Routine Preoperative Laboratory Testing: Economic Burden on Pre-Surgical Patients

Background: Routine pre-operative test, results in significant cost to the hospital and expense for the patient. The cost of a single laboratory test may be negligible but too many tests have increased cost for many national health schemes. Most of these patients cannot afford this extra cost thereby delaying surgery and adding up to emergencies. Implementation of change is necessary to reduce economic burden on the patient and enhance patient care. The aim of this study was to determine the economic burden of preoperative laboratory tests on pre-surgical patients in Komfo Anokye Teaching Hospital with a view to making appropriate recommendations that will reduce costs for the patients. Methodology: This was a prospective, cross-sectional study of patients undergoing elective surgery at K.A.T.H from 1 to 31 March 2014. A quantitative technique was used to effectively quantify laboratory results that were contained in a patient’s folder before an elective surgical procedure. Close and open ended questionnaire was developed and answered by reviewing patient’s folders during the pre-anaesthesia assessment. Cost of various laboratory investigations was obtained on request from one private laboratory and the KATH main laboratory. Data were analyzed using Statistical Package of Social Sciences (SSPS) version 22 and Microsoft Excel 2010. Results: The total cost of preoperative laboratory investigations in the study population was GHC 15, 321.19 (GHC 92.85 per individual); and for tests that were not indicated, GHC 3, 266.83 (GHC19.80 per individual). Conclusion: Routine preoperative laboratory tests ordered by Surgeons in Komfo Anokye Teaching Hospital impose an economic burden on the patients. The development of a comprehensive guideline that will help in the ordering of preoperative laboratory investigation will reduce costs for the patients.


Introduction
In the assessment and preparation of patients for surgery, preoperative laboratory investigations play a crucial role to ensure that the patient goes through anaesthesia and surgery with little or no complications [1] [2]. Even though preoperative laboratory investigation is important its request should be based on a sound clinical examination. Any test that is ordered before surgery should be based on the history of the patient, his or her co morbidities and the type of surgery to be done. Before a test is ordered, one should ask whether it can identify any abnormalities, change the diagnosis or influence the anaesthetic plan or the outcome of the patient [3] [4] [5]. Request for preoperative laboratory investigations should not be done simply because the patient is going to have surgery. It should rather be requested for specific clinical indications that can lead to increase perioperative risk.
At many health institutions, the practice has been that all preoperative tests and diagnostic studies be ordered by the surgeon or primary care physician.
Mostly these tests are requested without specific indication based on history or physical examination but rather on speculations that the anaesthetist may "require them" to proceed with the surgery and thus avoid delays and cancellations [5] [6].
A study conducted by Alison W. Vogt et al. concluded that an average of 72.5% of tests ordered by surgeons were considered not indicated by the anaesthesiologists and that their hospital could have saved $80,000 by eliminating un-indicated preoperative tests for the 5100 patients seen in preoperative clinic annually [7].
Routine pre-operative test results in significant cost to the hospital and expense for the patient. The cost of a single laboratory test may be negligible but too many tests have increased cost for many national health schemes [8] [9]. An unnecessary preoperative investigation adds a lot of cost to both the patient and insurance schemes, some of these laboratory investigations are not covered under the health insurance scheme thereby adding to the cost of surgery even if the patient is insured. Most of these patients cannot afford this extra cost thereby delaying surgery and adding up to emergencies. Implementation of change is necessary to reduce economic burden on the patient and enhance patient care.
The aim of this study was to determine the economic burden of preoperative laboratory tests on pre-surgical patients in Komfo Anokye Teaching Hospital with a view to making appropriate recommendations that will reduce costs for the patients.

Results
The study population was 165 candidates with a mean age of 50 years and a male to female ration of 1:1.1. At the time of pre-anaesthetic review, all the candidates had at least one laboratory result. 98.8% of the laboratory tests were ordered by the surgical team while the anaesthetist was responsible for only 1.2% of all laboratory requests (Table 1). Table 2 shows that Complete blood count (CBC) is the most frequently ordered Laboratory test for patients coming for elective surgical procedure at KATH. Out of the 165 folders reviewed, 163 representing 98.8% had a request for CBC, followed by Renal function test (75.8%), Grouping and cross-matching (63.6%), Serum electrolyte (57.0%), Liver function test (29.1%), Urinalysis (11.5%), Blood Glucose (10.9%), Coagulation studies (7.9%), Thyroid function test (5.5%), Haemoglobin and Haematocrit are ordered as part of another test. In none of the female patients was pregnancy test ordered. Most laboratory investigations were ordered within two weeks of surgery in 76.4% of the study population, within one month in 10.3%, within 2 months in 4.2%, within three months in 7.3%, above three months in 0.6% and above six months in 1.2% respectively.

Discussions
Our study shows that the total cost of preoperative laboratory investigations in the study population was GHC 15, 321.19 (GHC 92.85 per individual) and that  [10].
In the early 1940 when preoperative assessment evolved, preoperative investigations were based on thorough history and physical examination during preoperative visit. Laboratory test ordered were done selectively to confirm diagnosis [10]. However in the late 1960 when test ordering became easier because of the introduction of biochemical auto-analyzers routine testing became common without recourse to the economic burden on patients. The idea of routine testing was equated to efficient care [2].
This practice of requesting a series of laboratory test before surgery was adopted by a lot of hospitals with the assumption that the more investigations you do, the safer it is for the patient [2]. The practice continued without any scientific evidence until Kaplan et al. published an academic paper to debunk the practice. Their study was a retrospective one involving 2000 elective patients.
These patients had a battery of investigations such as complete blood cell count, differential blood count, prothrombin time, glucose level, serum electrolyte, renal function test and platelet count. Their results showed that only 96 (22%) of the tests revealed abnormalities. They also demonstrated that out of the 96 abnormal results only 10 could not be determined by history and examination.
Another revealing aspect was that out of these 10 only 4 were of actual clinical significance [11]. A lot of academic publications has challenged the practice of routine preoperative laboratory investigations in the past three decades. This practice leads to an increased cost of surgery without any benefit to the many surgical patients who underwent these investigations [2] [12] [13] [14].
A study at San Giovanni Battista Hospital in Turin found that if guidelines are applied it will decrease the mean number of tests prescribed from 20 to 3 per patient. They further stated that tests deemed inappropriate by guidelines did not add any relevant clinical information to their study. In economic terms they estimated a reduction of 63% in cost per patient (€69 to €26) for preoperative tests by introducing guideline criteria. As regards the cost per patient for preoperative evaluation and hospital stay (€115 considering only variable costs, €580 including all costs), the application of the guidelines would reduce costs by 41% -52% according to different cost evaluation approaches for hospital stay [10].
A study at Siriraj Hospital's also revealed that over investigation is common in their institutions and estimated US 200,000 dollars as the cost of over investigation. They concluded that utilizing preoperative guidelines will decrease unnecessary testing and the consequential financial burden on patients [15].
A study by Macuso et al. also demonstrated that the introduction of guidelines lead to a decrease in pre-operative laboratory test ordering by surgeons by 23% -44%. Economically the guidelines also lead to a cost savings of over $650,000 during the first 2 years for ambulatory surgery alone. It is worth noting that this decrease in test oedering did not lead to an increase adverse patient outcome either in the intra or post operative period [16].
In Stanford university, researchers studied retrospectively the ordering of preoperative laboratory investigations six months before the setting up of a preoperative anaesthesia evaluation clinic. Now, comparing the preoperative ordering of laboratory investigations 1 year after the setting up of the anaesthesia clinic to six months before the clinic, there was a reduction of 55%. This also translated in to cost saving of the hospital's expenses in preoperative laboratory investigations by 41% yielding $112 in cost savings per patient [3]. The preoperative anaesthesia clinic and the ordering of laboratory nvestigations by Anaesthesiologists instead of surgeons also prevented operating room cancellations, delays and adverse patient events.

Conclusion
The total cost of preoperative laboratory investigations in the study population