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Unnecessary Pre-Op Tests & Evidence-Based Guidelines

Another paper on the subject of unnecessary preoperative laboratory testing appeared not long ago. A group from the University of Texas Medical Branch looked at more than 73,000 elective hernia repairs in the National Surgical Quality Improvement Project (NSQIP) database. Almost 2/3 of the patients had preoperative laboratory tests. Of that group, 58.6% had a CBC, 53.5% had electrolytes, 23.7% had liver function studies, 18.7% had coagulation studies, and 9.9% had all of the above. Even 54% of patients with no comorbidities had at least one test. [polldaddy poll=7007133] An abnormal test was found in more than 60% of those tested; of the 7,200 patients who had lab tests done on the day of surgery, 61.6% had at least one abnormal test, including 23% with a coagulation abnormality, 41% with a chemical abnormality, and 33% with a liver function test abnormality. Despite these results, the scheduled surgery was done. Tests did not predict complications in patients without comorbidities. Obtaining a test (not necessarily an abnormal result) was associated with a higher risk of major complications (0.4% versus 0.2% p < 0.0001) but not wound complications. However, abnormal results did not predict complications. The authors of the paper recommended that surgical societies establish guidelines for preop testing. Hernia patients, particularly those without comorbidities, are similar to normal people. Obtaining lab studies on these patients is analogous to obtaining labs on the next 100 people who walk past the hospital. Few abnormal results will be found, and most of them will be false positives. This fact has been known for at least 30 years, yet surgeons — who as shown by...

Imaging Use & Atraumatic Headache in the ED

Atraumatic headache is one of the most common complaints in EDs, but only a small subset of patients who present to the ED with this complaint are found to have life-threatening intracranial pathology (ICP) upon imaging. Additionally, imaging guidelines for these patients remain unclear. As a result, emergency physicians face a serious diagnostic dilemma when managing atraumatic headache, says John W. Gilbert, MD. “Imaging infrequently reveals significant findings, but results from these tests nevertheless have the potential to detect life-threatening pathology.” [polldaddy poll=6862787] Several studies have demonstrated that overall use of diagnostic imaging in the ED is increasing. The causes are thought to be multifactorial, ranging from medicolegal concerns and patient demand to the availability of diagnostic scanners that operate at ever-faster rates. This has the potential to lead to imaging overutilization with little benefit and may potentially harm patients. In clinical studies, increased use of imaging has been associated with higher costs, longer patient wait times, greater exposure to ionizing radiation, and decreased ED flow and efficiency. “In the absence of clear evidence-based guidelines and given the potential consequences of misdiagnosis, many physicians understandably struggle when deciding whether to pursue further workup,” explains Dr. Gilbert. “In some cases, they may err on the side of increased testing. It’s important for physicians to be aware of recent trends in imaging utilization, particularly when there’s a sharp increase without obvious corresponding evidence of benefit. This information can help guide efforts toward better defining imaging criteria so that diagnostics are used appropriately.” Imaging & Diagnostics in Atraumatic Headache In the July 2012 Emergency Medicine Journal, Dr. Gilbert and colleagues had a...
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