Letters

RESEARCH LETTER gectomy, abdominal hysterectomy, radical prostatectomy,

Trends in Pulmonary Function Testing
Before Noncardiothoracic Surgery
Preoperative pulmonary function tests (PFTs) assess the
severity of known pulmonary disease, diagnose causes of
respiratory symptoms, and may help identify patients who
are at risk for postoperative
pulmonary complications.
Invited Commentary
While useful in selected
page 1359
patients, unnecessary test-
ing is costly.1 Few guidelines
Related articles pages 1272 for the appropriate use of
and 1352
preoperative PFTs exist,
with the most recent being
the April 2006 American College of Physicians guidelines2
on risk assessment and prevention of postoperative pulmo-
nary complications. We conducted a population-based
study in Ontario, Canada, to describe temporal trends in
preoperative PFTs and to assess whether the guidelines
influenced these trends.
Methods | Following research ethics approval from Sunny-
brook Health Sciences Centre, we conducted a retrospective
c o h o r t s t u d y u s i ng d e i d e nt i f i e d d a t a f r o m l i n ke d
population-based administrative databases. The cohort
included individuals who were 40 years or older who under-
went elective abdominal aortic aneurysm repair, carotid
endarterectomy, peripheral arterial bypass, hip replace-
ment, knee replacement, large-bowel resection, partial liver
resection, pancreatoduodenectomy, gastrectomy, esopha-
nephrectomy, or cystectomy from April 1, 2003, through
March 31, 2013.
The outcome of interest was preoperative PFT, defined as
physician claims for simple spirometry, flow-volume loop, lung
compliance, carbon monoxide diffusion capacity, or bron-
chial provocative studies within 60 days before surgery. For
comparison, we identified nonoperative PFTs, defined as tests
conducted from 181 through 365 days before surgery.
After dividing the study into 3-month intervals,3 rates of
preoperative and nonoperative PFTs were measured for each
interval. Temporal trends in PFT rates were plotted and visu-
ally inspected to assess for time points when they changed sub-
stantially. We tested for the effect of guidelines on trends using
segmented linear regression models.4 These analyses were then
repeated within subgroups that were stratified by periopera-
tive pulmonary risk based on the presence or absence of asthma
or chronic obstructive pulmonary disease.
Results | Of 511 625 individuals in the cohort, 3.6% under-
went preoperative PFTs while 3.3% had nonoperative PFTs.
Among high-risk individuals with asthma or chronic
obstructive pulmonary disease, the proportions who under-
went preoperative and nonoperative testing were similar at
8.3%. Conversely, among individuals without these condi-
tions, 2.0% had preoperative testing while 1.6% had nonop-
erative testing.
Plotted trends showed that preoperative PFT rates de-
creased during the study while nonoperative rates remained
stable (Figure 1). Trends in preoperative PFT rates appeared
to decrease following the American College of Physicians guide-

Figure 1. Trends in PFTs Before Elective Noncardiothoracic Surgery From April 1, 2003, Through March 31, 2013

60

55 Preoperative

50 Nonoperative

45
PFTs, No. per 1000 Procedures

40

35

30

25 Rates of pulmonary function tests

(PFTs) in Ontario, Canada. The
20 vertical dotted line represents the
15
publication of the American College
of Physicians guidelines regarding
10 risk assessment for perioperative
pulmonary complications. In
5
segmented regression modeling,
0 trends in preoperative testing
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 deceased significantly (P = .006)
Year of Hospital Admission following publication of these
guidelines.

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Figure 2. Trends in Preoperative and Nonoperative PFTs From April 1, 2003, Through March 31, 2013, in Subgroups
Stratified by Perioperative Pulmonary Risk
140
120
PFTs, No. per 1000 Procedures
100
80
60
40
20
0
2003 2004 2005
Rates of pulmonary function tests (PFTs) among patients with and without chronic obstructive pulmonary disease (COPD) or asthma. The vertical dotted line
represents the publication of the American College of Physicians guidelines regarding risk assessment for perioperative pulmonary complications. In segmented
regression modeling, trends in preoperative testing decreased significantly after publication of these guidelines in both the high-risk (P < .001) and
low-risk (P = .01) subgroups.
lines; this trend was confirmed using segmented regression
modeling (P = .006). Qualitatively similar patterns were ob-
served in subgroups with and without risk factors for postop-
erative pulmonary complications (Figure 2).
Discussion | Preoperative PFT rates in Ontario, Canada, were low,
decreasing from 1 of 23 procedures in 2003 to 1 of 38 proce-
dures in 2013. These trends were qualitatively similar in sub-
groups stratified by risk for postoperative pulmonary compli-
cations. Notably, these decreasing preoperative PFT rates
contrast starkly with concurrent increases in rates of other peri-
operative interventions, such as preoperative anesthesia
consultations5 and stress testing.6 While the April 2006 pub-
lication of the updated American College of Physicians guide-
lines was followed by substantial decreases in preoperative PFT
rates, these guidelines were unlikely to have been the sole rea-
son for this trend. Specifically, they were not associated with
any large-scale promotion projects or changes in provincial
health insurance payment schedules. The decline in preop-
erative PFT rates may, in part, be explained by increased use
of bedside spirometry and other alternative pulmonary tests,
which are not captured by provincial administrative data-
bases. While less costly and possibly more accessible at some
hospitals, these alternative tests have limitations, such as mea-
surement error.7
Given the low overall rate of preoperative PFTs, large-
scale efforts to reduce this testing are likely unnecessary. By
2013, preoperative PFTs were performed in less than 8% of On-
tario patients with risk factors for pulmonary complications
while preoperative testing rates among individuals without
known respiratory disease had approached rates seen in the
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Letters
COPD/asthma (preoperative PFT)
COPD/asthma (nonoperative PFT)
No asthma/COPD (preoperative PFT)
No asthma/COPD (nonoperative PFT)
2006 2007 2008 2009 2010 2011 2012 2013 2014
Year of Hospital Admission
nonoperative setting. These findings indicate the need for more
research to identify which surgical patients most benefit from
preoperative PFTs.
Louise Y. Sun, MD, SM, FRCPC
Andrea S. Gershon, MD, MSc, FRCPC
Dennis T. Ko, MD, MSc, FRCPC
Stephan R. Thilen, MD, MS
Lingsong Yun, MSc
W. Scott Beattie, MD, PhD, FRCPC
Duminda N. Wijeysundera, MD, PhD, FRCPC
Author Affiliations: Department of Anesthesia, Toronto General Hospital,
Toronto, Ontario, Canada (Sun, Beattie, Wijeysundera); Department of
Anesthesia, University of Toronto, Toronto, Ontario, Canada (Sun, Beattie,
Wijeysundera); Division of Cardiac Anesthesiology, University of Ottawa Heart
Institute, Ottawa, Ontario, Canada (Sun); Lung Health Program, Institute for
Clinical Evaluative Sciences, Toronto, Ontario, Canada (Gershon); Cardiovascular
Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario,
Canada (Ko, Yun, Wijeysundera); Department of Medicine, Sunnybrook Health
Sciences Centre, Toronto, Ontario, Canada (Gershon); Division of Cardiology,
Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario,
Canada (Gershon, Ko); Division of Cardiology, University of Toronto, Toronto,
Ontario, Canada (Gershon, Ko); Department of Anesthesiology and Pain
Medicine, University of Washington, Seattle (Thilen); Li Ka Shing Knowledge
Institute, St Michael’s Hospital, Toronto, Ontario, Canada (Wijeysundera).
Corresponding Author: Louise Y. Sun, MD, SM, FRCPC, Division of Cardiac
Anesthesiology, University of Ottawa Heart Institute, 40 Ruskin St, Room
H2410, Ottawa, ON K1Y 4W7, Canada (lsun@ottawaheart.ca).
Published Online: June 8, 2015. doi:10.1001/jamainternmed.2015.2087.
Author Contributions: Drs Sun and Wijeysundera had full access to all the data
in the study and take responsibility for the integrity of the data and the accuracy
of the data analysis.
Study concept and design: Sun, Beattie, Wijeysundera.
Acquisition, analysis, or interpretation of data: Sun, Gershon, Ko, Thilen, Yun,
Wijeysundera.
(Reprinted) JAMA Internal Medicine August 2015 Volume 175, Number 8 1411
 Letters
Drafting of the manuscript: Sun, Beattie, Wijeysundera.
Critical revision of the manuscript for important intellectual content: Sun,
Gershon, Ko, Thilen, Yun, Wijeysundera.
Statistical analysis: Sun, Yun, Wijeysundera.
Obtained funding: Wijeysundera.
Administrative, technical, or material support: Beattie, Wijeysundera.
Study supervision: Beattie, Wijeysundera.
Conflict of Interest Disclosures: Dr Gershon reports receiving support through
a Physicians’ Services Incorporated Foundation Fellowship in Translational
Health Research; Dr Ko, through a Clinician-Scientist Award from the Heart and
Stroke Foundation; Drs Beattie and Wijeysundera, through Merit Awards from
the University of Toronto Department of Anesthesia; and Dr Wijeysundera,
through a Clinician-Scientist Award from the Canadian Institutes of Health
Research. Dr Beattie reports being the R. Fraser Elliot Chair of Cardiac
Anesthesia at the University Health Network. No other disclosures were
reported.
Funding/Support: This study was supported in part by the Institute for Clinical
Evaluative Sciences, which is supported in part by the Ontario Ministry of Health
and Long-Term Care.
Role of the Funder/Sponsor: The funding sources had no role in the design and
conduct of the study; collection, management, analysis, and interpretation of
the data; preparation, review, or approval of the manuscript; and decision to
submit the manuscript for publication.
Disclaimer: The opinions, results, and conclusions are those of the authors, and
no endorsement by the Ontario Ministry of Health and Long-Term Care or the
Institute for Clinical Evaluative Sciences is intended or should be inferred.
1. De Nino LA, Lawrence VA, Averyt EC, Hilsenbeck SG, Dhanda R, Page CP.
Preoperative spirometry and laparotomy: blowing away dollars. Chest. 1997;111
(6):1536-1541.
2. Qaseem A, Snow V, Fitterman N, et al; Clinical Efficacy Assessment
Subcommittee of the American College of Physicians. Risk assessment for and
strategies to reduce perioperative pulmonary complications for patients
undergoing noncardiothoracic surgery: a guideline from the American College
of Physicians. Ann Intern Med. 2006;144(8):575-580.
3. Wijeysundera DN, Mamdani M, Laupacis A, et al. Clinical evidence, practice
guidelines, and β-blocker utilization before major noncardiac surgery. Circ
Cardiovasc Qual Outcomes. 2012;5(4):558-565.
4. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression
analysis of interrupted time series studies in medication use research. J Clin
Pharm Ther. 2002;27(4):299-309.
5. Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A.
A population-based study of anesthesia consultation before major noncardiac
surgery. Arch Intern Med. 2009;169(6):595-602.
6. Sheffield KM, McAdams PS, Benarroch-Gampel J, et al. Overuse of
preoperative cardiac stress testing in Medicare patients undergoing elective
noncardiac surgery. Ann Surg. 2013;257(1):73-80.
7. Stoller JK, Orens DK, Hoisington E, McCarthy K. Bedside spirometry in a
tertiary care hospital: the Cleveland Clinic experience. Respir Care. 2002;47(5):
578-582.
Prevalence of Overweight and Obesity
in the United States, 2007-2012
Overweight and obesity are associated with various chronic
conditions.1 These conditions are considerable health care and
societal burdens, yet could potentially be averted by prevent-
ing weight gain and obesity. In a prior analysis, now almost 20
years old, Must et al2 used a nationally representative data set
from 1988 through 1994 and reported the US chronic disease
burden associated with body mass index (BMI), thus inform-
ing clinical practice and the priorities for cost-effective pre-
vention strategies. Using the most recent data in the National
Health and Nutrition Examination Survey (NHANES, 2007-
2012), we updated the prevalence of overweight and obesity
by sex, age, and race/ethnicity and compared the values with
those of the earlier study.2
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Methods | The NHANES was designed to provide cross-
sectional estimates of the prevalence of major diseases, nu-
tritional disorders, and potential risk factors among the US
population. 3 We aggregated data from 2007-2008, 2009-
2010, and 2011-2012 and included only adults who were 25 years
or older (n = 15 208), excluding those who were pregnant at the
time of examination (n = 125) or provided insufficient data re-
garding weight and height (n = 827). The NHANES obtained ap-
proval from the National Center for Health Statistics Re-
search Ethics Review Board and participants provided written
consent.
Weight and height were measured during the physical ex-
amination using standard procedures. Patients’ BMIs (calcu-
lated as weight in kilograms divided by height in meters
squared) were classified according to the following catego-
ries: underweight (<18.5), normal weight (18.5-24.9), over-
weight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2
(35.0-39.9), and obesity class 3 (≥40).2
Data regarding patients’ age, sex, and race/ethnicity were
collected. Age was classified as 25 to 54 years or 55 or more
years. Self-reported race/ethnicity were categorized as Mexi-
can American, non-Hispanic black, non-Hispanic white, or
other.
We stratified the analyses by sex and calculated the
weighted proportion estimates in each BMI category by race
or ethnic group and age group. All statistical analyses were con-
ducted in Stata, version 12.0 (StataCorp LP), using survey analy-
sis procedures to account for the complex sampling design.
Results | Of the sample population, 39.96% (weighted n =
36 325 297) of men and 29.74% (weighted n = 28 894 630) of
women were overweight and 35.04% (weighted n = 31 847 198)
of men and 36.84% (weighted n = 35 792 733) of women were
obese. The weight status distribution was similar for both sexes
across racial groups (Table), except for the proportion of non-
Hispanic white women, which was higher in the normal-
weight than the overweight category. Compared with 20 years
ago, the greatest increase in the proportion of patients in the
obesity class 3 category was among non-Hispanic black women.
Discussion | Compared with 1988-1994,2 the distribution of the
population’s weight status has increased in the past 20 years.
The rising trends in overweight and obesity warrant timely at-
tention from health-policy and health care–system decision
makers. Clinical practice for the prevention and treatment of
chronic conditions has mainly focused on screening high-
risk populations. As a result, people in higher-weight catego-
ries are more likely to be diagnosed with the chronic diseases
associated with excess weight2 because of more frequent mea-
surements, compared with people in the normal-weight cat-
egory. This approach may ignore individuals with normal
weight and their weight gain, which puts them at risk.
Population-based strategies helping to reduce modifi-
able risk factors such as physical environment interventions,
enhancing primary care efforts to prevent and treat obesity,
and altering societal norms of behavior are required.4 In 2012,
the Institute of Medicine identified population-based obesity-
prevention strategies that target physical activity, healthy diet,
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