Tinker Ready

October 31, 2017

BOSTON — A team from the Rutgers New Jersey Medical School reduced the volume of preanesthesia testing and cut costs by 47% by applying patient-centered practice guidelines, according to a study presented here at Anesthesiology 2017 from the American Society of Anesthesiologists.

Moreover, no change in clinical outcomes was associated with the reduction in testing.

The team was able to apply the guidelines after a change in policy at University Hospital in Newark, New Jersey, limited ordering of preoperative testing to anesthesiologists in the hospital's preadmission testing (PAT) unit. Previously, the tests could be ordered by individual surgical services. 

 "A lot of these test were done out of habit, more so than specific clinical consideration as to what each individual needed," said lead author, Somdatta Gupta, MD. "We focused on individual needs."

By changing the ordering rules and applying the guidelines, the team cut the average monthly cost of testing from $172.70 per patient to $83.89. They estimate that about 25% of all testing done before the guidelines was inappropriate.

They note in the abstract that "current literature supports the benefits of a pre-anesthesia evaluation which will emphasize patient tailored testing. This is in contrast to the routine standardized protocols of preoperative exams that are still common practice in many institutions."

 "This policy was conveyed to all the surgical services in the hospital to ensure that preoperative testing would be ordered only by eligible personnel from the PAT Division of Anesthesiology, and not the individual specialties," they write.

They reported that the average monthly costs in the PAT clinic before implementation of  the guidelines was $33,333 from January to May 2016. The average monthly cost from September 2016 through January 2017 was $16,962.

The drop in costs per patient reflects an average monthly savings of $16,371, they write. They project that to annual savings of $196,445, which is a 49.1% reduction in costs.

"These were not the results we were expecting," Dr Gupta said. "We were astonished."

The new program also reduced the number of patients who needed testing. The average number of patients in the PAT clinic who required any preoperative tests declined from 231 to 193 per month, a decrease of 16.5%.

Before the new approach, the surgical specialties staff were ordering many tests that were not indicated, Dr Gupta said. She saw it herself while working in the unit, where she said she waived many of the ordered tests. 

"If they had a problem, they would call us," she said. "And we would be happy to answer their questions about the test."

Dr Gupta said the unit does not receive many calls.

Examples of inappropriate tests include a urinalysis for a carpal tunnel surgery and chest radiography for arthroscopy, they write. Applying the guidelines, which were developed by the National Institute of Health and Care Excellence (NICE) and the American Society of Anesthesiologists, led to about $17,000 in monthly savings. 

The study was monitored by a committee that "maintained the threads of communication; their frequent re-assessment of the processes reinforced, modified and improved PAT operation," they write.

They also note that "eliminating many of these routine tests did not alter clinical outcomes; indeed, it improved patients' satisfaction by reducing time spent in the PAT."

Deborah Richman, MB, ChB, FFA(SA), an associate professor of anesthesiology at the Stony Brook School of Medicine in New York, who moderated  the poster session, noted that the study did not measure patient satisfaction. However, the work contributes to the effort to make care more evidence based.

"This is a real challenge," she said. "She's done a very good job."

The authors and Dr Richman have disclosed no relevant financial relationships.

Anesthesiology 2017 from the American Society of Anesthesiologists. Abstract 2168. Presented October 23, 2017.

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