NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Centre for Clinical Practice Review of Clinical Guideline (CG3) Preoperative tests: the use of routine preoperative testes for elective surgery Background information Guideline issue date: 2003 7 year review: 2010 (first review was 2007) National Collaborating Centre: National Clinical Guidelines Centre (formerly NCC Acute Care) Review recommendation The guideline should be considered for an update, pending on the publication of the HTA project on Pre-operative testing: evidence synthesis, cost effectiveness and value of information analysis in 2012. Factors influencing the decision Literature search 1. From initial intelligence gathering and a high-level randomised control trial (RCT) search, clinical areas were identified to inform the development of clinical questions for focused searches. Through this stage of the process 3 studies were identified relevant to the guideline scope. The identified studies were related to the following clinical areas within the guideline: 1.1. Clinical utility of preoperative tests in ambulatory surgery including cataract surgery 1.2. Clinical utility of preoperative tests for planned/elective surgery, according to BMI and surgical classification. 1.3. Random glucose tests for planned/elective surgery in adult patients with ASA grade 1 to 3. CG03 Preoperative tests Review decision for web 1 of 6
2. Six clinical questions were developed based on the clinical areas above, qualitative feedback from other NICE departments and the views expressed by the Guideline Development Group, for the more focused literature searches. In total, 21 studies were identified through the focused searches. There is new evidence in four of the areas examined which may potentially change the current recommendation(s), they are: 2.1. The need for preoperative testing in ambulatory/day-case surgery, including cataract surgery. 2.2. The need for preoperative testing according to BMI and surgical classification for planned/elective surgery. 2.3. The clinical utility of random glucose test for planned/elective surgery in adult patients with ASA grade 1 to 3. 2.4. The clinical utility of cardiovascular risk assessment tests (apart from ECG) in adult patients with mild or systemic co-morbidity (ASA grade 2 and 3) before planned/elective grade 3 and 4 non-cardiac surgery. 3. An ongoing HTA project on Pre-operative testing: evidence synthesis, cost effectiveness and value of information analysis was also identified. This study will identify, assess and combine the evidence for three of the most common pre-operative tests (full blood count, electrolytes, renal function through urea); and pulmonary function tests (PFT); in order to provide a definitive account of their clinical worth and an assessment of whether this is sufficient to justify their cost. The study is due to publish early 2012. Guideline Development Group and National Collaborating Centre perspective 4. A questionnaire was distributed to GDG members and the National Collaborating Centre to consult them on the need for an update of the guideline. Four responses were received with respondents highlighting the following areas: CG03 Preoperative tests Review decision for web 2 of 6
4.1. The likely impact of the ongoing HTA project on Pre-operative testing: evidence synthesis, cost effectiveness and value of information analysis. 4.2. The clinical utility of blood glucose test for people with undiagnosed type 2 diabetes and poorly controlled diabetes prior to all grades of surgery and the Group and Save Testing for Major (3) and Major+ (4) surgeries 4.3. Consider the inclusion of new tests in the guideline, for example, static Echo, stress Echo, myocardial perfusion scanning, and cardiopulmonary exercise test 4.4. To address the sensitive and important issue of assessing the pregnancy status of 12-16 year olds 5. Feedback from the GDG and NCC contributed towards the development of the clinical questions for the focused searches. Implementation and post publication feedback 6. Key themes emerging from post-publication feedback included preoperative tests before ASA grade 1 surgery for patients older than 60 years and cardiopulmonary exercise testing (CPX) to determine preoperative fitness. This feedback contributed towards the development of clinical question one as described above. 7. Feedback from NICE implementation uptake report mentioned a study that found patients have blood tests performed in excess of the NICE guideline with coagulation screens requested in excess of guideline 17.8% of cases. Relationship to other NICE guidance 8. No NICE guidance is related to CG03. CG03 Preoperative tests Review decision for web 3 of 6
Summary of Stakeholder Feedback Review proposal put to consultees: The guideline should be considered for an update, pending on the publication of the HTA project in 2012. 9. In total 17 stakeholders commented on the review proposal recommendation during the 2 week consultation period. 10. Sixteen stakeholders agreed with the review proposal recommendation that this guideline should be updated with the majority also agreeing that the update should wait for the publication of the HTA report. 11. Literature was submitted through stakeholder consultation relating to: Health economics evaluation on whether routine preoperative tests are necessary Specific preoperative obesity risk assessment before bariatric surgery Prognostic accuracy of six diagnostic tests for predicting perioperative risks in patients undergoing major vascular surgery Cardiopulmonary exercise testing as a risk assessment for noncardiopulmonary surgery 12. During consultation, areas to consider for review in an update of the guideline were highlighted including: The need to refine child bearing age as 12-55 years old The need to specify the timing for pregnancy tests The need to restructure the guideline and more emphasis on children 13. During consultation, new area to consider for review in an update of the guideline was highlighted including: CG03 Preoperative tests Review decision for web 4 of 6
Glycosylated haemoglobin - HbA1c tests for inclusion in preoperative tests Anti-discrimination and equalities considerations 14. No evidence was identified to indicate that the guideline scope does not comply with anti-discrimination and equalities legislation. The original scope included ASA grade 1 (adults and children) and ASA grade 2 and 3 (adults only) undergoing planned/elective surgery. Conclusion 15. From the evidence and intelligence identified through the process, it suggests that some areas of the guideline may need updating at this stage, particularly in relation to: Preoperative testing in ambulatory surgery including cataract surgery The clinical utility of cardiovascular risk assessment tests (apart from ECG) before grade 3 and 4 non-cardiac surgery The clinical utility of random glucose test for adult patients with ASA grade 1 to 3 Preoperative testing according to BMI Areas mentioned by stakeholders need to be considered 16. As the ongoing HTA project on Pre-operative testing: evidence synthesis, cost effectiveness and value of information analysis would have a significant impact on current recommendations on the most common preoperative tests (full blood count, electrolytes, renal function through urea), the publication of its results in 2012 needs to be considered in the update of the guideline. The guideline should be considered for an update, pending on the publication of the HTA project in 2012. CG03 Preoperative tests Review decision for web 5 of 6
Relationship to quality standards 17. This topic is not currently being considered for a quality standard. Fergus Macbeth - Centre Director Sarah Willett - Associate Director Mousumi Biswas - Technical Analyst Centre for Clinical Practice March 2011 CG03 Preoperative tests Review decision for web 6 of 6