Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness Review 2013

Project Summary Title and Description

Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness Review 2013
Objectives: Preoperative testing is used to guide the action plan for patients undergoing surgical and other procedures that require anesthesia and to predict potential postoperative complications. There is uncertainty whether routine or per-protocol testing in the absence of a specific indication prevents complications and improves outcomes, or whether it causes unnecessary delays, costs, and harms due to false-positive results. Data sources: We searched MEDLINE® and Ovid Healthstar® (from inception to July 22, 2013), as well as Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews. Review methods: We included comparative and cohort studies of both adults and children undergoing surgical and other procedures requiring either anesthesia or sedation (excluding local anesthesia). We included all preoperative tests that were likely to be conducted routinely (in all patients) or on a per-protocol basis (in selected patients). For comparative studies, the comparator of interest was either no testing or ad hoc testing done at the discretion of the clinician. We also looked for studies that compared routine and per-protocol testing. The outcomes of interest were mortality, perioperative events, complications, patient satisfaction, resource utilization, and harms related to testing. Results: Fifty-seven studies (14 comparative and 43 cohort) met inclusion criteria for the review. Well-conducted randomized controlled trials (RCTs) of cataract surgeries suggested that routine testing with electrocardiography, complete blood count, and/or a basic metabolic panel did not affect procedure cancellations (2 RCTs, relative risks [RRs] of 1.00 or 0.97), and there was no clinically important difference for total complications (3 RCTs, RR = 0.99; 95% confidence interval, 0.86 to 1.14). Two RCTs and six nonrandomized comparative studies of general elective surgeries in adults varied greatly in the surgeries and patients included, along with the routine or per-protocol tests used. They also mostly had high risk of bias due to lack of adjustment for patient and clinician factors, making their results unreliable. Therefore, they yielded insufficient evidence regarding the effect of routine or per-protocol testing on complications and other outcomes. There was also insufficient evidence for patients undergoing other procedures. No studies reported on quality of life, patient satisfaction, or harms related to testing. Conclusions: There is high strength of evidence that, for patients scheduled for cataract surgery, routine preoperative testing has no effect on total perioperative complications or procedure cancellation. There is insufficient evidence for all other procedures and insufficient evidence comparing routine and per-protocol testing. There is no evidence regarding quality of life or satisfaction, resource utilization, or harms of testing and no evidence regarding other factors that may affect the balance of benefits and harms. The findings of the cataract surgery studies are not reliably applicable to other patients undergoing other higher risk procedures. Except arguably for cataract surgery, numerous future adequately powered RCTs or well-conducted and analyzed observational comparative studies are needed to evaluate the benefits and harms of routine preoperative testing in specific groups of patients with different risk factors for surgical and anesthetic complications undergoing specific types of procedures and types of anesthesia.
Authors of Report
Methodology description
We conducted literature searches of studies in MEDLINE® and Ovid Healthstar® (inception – 22 July 2013), as well as the Cochrane Central Trials Registry® and Cochrane Database of Systematic Reviews® (through 2nd Quarter, 2013). The reference lists of prior systematic reviews and relevant guidelines were hand-searched. All citations were screened to identify articles relevant to each Key Question. The search included terms for surgical procedures, preoperative care, diagnostic tests, including the specific tests ECG, chest radiography, blood counts, coagulation tests, biochemistry, glucose, urinalysis, kidney function tests, liver function tests, pregnancy tests, hemoglobinopathies, and pulmonary function tests (see Appendix A for complete search strings). The EPC has developed a computerized screening program, Abstrackr, to automate the screening of abstracts for eligible articles for full-text screening ( Three team members double-screened all abstracts after an iterative training period to ensure that all screeners agreed upon the eligibility criteria. Abstrackr allowed us to label each citation as "accept," "reject," or "maybe." All abstracts with disagreements between readers or labeled as "maybe" were reconciled by the whole team in conference. Full-text articles were retrieved for all potentially relevant articles. These were rescreened for eligibility. All rejected articles were confirmed by the team leader. The reasons for excluding these articles are tabulated in Appendix B. Study eligibility was based on the following selection criteria: population and surgical procedure of interest, interventions (i.e., tests) and comparators of interest, outcomes of interest, and study designs. We did not consider outcomes when conducting abstract screening.
For access to the full report available on the AHRQ website, follow this link:
Funding Source
National Eye Institute; National Institutes of Health (NIH); the Agency for Health Research and Quality (AHRQ).

Key Questions

1. What is the comparative effectiveness of (topic specific interventions)?
2. Quality -- RCT
3. Quality -- Comparative NonRCT
4. Quality -- Cohort

Associated Extraction Forms

Associated Studies (each link opens a new tab)

The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children.1998
Preoperative laboratory screening before administration of general anesthesia in the office.1970
The value of preoperative studies. Prospective study of preoperative thoracic radiographs and ECGs of 201 patients.1989
Cost/benefit of preoperative examinations for routine elective surgery.-- Not Found --
Predictive value of preoperative fasting glucose test of diabetic patients regarding surgical outcome in cataract surgery.-- Not Found --
Are routine preoperative medical tests needed with cataract surgery? Study of visual acuity outcome.
The value of preoperative estimation of haemoglobin in children undergoing tonsillectomy.1990
Is routine preoperative chest X-ray indicated in elderly patients undergoing elective surgery?2008
Preoperative laboratory testing of children undergoing elective surgery.1990
Routine pre-operative chest radiographs in non-cardiopulmonary surgery.1988
Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly.1999
National survey of preoperative management and patient selection in ambulatory surgery centers.-- Not Found --
Value of routine preoperative tests: a multicentre study in four general hospitals.1995
Evaluation of a pregnancy-testing protocol in adolescents undergoing surgery.1998
15 years of preoperative ambulatory care in Graz.1994
Are routine preoperative chest radiographs necessary in asymptomatic patients undergoing noncardiothoracic surgery?2007
Contribution of preoperative investigations to the anaesthetic management of adult trauma patients.1993
Outpatient preoperative examination by the anesthesiologist. I. Fewer procedures and preoperative hospital days.1995
Significance and causes of abnormal preoperative coagulation test results in children.2012
Clinical evaluation and cost effectiveness of preoperative laboratory assessment on patients undergoing total hip arthroplasty.1989
Risk of hemorrhage after adenoidectomy and tonsillectomy. Value of the preoperative determination of partial thromboplastin time, prothrombin time and platelet count.2008
The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery.2000
Significance of blood tests prior to adenoidectomy.2008
Are blood tests prior to ear operations in children necessary?--A retrospective analysis.2009
Information yield from routine pre-operative chest radiography and electrocardiography.1992
Strategies in the high-risk cardiac patient undergoing non-cardiac surgery.2004
Usefulness of exercise echocardiography in predicting cardiac events in an outpatient population.1998
Preoperative evaluation and cataract surgery.-- Not Found --
How useful are routine chest x-rays of preoperative patients at risk for postoperative chest disease?1988
Routine preoperative electrocardiogram and chest x-ray prior to elective surgery in Alberta, Canada.2010
Determining the necessity for routine preoperative laboratory tests and x-rays: a cooperative PSRO/hospital study.1979
Prognostic significance of the combined use of preoperative platelet count and serum carcinoembryonic antigen level in non-small-cell lung cancer.2010
The value of preoperative chest X-rays in gynecological patients.1988
Cardiac risk assessment before vascular surgery: a prospective study comparing clinical evaluation, dobutamine stress echocardiography, and dobutamine Tc-99m sestamibi tomoscintigraphy.1997
Unindicated preoperative testing: ASA physical status and financial implications.1997
Value of the chest X-ray as a screening test for elective surgery in children.1981
Cost-effectiveness of preoperative examinations.1997
Preoperative electrocardiography: its cost-effectiveness in detecting abnormalities when a previous tracing exists.1979
Costs of unnecessary tests.1979
Preoperative evaluation of the healthy patient.1979
Multifactorial index of cardiac risk in noncardiac surgical procedures.1977
Use of biochemical profile in children's hospital: results of two controlled trials.1975
Preadmission anaesthesia consultation clinic.1992
Preoperative screening for pediatric ambulatory surgery: evaluation of a telephone questionnaire method.1992
Usefulness of selectively ordered preoperative tests.1988
The value of routine preoperative investigations.1988
Evaluation of a protocol for selective ordering of preoperative tests in healthy subjects.1987
Blood tests before elective surgery.1987
The yield of the routine admission electrocardiogram. A study in a general medical service.1985
The impact of routine admission chest x-ray films on patient care.1985
Efficacy of routine screening and lateral chest radiographs in a hospital-based population.1974
Routine preoperative electrocardiograms.1984
Preoperative electrocardiography effect of new abnormalities on clinical decisions.1983
Assessment of fitness for surgical procedures and the variability of anaesthetists' judgments.
Changing the admission process for elective surgery: an economic analysis.1995
Routine investigations in elective surgical patients.1979
Value of routine preoperative chest x-rays: a meta-analysis.1993
Pre-operative haemoglobin estimation in paediatric ENT surgery.1993
Dobutamine stress echocardiography for assessment of perioperative cardiac risk in patients undergoing major vascular surgery.1993
Routine preoperative exercise testing in patients undergoing major noncardiac surgery.1985
Economic benefits attributed to opening a preoperative evaluation clinic for outpatients.
The pre-operative ECG in day surgery: a habit?1999
Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital.1996
Unnecessary preoperative investigations: evaluation and cost analysis.1996
The utility of preoperative laboratory testing in general surgery patients for outpatient procedures.1997
Efficacy and financial benefit of an anesthesiologist-directed university preadmission evaluation center.1997
The utility of dobutamine echocardiography in preoperative evaluation for elective aortic surgery.1997
Pre-admission clinic in an orthopaedic department: evaluation over a 6-month period.1998
Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery.1999
Cost-effective preoperative evaluation and testing.1999
Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population.1999
The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients.2001
The role of myocardial perfusion scanning, heart rate variability and D-dimers in predicting the risk of perioperative cardiac complications after peripheral vascular surgery.2001
Identifying patient preoperative risk factors and postoperative adverse events in administrative databases: results from the Department of Veterans Affairs National Surgical Quality Improvement Program.2002
Comparison between serum creatinine and creatinine clearance for the prediction of postoperative mortality in patients undergoing major vascular surgery.2003
The dilemma of immediate preoperative hypertension: to treat and operate, or to postpone surgery?2003
Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests.2005
Preoperative testing is inconsistent with published guidelines and rarely changes management.2006
Hyperglycemia independently increases the risk of perioperative stroke, myocardial infarction, and death after carotid endarterectomy.2006
Preoperative electrocardiograms: patient factors predictive of abnormalities.2009
Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians.
Risk factors for perioperative acute kidney injury after adult cardiac surgery: role of perioperative management.2012
Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians2006
Efficacy of the routine admission urinalysis.1987
Usefulness of routine preoperative chest roentgenograms in elderly patients.1987
Hemostatic assessment of patients before tonsillectomy: a prospective study.1994
Spirometry as a preoperative screening test in morbidly obese patients.1986
The utility of preoperative electrocardiograms in the ambulatory surgical patient.1992
Are routine preoperative laboratory screening tests necessary to evaluate ambulatory surgical patients?1988
Preoperative laboratory testing: should any tests be "routine" before surgery?1993
Abnormal coagulation profiles in tonsillectomy and adenoidectomy patients.1990
How well does the activated partial thromboplastin time predict postoperative hemorrhage?1986
The preoperative electrocardiogram as an indicator of risk in major noncardiac surgery.1986
Preoperative evaluation and postoperative prediction of hemostatic function with thromboelastography in patients undergoing redo cardiac surgery.1998
The admission urinalysis: impact on patient care.-- Not Found --
An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy.1987
Comparative effectiveness of the beta-(N,N-diethylamino)ethylamide hydrochloride of fusaric acid, obzidan and atenolol in experimental adrenaline-induced cardiac arrhythmia.-- Not Found --
Upper abdominal surgery: does a lung function test exist to predict early severe postoperative respiratory complications?1997
Preoperative history and coagulation screening in children undergoing tonsillectomy.1992
Negative impact of cardiac evaluation before vascular surgery.2000
Should pregnancy testing be routine in adolescent patients prior to surgery?1996
Preoperative evaluation of cardiac failure and ischemia in elderly patients by cardiopulmonary exercise testing.1993
The role of the routine pre-operative chest X-ray in the elderly general surgical patient.1982
Evaluation of the efficacy of routine preoperative electrocardiograms.1997
Coagulation tests during cardiopulmonary bypass correlate with blood loss in children undergoing cardiac surgery.1999
The utility of preoperative hemostatic assessment in adenotonsillectomy.1997
Usefulness of preoperative laboratory assessment of patients undergoing elective herniorrhaphy.1992
Routine prothrombin time determination before elective gynecologic operations.1991
Is the pediatric preoperative hematocrit determination necessary?1992
Are routine preoperative chest radiographs useful in general surgery? A prospective, multicentre study in 3959 patients. Association des Chirurgiens de l'Assistance Publique pour les Evaluations médicales.1996
The clinical significance of thrombocytosis in women presenting with a pelvic mass.
Preoperative medical evaluation in patients having joint replacement surgery: added benefits.1996
Prothrombin and partial thromboplastin times as preoperative screening tests.1982
Efficacy of preadmission testing in ambulatory surgical patients.1992
The usefulness of preoperative laboratory screening.1985
The preoperative chest X-ray.1974
The unproven utility of the preoperative urinalysis: economic evaluation.1989
The unproven utility of preoperative urinalysis. Clinical use.1988
Preoperative chest radiography: value as a baseline examination for comparison.1987
Preoperative coagulation testing on a gynecologic oncology service.1994
Can postoperative pulmonary complications after elective cholecystectomy be predicted?1988
Usefulness of screening chest roentgenograms in preoperative patients.1983
Predictive factors of hyperfibrinolytic activity during liver transplantation in cirrhotic patients.1994
Preoperative evaluation of pulmonary function. Validity, indications, and benefits.1979
The value of preoperative screening investigations in otherwise healthy individuals.1987
Usefulness of selective preoperative chest x-ray films. A prospective study.1987
Pitfalls in the role of standardized preadmission laboratory screening for ambulatory surgery.1989
Preoperative chest radiology. National study by the Royal College of Radiologists.1979
Creatinine clearance in critically ill surgical patients.1979
Evaluation of a protocol for selective ordering of preoperative tests.1986
The role of the routine pre-operative electrocardiogram in the elderly surgical patient.1983
Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes.2005
A prospective evaluation of preoperative screening laboratory tests in general surgery patients.2002
Review of systems, physical examination, and routine tests for case-finding in ambulatory patients.1995
Value of routine pre-operative chest X-ray in patients over the age of 40 years.1997
The prediction of cardiac risk in patients undergoing vascular surgery.1987
Preoperative laboratory screening in healthy Mayo patients: cost-effective elimination of tests and unchanged outcomes.1991
The pre-operative electrocardiogram: an assessment.1983
Hematologic screening tests in patients with operative prostatic disease.1978
Preoperative cardiac assessment in patients undergoing aortic surgery: analysis of factors affecting the cardiac outcomes.2010
Is routine pre-operative electrocardiogram necessary?1989
Preoperative evaluation in urology. A reassessment.1989
Evaluation of the impact of guidelines for rationalizing the prescription of preop tests for patients ASA 1 and 2 undergoing elective surgery.-- Not Found --
Cost-efficient carotid surgery: a comprehensive evaluation.1996
Waste of medical tests in preoperative evaluation for cataract surgery.-- Not Found --
Preoperative pregnancy testing in adolescents.1996
Preoperative echocardiographic evaluation of patients referred for lung volume reduction surgery.1998
Impact of end user involvement in implementing guidelines on routine pre-operative tests.2002
Improved preoperative iron status assessment by soluble transferrin receptor in elderly patients undergoing knee and hip replacement.2006
The impact of routine preoperative complete blood count (CBC) in elective operations in Srinagarind Hospital.1995
The impact of routine preoperative chest X-ray in Srinagarind Hospital, Khon Kaen.1990
The impact of routine preoperative urinalysis in Srinagarind Hospital, Khon Kaen.1995
The impact of routine preoperative electrocardiogram in patients age > or = 40 years in Srinagarind Hospital.1992
Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants.2000
Pursuit of abnormal coagulation screening tests generates modest hidden preoperative costs.1989
Impact of preoperative testing on ophthalmologic and systemic outcomes in cataract surgery.
Prospective assessment of a protocol for selective ordering of preoperative chest x-rays.1988
Value of preoperative screening studies.1988
A cost-effectiveness analysis of coagulation testing prior to tonsillectomy and adenoidectomy in children.2010
Preoperative screening for sickle cell disease in children: clinical implications.2005
Utility of preoperative chest radiography in smokers undergoing transurethral resection of urinary bladder tumors.2011
Limited value of routine preoperative laboratory studies in children.1992
Evaluation of the quality of preoperative electrocardiogram interpretation by anesthesiologists.1990
How cost effective are routine preoperative investigations?1980
Preoperative screening for coagulation disorders in children undergoing adenoidectomy (AT) and tonsillectomy (TE): does it prevent bleeding complications?-- Not Found --
The use of ambulatory testing in prepaid and fee-for-service group practices. Relation to perceived profitability.1986
Usefulness of preoperative chest radiography in elective surgery.-- Not Found --
Usefulness of the preoperative electrocardiogram in elective surgery.1996
Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics.2000
Preoperative chest x-ray films in elective surgery: a valid screening tool.1990
Indications for electrocardiogram in the preoperative assessment for programmed surgery.2002
Indications for thoracic radiography in the preoperative evaluation for elective surgery.2002
Electrocardiographic exercise stress testing for cardiac risk assessment in patients undergoing noncardiac surgery.2001
A prospective evaluation of the value of preoperative laboratory testing for office anesthesia and sedation.1999
Prevalence of positive preoperative pregnancy testing in teenagers scheduled for orthopedic surgery.-- Not Found --
A prospective multicenter evaluation of preoperative hemostatic screening tests. The French Associations for Surgical Research.1995
Value of preoperative prothrombin time/partial thromboplastin time as a predictor of postoperative hemorrhage in pediatric patients undergoing tonsillectomy.1997
Pre-operative measurement of heart rate variability predicts hypotension during general anesthesia.2006
Preoperative testing prior to elective surgery.2003
The findings of preoperative cardiac screening studies in adolescent idiopathic scoliosis.2011
Evaluation of pre-operative chest x-ray.1987
Routine pre-operative blood testing: is it necessary?2002
Collagen-induced whole blood platelet aggregation in patients undergoing surgical procedures associated with minimal to moderate blood loss.1998
One-year experience with day-of-surgery pregnancy testing before elective orthopedic procedures.2008
Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients.2002
Relationship between the result of preoperative pulmonary function test and postoperative pulmonary complications.1987
Preoperative identification of patients with impaired (primary) haemostasis. A practical concept.2007
Do "screening" coagulation tests predict bleeding in patients undergoing fiberoptic bronchoscopy with biopsy?1994
Laboratory screening prior to ECT2001
Once again, the routine preoperative thorax photo.1989
Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve-lead electrocardiogram.1997
Implementation of guidelines for preoperative laboratory investigations in patients scheduled to undergo elective surgery.1994
Noninvasive evaluation of cardiac risk before elective vascular surgery.1987
Usefulness of preoperative screening tests in perioperative respiratory therapy.1979
The usefulness of routine preoperative chest X-rays and ECGs: a prospective audit.2003
Are routine preoperative medical tests needed with cataract surgery?2001
Preoperative screening: value of previous tests.1990
Is routine pre-operative blood testing in children necessary?2006
Usefulness of routine preoperative testing: a prospective single-observer study.2005
The value of routine preoperative investigations.1987
Value of selective prescription of preanesthetic laboratory tests.1996
Rational preoperative evaluation.1986
Influence of preoperative medical assessment prior to elective endovascular aneurysm repair for abdominal aortic aneurysm.2012
Preoperative work up: are the requirements different in a developing country?1998
Personal experience with the stress test before thoracic surgery procedures.1994
Preoperative routine chest x-ray: expensive and of little value.1997
Is preoperative haemoglobin testing justified in children undergoing minor elective surgery?1991
Value of preoperative chest X-ray examinations in children.1977
Preoperative pregnancy testing: "justice and testing for all".1996
Usefulness of routine pre-operative chest radiography for anaesthetic management: a prospective multicentre pilot study.1999
Global health implications of preanesthesia medical examination for ophthalmic surgery.2013
Preoperative testing before noncardiac surgery: guidelines and recommendations.2013
Day of surgery urine cultures identify urogynecologic patients at increased risk for postoperative urinary tract infection.2013
Cardiopulmonary exercise testing as a predictor of complications in oesophagogastric cancer surgery.2013
Effectiveness of preoperative screening for sickle cell disease in a population with a newborn screening program: a cohort study.2013
Value of selective prescription of preanesthetic laboratory tests.1996
Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control?2006
Elimination of preoperative testing in ambulatory surgery.2009
The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective, randomized trial.2003
Impact of new guidelines on physicians' ordering of preoperative tests.1999

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