Sometimes it’s worth second and third looks at the biggies. The cash machine known as the industry of “preop” clearance rests on little to no data. The CARP Trial
I’ve been teaching CARP for a number of years. As for “cardiology clearance,“ I teach that “heart is too important an organ to be left to a cardiologist!“ Yes, I’m a bit of a contrarian. But if someone noted below about the only thing you can help them with is on adjusting anticoagulant.
At the end of my talk on surgical clearance are two choices: an opportunity to cancel an unnecessary surgery. Or ready yet, do the surgery yourself if it’s a small thing that you can do in the office! I did that in a surgical request for clearance for a small skin tag around the anus. I sent a copy of the path to the referring surgeon. He laughed.
As a retired oral and Maxillofacial surgeon with private practice, academic, and corporate managed care experience, I believe the driving force behind this preop testing request explosion (at least in my domain) is fear of litigation e.g. a patient “is not medically cleared” and has an adverse event. Younger surgeons especially are prone to requesting preop clearance. I do not know if this is a function of their training or perhaps lack of confidence. Even when presented with “the data” I was unable to change surgeons’ behavior. Thanks for another wonderful, thought provoking contribution!
Much more than fashion, I think the embedded economic incentives are a powerful reason that we continue with unnecessary testing (not to mention intervention). In addition, we need to consider the CYA factor -- the surgeon looking to shift some degree of liability for a bad outcome to another party.
A great reminder of the silliness of this. Our GI group requires a “cardiac clearance” before EGDs and colonoscopies on patients if they’ve ever seen a cardiologist. If we saw a patient two years ago to help with their BP, they want a clearance. We have a routine form that the staff sends back now.
It might be non physician clinicians (I am one) who are ordering too many tests. But if a patient has a lot of cardiac issues, they usually get cardiac clearance from a cardiologist in my system.
My routine is BMP, CBC within 90 days, A1c for diabetics, a chest xray for a pt with respiratory issues, an EKG for cardiac history (cxr and ekg within the last 6 months).
In my experience, it is the surgeons who are demanding extra testing. Ortho surgeons want UAs for joint replacements sometimes, I think that is bad practice. Once, a plastic surgeon wanted a stress test on a healthy 40 year old woman. I said no. If these surgeons want to order their own testing, that’s up to them. But they need to know, we are not working for them.
I don't have all the specifics, but when my sister had a history of MVR. Before her shoulder surgery she was sent for cardiac clearance. It was a good thing in this case. On the exam they found that her MVR had worsened quite a bit and she had an aneurysm on her aortic arch. Apparently she had some increased SOB when climbing stairs at home, but since it was gradual, she didn't really think anything about it. She wound up having heart surgery instead of the shoulder surgery. Is this something that an anesthesiologist would have picked up on a regular exam? I am asking.
As one of the older physicians that predate Stent and predate angioplasty, the vascular surgeons requested us to do “starling curves” . They would take patients undergoing major vascular surgery. and would ask us to put in Swan Ganz catheters . We would infuse saline and watch the wedge pressure response . It was very interesting in that individuals with normal LV function (and renal) infusing saline did nothing to their wedge, and as fast as you could infuse it, the patients excreted it. In individuals who had either impaired LV function or, perhaps valve disease, etc,, infusion of saline often resulted in rapid and substantial elevations in the wedge pressure. No one was injured during the test and the people that responded poorly did not get surgery. In the surgeon’s mind, this was the stress test that they were going to impose when they did aneurysm repair. For context, this was in the early 1980s, and the nuclear studies that we used were planar which I doubt a significant portion of physicians today have ever seen. The lesson I learned was that in the setting of normal LV function and normal renal function, if you think they need fluids, you could give it as fast as you want their Foleys became a fire hose. The net effect was their operative mortality was quite low. Further context as to the historical timeframe my mother at that point had scleroderma, and we had to have relatives in Canada ship us Tagamet as it was not available in the United States, and she had intense reflux. We were admitting people and rapidly titrating captopril with heart failure because it had just come on the market. So yes, I could imagine the concept of electively putting in a swan and two IVs and doing a science experiment seems somewhat out of place today, but in reality it was quite effective
I had a bad experience with this pre-clearance with my cataract surgery. Note I only have one good eye and the administration of the hospital told me if my blood pressure didn’t come down, they would not do the operation. Needless to say, they worried me so much that my blood pressure didn’t come down, and was right where it would have been had I not seen a doctor for blood pressure. A beautiful nurse talked me through my pre-op procedures, and everything was fine. Lost one month to needless worry and some money I had budgeted for the cataract operation. I couldn’t afford the drops after the removal, but my eye doctor saved the day by giving me samples. I can see better than I have all my life thanks to her. This was in Texas in 2015.
I'm an old (retired) doc. Since 2004 my clearance note routinely concluded: "Based on the CARP trial, preoperative stress testing and/or revascularization are not indicated. Therefore, the patient is in optimal CV condition to proceed with surgery."
The patient was relieved. The surgeon was suspicious.
As a cardiologist, I refuse to be part of the pre-operative industrial complex and order unnecessary testing. The number of requests for preoperative clearance has increased exponentially, and we’re now getting quite a few for dental cleanings and extractions. If the patient is on an anticoagulant, I could understand asking for guidance on the extraction but I’m still looking for a patient that’s too high risk to have a dental cleaning. 😆
I remember when CARP came out. We read the conclusion, nodded, and kept ordering stress tests. Twenty years on, I still get referrals asking me to "clear" a patient for a knee replacement, and the patient is usually more worried about the “clearance” than the operation. Part of it is habit; part of it is that nobody gets blamed for being thorough. Still, it's odd how a trial this clean has changed so little.
And with the increased indications for anticoagulant and anti platelet treatments, that’s a major driver for recommendations on how to handle them peri-op.
I absolutely love this post I am a cardiologist in VA and am getting ready to give a talk on preop I am simply inundated by these and not only high risk but for colonoscopies, cataract and tooth extraction My only respectful disagreement is that no these patients have not been examined or even see until day of procedure by their surgeon
“…the new influx of non-MD clinicians have continued the preop practices.”
Rather than blame the mid-level practitioners, let’s look at the docs who allow/request them to include clearance studies in their practice pathways.
I don’t mean to blame APCs. It’s not just them. It’s just harder for less experienced clinicians to go against the fashions
I’ve been teaching CARP for a number of years. As for “cardiology clearance,“ I teach that “heart is too important an organ to be left to a cardiologist!“ Yes, I’m a bit of a contrarian. But if someone noted below about the only thing you can help them with is on adjusting anticoagulant.
At the end of my talk on surgical clearance are two choices: an opportunity to cancel an unnecessary surgery. Or ready yet, do the surgery yourself if it’s a small thing that you can do in the office! I did that in a surgical request for clearance for a small skin tag around the anus. I sent a copy of the path to the referring surgeon. He laughed.
As a retired oral and Maxillofacial surgeon with private practice, academic, and corporate managed care experience, I believe the driving force behind this preop testing request explosion (at least in my domain) is fear of litigation e.g. a patient “is not medically cleared” and has an adverse event. Younger surgeons especially are prone to requesting preop clearance. I do not know if this is a function of their training or perhaps lack of confidence. Even when presented with “the data” I was unable to change surgeons’ behavior. Thanks for another wonderful, thought provoking contribution!
Much more than fashion, I think the embedded economic incentives are a powerful reason that we continue with unnecessary testing (not to mention intervention). In addition, we need to consider the CYA factor -- the surgeon looking to shift some degree of liability for a bad outcome to another party.
A great reminder of the silliness of this. Our GI group requires a “cardiac clearance” before EGDs and colonoscopies on patients if they’ve ever seen a cardiologist. If we saw a patient two years ago to help with their BP, they want a clearance. We have a routine form that the staff sends back now.
Great article
It might be non physician clinicians (I am one) who are ordering too many tests. But if a patient has a lot of cardiac issues, they usually get cardiac clearance from a cardiologist in my system.
My routine is BMP, CBC within 90 days, A1c for diabetics, a chest xray for a pt with respiratory issues, an EKG for cardiac history (cxr and ekg within the last 6 months).
In my experience, it is the surgeons who are demanding extra testing. Ortho surgeons want UAs for joint replacements sometimes, I think that is bad practice. Once, a plastic surgeon wanted a stress test on a healthy 40 year old woman. I said no. If these surgeons want to order their own testing, that’s up to them. But they need to know, we are not working for them.
I don't have all the specifics, but when my sister had a history of MVR. Before her shoulder surgery she was sent for cardiac clearance. It was a good thing in this case. On the exam they found that her MVR had worsened quite a bit and she had an aneurysm on her aortic arch. Apparently she had some increased SOB when climbing stairs at home, but since it was gradual, she didn't really think anything about it. She wound up having heart surgery instead of the shoulder surgery. Is this something that an anesthesiologist would have picked up on a regular exam? I am asking.
As one of the older physicians that predate Stent and predate angioplasty, the vascular surgeons requested us to do “starling curves” . They would take patients undergoing major vascular surgery. and would ask us to put in Swan Ganz catheters . We would infuse saline and watch the wedge pressure response . It was very interesting in that individuals with normal LV function (and renal) infusing saline did nothing to their wedge, and as fast as you could infuse it, the patients excreted it. In individuals who had either impaired LV function or, perhaps valve disease, etc,, infusion of saline often resulted in rapid and substantial elevations in the wedge pressure. No one was injured during the test and the people that responded poorly did not get surgery. In the surgeon’s mind, this was the stress test that they were going to impose when they did aneurysm repair. For context, this was in the early 1980s, and the nuclear studies that we used were planar which I doubt a significant portion of physicians today have ever seen. The lesson I learned was that in the setting of normal LV function and normal renal function, if you think they need fluids, you could give it as fast as you want their Foleys became a fire hose. The net effect was their operative mortality was quite low. Further context as to the historical timeframe my mother at that point had scleroderma, and we had to have relatives in Canada ship us Tagamet as it was not available in the United States, and she had intense reflux. We were admitting people and rapidly titrating captopril with heart failure because it had just come on the market. So yes, I could imagine the concept of electively putting in a swan and two IVs and doing a science experiment seems somewhat out of place today, but in reality it was quite effective
I had a bad experience with this pre-clearance with my cataract surgery. Note I only have one good eye and the administration of the hospital told me if my blood pressure didn’t come down, they would not do the operation. Needless to say, they worried me so much that my blood pressure didn’t come down, and was right where it would have been had I not seen a doctor for blood pressure. A beautiful nurse talked me through my pre-op procedures, and everything was fine. Lost one month to needless worry and some money I had budgeted for the cataract operation. I couldn’t afford the drops after the removal, but my eye doctor saved the day by giving me samples. I can see better than I have all my life thanks to her. This was in Texas in 2015.
Good article in JAMA about eight years ago saying that preop for cataract are totally unnecessary and America waste $1 billion a year on them
I'm an old (retired) doc. Since 2004 my clearance note routinely concluded: "Based on the CARP trial, preoperative stress testing and/or revascularization are not indicated. Therefore, the patient is in optimal CV condition to proceed with surgery."
The patient was relieved. The surgeon was suspicious.
You’re absolutely right. The only reason they want us to do them so that the lazy anesthesiologist can copy our note.
Your comment is laughable.
As a cardiologist, I refuse to be part of the pre-operative industrial complex and order unnecessary testing. The number of requests for preoperative clearance has increased exponentially, and we’re now getting quite a few for dental cleanings and extractions. If the patient is on an anticoagulant, I could understand asking for guidance on the extraction but I’m still looking for a patient that’s too high risk to have a dental cleaning. 😆
I remember when CARP came out. We read the conclusion, nodded, and kept ordering stress tests. Twenty years on, I still get referrals asking me to "clear" a patient for a knee replacement, and the patient is usually more worried about the “clearance” than the operation. Part of it is habit; part of it is that nobody gets blamed for being thorough. Still, it's odd how a trial this clean has changed so little.
If you kept ordering stress tests despite knowing better, that's on you.
The collective "we," I'm afraid. But I'll happily take a share of the blame on behalf of the profession.
And with the increased indications for anticoagulant and anti platelet treatments, that’s a major driver for recommendations on how to handle them peri-op.
I absolutely love this post I am a cardiologist in VA and am getting ready to give a talk on preop I am simply inundated by these and not only high risk but for colonoscopies, cataract and tooth extraction My only respectful disagreement is that no these patients have not been examined or even see until day of procedure by their surgeon