Quality improvement in preoperative assessment by implementation of an electronic decision support tool

M. Flamm; G. Fritsch; M. Hysek; S. Klausner; K. Entacher; S. Panisch; A.C. Soennichsen

doi:10.1136/amiajnl-2012-001178

Quality improvement in preoperative assessment by implementation of an electronic decision support tool

M. Flamm
, G. Fritsch
, M. Hysek
, S. Klausner
, K. Entacher
, S. Panisch
, A.C. Soennichsen

Information Technologies and Digitalisation

Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University
Department of Evidence-based Medicine and Clinical Epidemiology, Danube University Krems
Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University
Institute of General Practice and Family Medicine, University of Witten/Herdecke

Research output: Contribution to journal › Article › peer-review

Abstract

Objectives
To evaluate the impact of the electronic decision support (eDS) tool ‘PReOPerative evaluation’ (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria.

Materials and methods
The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray.

Results
The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8% (CG) vs 31.5% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05±0.27 (CG) vs 0.55±1.00 (IG), p<0.001). 4.2% (CG) vs 30.1% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6% (CG) vs 49.3% (IG), p<0.001).

Discussion
PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients' burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.

Original language	English
Pages (from-to)	e91-e96
Journal	Journal of the American Medical Informatics Association : JAMIA
Volume	20
Issue number	E1
DOIs	https://doi.org/10.1136/amiajnl-2012-001178
Publication status	Published - 2013

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

electrolyte
adult
article
Austria
blood cell count
controlled study
cost control
decision support system
elective surgery
electrocardiogram
electronic decision support tool
female
health care cost
health care practice
human
information processing device
liver function test
major clinical study
male
practice guideline
preoperative evaluation
reimbursement
thorax radiography
total quality management
aged
clinical guideline
diagnostic test
economics
electronic decision support
evaluation
implementation
middle aged
preoperative care
standard
utilization review
preoperative assessment
Adult
Aged
Decision Support Systems, Clinical
Diagnostic Tests, Routine
Female
Guideline Adherence
Humans
Male
Middle Aged
Practice Guidelines as Topic
Preoperative Care
Quality Improvement
Surgical Procedures, Elective
MLCS
MLOWN

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10.1136/amiajnl-2012-001178

https://www.scopus.com/inward/record.uri?eid=2-s2.0-84881320586&doi=10.1136%2famiajnl-2012-001178&partnerID=40&md5=ca92c92908dcf7ecafd6e564f79bcd2a

Cite this

@article{d4742be3aa4345e9a09f32085204af7c,

title = "Quality improvement in preoperative assessment by implementation of an electronic decision support tool",

abstract = "Objectives To evaluate the impact of the electronic decision support (eDS) tool {\textquoteleft}PReOPerative evaluation{\textquoteright} (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria. Materials and methods The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray. Results The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8\% (CG) vs 31.5\% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05±0.27 (CG) vs 0.55±1.00 (IG), p<0.001). 4.2\% (CG) vs 30.1\% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6\% (CG) vs 49.3\% (IG), p<0.001). Discussion PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients' burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.",

keywords = "electrolyte, adult, article, Austria, blood cell count, controlled study, cost control, decision support system, elective surgery, electrocardiogram, electronic decision support tool, female, health care cost, health care practice, human, information processing device, liver function test, major clinical study, male, practice guideline, preoperative evaluation, reimbursement, thorax radiography, total quality management, aged, clinical guideline, diagnostic test, economics, electronic decision support, evaluation, implementation, middle aged, preoperative care, standard, utilization review, preoperative assessment, Adult, Aged, Decision Support Systems, Clinical, Diagnostic Tests, Routine, Female, Guideline Adherence, Humans, Male, Middle Aged, Practice Guidelines as Topic, Preoperative Care, Quality Improvement, Surgical Procedures, Elective, MLCS, MLOWN",

author = "M. Flamm and G. Fritsch and M. Hysek and S. Klausner and K. Entacher and S. Panisch and A.C. Soennichsen",

note = "Cited By :17 Export Date: 14 December 2023 CODEN: JAMAF Correspondence Address: Flamm, M.; Department of Evidence-based Medicine and Clinical Epidemiology, , Krems, Austria; email: [email protected] References: Kaplan, E.B., Sheiner, L.B., Boeckmann, A.J., The usefulness of preoperative laboratory screening (1985) JAMA, 253, pp. 3576-3581; Vogt, A.W., Henson, L.C., Unindicated preoperative testing: ASA physical status and financial implications (1997) J Clin Anesth, 9, pp. 437-441; Narr, B.J., Warner, M.E., Schroeder, D.R., Outcomes of patients with no laboratory assessment before anesthesia and a surgical procedure (1997) Mayo Clin Proc, 72, pp. 505-509; Munro, J., Booth, A., Nicholl, J., Routine preoperative testing: a systematic review of the evidence (1997) Health Technol Assess, 1, pp. 1-4; Schein, O.D., Katz, J., Bass, E.B., The value of routine preoperative medical testing before cataract surgery. Study of medical testing for cataract surgery (2000) N Engl J Med, 342, pp. 168-175; Cavallini, G.M., Saccarola, P., D'Amico, R., Impact of preoperative testing on ophthalmologic and systemic outcomes in cataract surgery (2004) Eur J Ophthalmol, 14, pp. 369-374; Keay, L., Lindsley, K., Tielsch, J., Routine preoperative medical testing for cataract surgery (2012) Cochrane Database Syst Rev, 3, pp. CD007293; Dzankic, S., Pastor, D., Gonzalez, C., The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients (2001) Anesth Analg, 93, pp. 301-308; Fritsch, G., Flamm, M., Hepner, D.L., Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications (2012) Acta Anaesthesiol Scand, 56, pp. 339-350; Chung, F., Yuan, H., Yin, L., Elimination of preoperative testing in ambulatory surgery (2009) Anesth Analg, 108, pp. 467-475; (2012) NICE-Guideline CG3 Preoperative Tests-the use of routine preoperative tests for elective surgery, , http://www.nice.org.uk, National Institute for Health and Clinical Excellence, accessed 10 Jan 2012; Fleisher, L.A., Beckman, J.A., Brown, K.A., (2007) Circulation, 116, pp. e418-e499. , ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery; Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation (2002) Anesthesiology, 96, pp. 485-496; Apfelbaum, J.L., Connis, R.T., Nickinovich, D.G., Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation (2012) Anesthesiology, 116, pp. 522-538; Flamm, M., Fritsch, G., Seer, J., Non-adherence to guidelines for preoperative testing in a secondary care hospital in Austria: the economic impact of unnecessary and double testing (2011) Eur J Anaesthesiol, 28, pp. 867-873; Hofmarcher, M.M., Rack, H.M., Austria: health system review (2006) Health Syst Transition, 8, pp. 1-247; (2009) Preoperative Assessment, , http://www.oegari.at/arbeitsgruppe.asp?id=205, Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine OeGARI, accessed 10 Jan 2012; McKibbon, K.A., Lokker, C., Handler, S.M., The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials (2012) J Am Med Inform Assoc, 19, pp. 22-30; Ferrando, A., Ivaldi, C., Buttiglieri, A., Guidelines for preoperative assessment: impact on clinical practice and costs (2005) Int J Qual Health Care, 17, pp. 323-329; Ohno-Machado, L., Cost-effectiveness of informatics and health IT: impact on finances and quality of care (2012) JAMIA, 19, p. 327; Bryson, G.L., Wyand, A., Bragg, P.R., Preoperative testing is inconsistent with published guidelines and rarely changes management (2006) Can J Anaesth, 53, pp. 236-241; Davis, D.A., Taylor-Vaisey, A., Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines (1997) CMAJ, 157, pp. 408-416; Mancuso, C.A., Impact of new guidelines on physicians' ordering of preoperative tests (1999) J Gen Intern Med, 14, pp. 166-172; Greer, A.E., Irwin, M.G., Implementation and evaluation of guidelines for preoperative testing in a tertiary hospital (2002) Anaesth Intensive Care, 30, pp. 326-330; (2012) Bundesqualit{\"a}tsleitlinie zur integrativen Versorgung von erwachsenen Patientinnen und Patienten f{\"u}r die pr{\"a}operative Diagnostik bei elektiven Eingriffen, , http://www.bmg.gv.at/cms/home/attachments/3/5/6/CH1063/CMS1334240501976/5\_praeop\_endgueltige\_fassung\_komplett\_neu\_0-fehler.pdf, Austrian Ministry of Health, accessed 10 Jan 2012; Weiner, J.P., Kfuri, T., Chan, K., 'e-Iatrogenesis': the most critical unintended consequence of CPOE and other HIT (2007) J Am Med Inform Assoc, 14, pp. 387-388",

year = "2013",

doi = "10.1136/amiajnl-2012-001178",

language = "English",

volume = "20",

pages = "e91--e96",

journal = "Journal of the American Medical Informatics Association : JAMIA",

issn = "1067-5027",

publisher = "Oxford University Press",

number = "E1",

}

TY - JOUR

T1 - Quality improvement in preoperative assessment by implementation of an electronic decision support tool

AU - Flamm, M.

AU - Fritsch, G.

AU - Hysek, M.

AU - Klausner, S.

AU - Entacher, K.

AU - Panisch, S.

AU - Soennichsen, A.C.

N1 - Cited By :17 Export Date: 14 December 2023 CODEN: JAMAF Correspondence Address: Flamm, M.; Department of Evidence-based Medicine and Clinical Epidemiology, , Krems, Austria; email: [email protected] References: Kaplan, E.B., Sheiner, L.B., Boeckmann, A.J., The usefulness of preoperative laboratory screening (1985) JAMA, 253, pp. 3576-3581; Vogt, A.W., Henson, L.C., Unindicated preoperative testing: ASA physical status and financial implications (1997) J Clin Anesth, 9, pp. 437-441; Narr, B.J., Warner, M.E., Schroeder, D.R., Outcomes of patients with no laboratory assessment before anesthesia and a surgical procedure (1997) Mayo Clin Proc, 72, pp. 505-509; Munro, J., Booth, A., Nicholl, J., Routine preoperative testing: a systematic review of the evidence (1997) Health Technol Assess, 1, pp. 1-4; Schein, O.D., Katz, J., Bass, E.B., The value of routine preoperative medical testing before cataract surgery. Study of medical testing for cataract surgery (2000) N Engl J Med, 342, pp. 168-175; Cavallini, G.M., Saccarola, P., D'Amico, R., Impact of preoperative testing on ophthalmologic and systemic outcomes in cataract surgery (2004) Eur J Ophthalmol, 14, pp. 369-374; Keay, L., Lindsley, K., Tielsch, J., Routine preoperative medical testing for cataract surgery (2012) Cochrane Database Syst Rev, 3, pp. CD007293; Dzankic, S., Pastor, D., Gonzalez, C., The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients (2001) Anesth Analg, 93, pp. 301-308; Fritsch, G., Flamm, M., Hepner, D.L., Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications (2012) Acta Anaesthesiol Scand, 56, pp. 339-350; Chung, F., Yuan, H., Yin, L., Elimination of preoperative testing in ambulatory surgery (2009) Anesth Analg, 108, pp. 467-475; (2012) NICE-Guideline CG3 Preoperative Tests-the use of routine preoperative tests for elective surgery, , http://www.nice.org.uk, National Institute for Health and Clinical Excellence, accessed 10 Jan 2012; Fleisher, L.A., Beckman, J.A., Brown, K.A., (2007) Circulation, 116, pp. e418-e499. , ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery; Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation (2002) Anesthesiology, 96, pp. 485-496; Apfelbaum, J.L., Connis, R.T., Nickinovich, D.G., Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation (2012) Anesthesiology, 116, pp. 522-538; Flamm, M., Fritsch, G., Seer, J., Non-adherence to guidelines for preoperative testing in a secondary care hospital in Austria: the economic impact of unnecessary and double testing (2011) Eur J Anaesthesiol, 28, pp. 867-873; Hofmarcher, M.M., Rack, H.M., Austria: health system review (2006) Health Syst Transition, 8, pp. 1-247; (2009) Preoperative Assessment, , http://www.oegari.at/arbeitsgruppe.asp?id=205, Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine OeGARI, accessed 10 Jan 2012; McKibbon, K.A., Lokker, C., Handler, S.M., The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials (2012) J Am Med Inform Assoc, 19, pp. 22-30; Ferrando, A., Ivaldi, C., Buttiglieri, A., Guidelines for preoperative assessment: impact on clinical practice and costs (2005) Int J Qual Health Care, 17, pp. 323-329; Ohno-Machado, L., Cost-effectiveness of informatics and health IT: impact on finances and quality of care (2012) JAMIA, 19, p. 327; Bryson, G.L., Wyand, A., Bragg, P.R., Preoperative testing is inconsistent with published guidelines and rarely changes management (2006) Can J Anaesth, 53, pp. 236-241; Davis, D.A., Taylor-Vaisey, A., Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines (1997) CMAJ, 157, pp. 408-416; Mancuso, C.A., Impact of new guidelines on physicians' ordering of preoperative tests (1999) J Gen Intern Med, 14, pp. 166-172; Greer, A.E., Irwin, M.G., Implementation and evaluation of guidelines for preoperative testing in a tertiary hospital (2002) Anaesth Intensive Care, 30, pp. 326-330; (2012) Bundesqualitätsleitlinie zur integrativen Versorgung von erwachsenen Patientinnen und Patienten für die präoperative Diagnostik bei elektiven Eingriffen, , http://www.bmg.gv.at/cms/home/attachments/3/5/6/CH1063/CMS1334240501976/5_praeop_endgueltige_fassung_komplett_neu_0-fehler.pdf, Austrian Ministry of Health, accessed 10 Jan 2012; Weiner, J.P., Kfuri, T., Chan, K., 'e-Iatrogenesis': the most critical unintended consequence of CPOE and other HIT (2007) J Am Med Inform Assoc, 14, pp. 387-388

PY - 2013

Y1 - 2013

N2 - Objectives To evaluate the impact of the electronic decision support (eDS) tool ‘PReOPerative evaluation’ (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria. Materials and methods The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray. Results The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8% (CG) vs 31.5% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05±0.27 (CG) vs 0.55±1.00 (IG), p<0.001). 4.2% (CG) vs 30.1% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6% (CG) vs 49.3% (IG), p<0.001). Discussion PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients' burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.

AB - Objectives To evaluate the impact of the electronic decision support (eDS) tool ‘PReOPerative evaluation’ (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria. Materials and methods The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray. Results The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8% (CG) vs 31.5% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05±0.27 (CG) vs 0.55±1.00 (IG), p<0.001). 4.2% (CG) vs 30.1% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6% (CG) vs 49.3% (IG), p<0.001). Discussion PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients' burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.

KW - electrolyte

KW - adult

KW - article

KW - Austria

KW - blood cell count

KW - controlled study

KW - cost control

KW - decision support system

KW - elective surgery

KW - electrocardiogram

KW - electronic decision support tool

KW - female

KW - health care cost

KW - health care practice

KW - human

KW - information processing device

KW - liver function test

KW - major clinical study

KW - male

KW - practice guideline

KW - preoperative evaluation

KW - reimbursement

KW - thorax radiography

KW - total quality management

KW - aged

KW - clinical guideline

KW - diagnostic test

KW - economics

KW - electronic decision support

KW - evaluation

KW - implementation

KW - middle aged

KW - preoperative care

KW - standard

KW - utilization review

KW - preoperative assessment

KW - Adult

KW - Aged

KW - Decision Support Systems, Clinical

KW - Diagnostic Tests, Routine

KW - Female

KW - Guideline Adherence

KW - Humans

KW - Male

KW - Middle Aged

KW - Practice Guidelines as Topic

KW - Preoperative Care

KW - Quality Improvement

KW - Surgical Procedures, Elective

KW - MLCS

KW - MLOWN

U2 - 10.1136/amiajnl-2012-001178

DO - 10.1136/amiajnl-2012-001178

M3 - Article

SN - 1067-5027

VL - 20

SP - e91-e96

JO - Journal of the American Medical Informatics Association : JAMIA

JF - Journal of the American Medical Informatics Association : JAMIA

IS - E1

ER -

Quality improvement in preoperative assessment by implementation of an electronic decision support tool

Abstract

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Keywords

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