org
211
Decisions
Regarding
Preoperative
Laboratory
Testing

has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Kenneth
Rosenfeld,
MD,
helped
design
the
study.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Laura
Wolfe,
BA,
helped
conduct
the
study.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Valerie
Redmond,
BA,
helped
conduct
the
study.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Deepti
Agarwal,
MD,
helped
conduct
the
study.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Irim
Salik,
MD,
helped
conduct
the
study.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Karen
Goldsteen,
PhD,
helped
design
the
study
and
analyze
the
data.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Melody
Goodman,
PhD,
helped
analyze
the
data.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.
Peter
S.A.
Glass,
MB,
helped
design
the
study
and
write
the
manuscript.
This
author
has
seen
the
original
study
data,
reviewed
the
analysis
of
the
data,
and
approved
the
final
manuscript.

RECUSE
NOTES

Franklin
Dexter
is
the
Statistical
Editor
and
Section
Editor
for
Economics,
Education,
and
Policy
for
the
Journal.
This
manuscript
was
handled
by
Steve
Shafer,
Editor-in-Chief,
and
Dr.
Dexter
was
not
involved
in
any
way
with
the
editorial
process
or
decision.

Peter
S.A.
Glass
is
Section
Editor
of
Ambulatory
Anesthesiology
for
the
Journal.
This
manuscript
was
handled
by
Steve
Shafer,
Editor-in-Chief,
and
Dr.
Glass
was
not
involved
in
any
way
with
the
editorial
process
or
decision.

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