Research

Aesthetic Surgery Journal

Patterns of Preoperative Laboratory Testing in 2014, Vol 34(1) 133­–141

© 2013 The American Society for
Aesthetic Plastic Surgery, Inc.
Patients Undergoing Outpatient Plastic Surgery Reprints and permission:
http://www​.sagepub.com/

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DOI: 10.1177/1090820X13515880
www.aestheticsurgeryjournal.com

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John P. Fischer, MD; Eric K. Shang, MD; Jonas A. Nelson, MD;
Liza C. Wu, MD; Joseph M. Serletti, MD; and Stephen J. Kovach, MD

Abstract
Background: Preoperative laboratory testing is commonplace in the clinical setting and is often utilized at surgeon discretion. We searched the
American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) data set to determine the impact of preoperative laboratory
testing in ambulatory plastic surgery patients.
Objective: The authors assess the utilization and predictive value of preoperative laboratory testing in outpatient plastic surgery procedures.
Methods: Patients undergoing ambulatory plastic surgery were identified from the 2005 to 2010 NSQIP databases. Laboratory tests were categorized
by group: hematologic, chemistry, coagulation, and liver function tests (LFT). We defined complications in 2 groups: major postoperative and wound
complications. Multivariate analyses were used to identify patient characteristics associated with testing and to assess the ability of laboratory testing to
predict postoperative complications.
Results: A total of 5359 (62.0%) patients underwent testing; 881 (16.4%) tests were performed on the day of surgery. In patients with no defined
NSQIP comorbidities, 59.4% underwent preoperative testing and had a significantly lower rate of abnormal findings (33.4% vs 25.3%, P < .0001). In
multivariate analyses, testing was associated with older age, American Society of Anesthesiologists class >2, Hispanic or African American race, body
contouring procedures, epidural or spinal procedures, and with diabetes, hypertension, and cancer. Major complications occurred in 0.34% of patients.
Our analysis demonstrated that neither testing nor abnormal results were associated with postoperative complications, either major (P = .178) or wound
(P = .150).
Conclusions: We found no association between abnormal laboratory testing and postoperative morbidity. Preoperative testing in low-risk ambulatory
plastic surgery patients may be costly and has limited direct clinical benefit.

Keywords
preoperative testing, complication, ambulatory surgery, laboratory, labs

Accepted for publication April 25, 2013.

Preoperative laboratory testing is commonplace and is often
utilized at surgeon discretion without formal evidence-based
input.1-3 Although the cost of laboratory testing for an indi-
vidual may be low and of little fiscal consequence, the aggre-
gate cost of inefficient or potentially unnecessary preoperative
laboratory testing in low-risk ambulatory surgery patients
may be profound and approaches $30 billion per year.4-6 The
number of ambulatory surgery procedures per year in the
United States is increasing and represents more than two-
thirds of the surgical procedures performed annually.7
Unfortunately, recommendations for preoperative testing
can vary widely, depending on the studies and reviews
cited.4,8-10 Many authors have advocated against the use
of routine preoperative laboratory testing, especially in
asymptomatic and clinically normal patients undergoing
elective, low-risk surgery, on the basis that it infrequently
From the Department of Surgery, Division of Plastic Surgery,
Hospital of the University of Pennsylvania, Philadelphia.
Corresponding Author:
Dr John P. Fischer, Division of Plastic Surgery, University of
Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
E-mail: John.Fischer2@uphs.upenn.edu
134 Aesthetic Surgery Journal 34(1)
changes management. In fact, several randomized controlled
trials featuring the elimination of preoperative testing in low-
risk patients found no difference in adverse events.11,12
Despite this evidence, preoperative testing is still common
in the ambulatory plastic surgery setting. In this study, we
searched the American College of Surgeons–National
Surgical Quality Improvement Program (ACS-NSQIP) data
sets to determine the impact of preoperative laboratory
testing in ambulatory plastic surgery patients. We exam-
ined all patients undergoing ambulatory plastic surgery
and also a subgroup of patients with no NSQIP-quantified
comorbidities, presuming that this group of patients had
no indication for preoperative testing. We also identified
factors associated with the use of preoperative laboratory
testing and assessed the impact of obtaining preoperative
laboratory results on adverse patient outcomes.
Methods
General
We reviewed the 2005 to 2010 ACS-NSQIP databases, iden-
tifying encounters for outpatient plastic surgery proce-
dures using defined NSQIP parameters.13 Institutional
review board exemption was obtained for this study.
Deidentified patient information is freely available to all
institutional members who comply with the ACS-NSQIP
Data Use Agreement. The Data Use Agreement implements
the protections afforded by the Health Insurance Portability
and Accountability Act (HIPAA) of 1996. The ACS-NSQIP
and the hospitals participating in the ACS-NSQIP are the
source of the data used herein; they have not verified and
are not responsible for the statistical validity of the data
analysis or the conclusions derived by the authors of this
study.
The NSQIP data are collected by trained research nurses
at various institutions using a systematic sampling of gen-
eral and vascular operations performed in each participat-
ing institution. Results from audits completed to date
reveal a disagreement rate of 1.8% for program variables.
Each data set contains 240 HIPAA-compliant variables for
each case encounter, including patient demographics, pre-
operative risk factors, baseline comorbidities, intraopera-
tive variables, and 30-day postoperative morbidity and
mortality. The list and definitions of variables collected in
the database can be found at the ACS-NSQIP website
(http://site.acsnsqip.org/). Patients are contacted by letter
or telephone survey after discharge to ensure a full 30-day
follow-up period. Data were accessed on December 1,
2012.
Cohort Selection
The NSQIP Participant Use Files (PUF) include 1 334 886
patients who underwent surgery at participating institu-
tions between 2005 and 2010. Patients who underwent
outpatient plastic surgery procedures were selected through
defined NSQIP variables for “surgspec” and “inout.” We
eliminated patients with age <18 years, incomplete data
for sex or ethnicity, American Society of Anesthesio–
logists (ASA) physical status class 4 or 5, emergent opera-
tions, acute renal failure, impaired sensorium, ventilatory
support, or sepsis. The final cohort included 8645 patients
(Figure 1).
Specific patient characteristics evaluated in this study
included age, sex, race, obesity (body mass index [BMI]
≥30 kg/m2), and presence of comorbidities. Procedure-
related variables included year of surgical procedure, type
of anesthesia administered, and type of procedure.
Procedure types were divided into 5 main groups: breast
reconstruction, body contouring, and face, hand, and gen-
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eral reconstruction. These groupings, along with the 2
most common Current Procedural Terminology (CPT) codes
in each categorized grouping, are summarized in Table 1.
Laboratory Testing
Preoperative laboratory testing was defined as testing that
occurred within 30 days before a surgical procedure. The
NSQIP database includes the following laboratory tests:
hematocrit, white blood cell (WBC) count, platelet count,
sodium, serum urea nitrogen (SUN), creatinine, partial
thromboplastin time (PTT), prothrombin time (PT), inter-
national normalized ratio (INR), albumin, total bilirubin,
aspartate aminotransferase (AST), and alkaline phos-
phatase. Preoperative tests were grouped by type.
Hematology tests were defined to include hematocrit,
WBC, and platelets. Chemistry tests were defined to
include sodium, SUN, and creatinine. Coagulation tests
were defined to include PTT, PT, and/or INR. Liver func-
tion test (LFT) panel was defined to include albumin, AST,
total bilirubin, and alkaline phosphatase.
We defined abnormal laboratory values based on previ-
ously published reports using the NSQIP data sets.1
Normal ranges were defined as follows: hematocrit, 34%
to 45%; WBC, 4000/mm3 to 12 000/mm3; and platelets,
150 000/mm3 to 400 000/mm3. Sodium levels from 135 to
145 mmol/L, SUN <23 mg/dL, and creatinine <1.04 mg/
dL. Coagulation tests were defined as normal if the follow-
ing conditions were met: PTT <38 seconds, PT <14.7
seconds, and INR <1.5. LFT were defined as normal if the
following conditions were met: albumin >3.5 g/dL, total
bilirubin <1.1 mg/dL, AST <40 U/L, and alkaline phos-
phatase <122 U/L.
Outcomes
The primary outcome was to determine the incidence of
patients who underwent preoperative laboratory testing
prior to elective, ambulatory plastic surgery. This included
a breakdown of test type and the incidence of abnormal
test results. Of interest was the use of laboratory testing in
patients with and without NSQIP-defined comorbidities.
Additionally, we sought to characterize the use of same-
day laboratory testing and its impact on management.
Fischer et al 135
Figure 1.  Selection criteria used to obtain study cohort of ambulatory plastic surgery patients. ASA, American Society of
Anesthesiologists; CPT, Current Procedural Terminology; NSQIP, National Surgical Quality Improvement Program.
We defined complications into 2 groups: major postopera-
tive events and wound complications. The incidence of any
complication was defined as either a major or wound com-
plication. Major postoperative complications were specifi-
cally defined according to previously published criteria based
on reported NSQIP variables1: unplanned intubation, pulmo-
nary embolism, stroke, coma for greater than 24 hours, renal
failure requiring dialysis, myocardial infarction, cardiac
arrest, sepsis, septic shock, blood transfusions, or death.
Wound-related complications were similarly defined and
included superficial and deep surgical site infections, organ
space infections, and wound dehiscence. We also assessed
whether patients required >24 hours admission.
Statistical Analysis
Descriptive statistics were obtained for the overall cohort,
and the use of each type of preoperative testing was
described. Patient-related and procedure characteristics were
compared between those who underwent laboratory testing
and those who did not. Pearson χ2 tests were used to analyze
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categorical variables; unpaired Student t tests were employed
for continuous variables. Comorbidities with an incidence
less than 1% in both groups were not reported. Subgroup
analysis was performed for the cohort of patients who under-
went same-day preoperative laboratory testing and those
with no NSQIP-defined comorbidities.
Multivariate logistic regression analysis was used to
determine factors predictive of the use of preoperative
laboratory testing and the effect of preoperative laboratory
testing on the incidence of postoperative complications.
Logistic regression was performed using backward selec-
tion methods, with a cutoff of P < .10. All tests were
2-tailed, and statistical significance was defined as P <
.05. All statistics were calculated using MATLAB algo-
rithms (MathWorks, Natick, Massachusetts).
Results
Cohort Characteristics
During the study period, a total of 8645 patients under-
went ambulatory plastic surgery procedures. A total of
136 Aesthetic Surgery Journal 34(1)

Table 1.  Summary of the Most Common Procedures Identified in the Table 2.  Summary of Patient and Procedure Characteristics Among
Study Cohort From General Categories Those Who Received Preoperative Laboratory Testing
Specific Procedures No Laboratory Testing Laboratory Test-
Type of Procedure (Associated CPT Codes) Number (n = 3286) ing (n = 5359) P Value

Breast reconstruction Breast reduction (19318) 1581 Age, mean (SD), y 45.6 (15.1) 49.4 (15.2) <.0001

Implant-based reconstruction (19340, 770 Sex

19342, 19357)
 Male 762 (23.2) 826 (15.4) <.0001
Body Panniculectomy/abdominoplasty (15830, 568
15847)  Female 2524 (77.8) 4533 (84.6)

Suction-assisted lipectomy (15876-15879) 4 Race

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Face Orbital fracture (21390) 54  White 2871 (87.4) 4449 (83.0) <.0001

Mandible fracture (21461-21470) 42  Black 921 (9.8) 648 (12.1)

Hand Tendon repair (26350, 26356, 26357, 213  Hispanic 22 (0.7) 158 (2.9)
26370, 26372, 26390, 26410, 26412,
26418, 26433)  Asian 57 (1.7) 82 (1.5)

Excision of ganglion wrist (25110, 25111) 173  Other 15 (0.5) 22 (0.4)

General Full-thickness skin graft (15200, 15220, 238 Length of stay, mean 0.14 (1.7) 0.24 (2.4) .005
15240, 1526) (SD), d

Adjacent tissue transfer (14300, 14301) 91 Procedure type

CPT, Current Procedural Terminology.  Breast 1869 (56.9) 3448 (64.3) <.0001

  Body contouring 120 (3.7) 452 (8.4)

 Face 210 (6.4) 231 (4.3)

5359 (62.0%) patients underwent testing, of whom 881
 Hand 777 (23.6) 704 (13.1)
(16.4%) underwent same-day testing. The patients under-
going preoperative laboratory testing significantly differed   General recon- 310 (9.4) 524 (9.8)
from the patients without testing with regard to age (49.4 struction
± 15.2 vs 45.6 ± 15.1 years, P < .0001), ASA physical
ASA classification
status >2 (20.3% vs 13.4%, P < .0001), Hispanic or
African American race (4.4% vs 2.4%, P < .0001), body   Class 1 711 (21.6) 899 (16.8) <.0001
contouring procedures (8.4% vs 3.7%, P < .0001), epi-
  Class 2 2134 (64.9) 3370 (62.9)
dural or spinal procedures (1.1% vs 0.2%, P < .0001),
and in having at least 1 defined NSQIP comorbidity   Class 3 441 (13.4) 1090 (20.3)
(44.8% vs 38.4%, P < .0001). The univariate analyses of
other risk factors associated with laboratory testing are Anesthesia type
summarized in Tables 2 and 3.  General 2938 (89.4) 4985 (93.0) <.0001

 MAC 164 (5.0) 188 (3.5)

Preoperative Tests
 Epidural/spinal 9 (0.2) 61 (1.1)

The most commonly obtained tests were complete blood
count (CBC) (57.4%), chemistry (44.3%), LFT (21.3%),
and coagulation (20.5%). In all, 3811 patients underwent
more than 1 type of testing: 2 tests in 17.9%, 3 tests in
15.0%, and all 4 tests in 11.2%. Abnormal testing was
observed in 1970 (36.7%) with the following distribution:
hematologic, 18.3%; chemistry, 22.4%; coagulation,
6.7%; and LFT, 26.9%. Most patients with abnormal test-
ing had 1 abnormal type of test (79.8%), whereas 17.4%
had 2 abnormal tests and 2.6% had 3 abnormal tests. Less
than 1% of patients had all 4 types of tests abnormal (n
= 5). Of the cohort of patients undergoing preoperative
laboratory testing, 16.4% underwent same-day laboratory
 Local/regional 171 (5.2) 122 (2.3)
Values are presented as number (%) unless otherwise indicated. ASA, American Society of
Anesthesiologists; MAC, monitored anesthesia care.
testing, and 33.5% (n = 296) patients had an abnormal
finding (Table 4). All of these patients went on to undergo
surgery.
In patients with no defined NSQIP comorbidities, 2957
(59.4%) still underwent preoperative testing and with a
significantly lower rate of abnormal findings (25.3% vs
Fischer et al 137

Table 3.  Summary of Comorbidities Among Patients Who Received Table 4.  Incidence of Abnormal Tests From Study Group Including Day
Preoperative Laboratory Testing of Surgery and Noncomorbid Patient Groups
No Laboratory Testing Laboratory Testing Total, No. (%) Abnormal, No. (%)
(n = 3286), No. (%) (n = 5359), No. (%) P Value
Overall cohort (n = 8645)
At least 1 NSQIP 1264 (38.4) 2402 (44.8) <.0001
comorbidity   Any test 5359 (62.0) 1970 (36.7)

At least 2 NSQIP 80 (2.4) 395 (5.5) <.0001  Hematology 4966 (57.4) 1115 (22.4)
comorbidities
 Chemistry 3827 (44.3) 700 (18.3)
Obesity (BMI >30 934 (28.2) 1785 (33.5) <.0001
kg/m2)  LFT 1839 (21.3) 495 (26.9)

Smoking 682 (20.8) 849 (15.8) <.0001  Coagulation 1769 (20.5) 119 (6.7)

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Alcohol 78 (2.4) 95 (1.8) .057 Day of surgery tests (n = 881)

Diabetes 178 (5.4) 531 (10.4) <.0001   Any test 881 (100.0) 296 (33.5)

Hypertension 610 (18.6) 1573 (29.4) <.0001  Hematology 698 (79.2) 156 (22.3)

Dyspnea 88 (2.6) 176 (3.3) .122  Chemistry 429 (48.7) 78 (18.2)

Chronic obstructive 32 (1.0) 73 (1.4) .129  LFT 67 (7.6) 17 (25.3)

pulmonary disease
 Coagulation 130 (14.8) 25 (19.2)
Previous percutane- 38 (1.2) 93 (1.7) .033
ous cardiac No comorbidities (n = 4979)
intervention
  Any test 2957 (59.4) 748 (25.3)
Bleeding disorders 23 (0.7) 74 (1.4) .003
 Hematology 2845 (57.1) 485 (17.0)
Prior transient 20 (0.6) 66 (1.2) .004
 Chemistry 1899 (38.1) 163 (8.6)
ischemic attack

 LFT 1016 (20.4) 169 (16.6)

Prior stroke 10 (0.3) 36 (0.7) .022

 Coagulation 1038 (20.8) 37 (3.6)

Currently on steroids 30 (0.9) 68 (1.2) .143
LFT, liver function tests.
Chemotherapy 32 (1.0) 95 (1.8) .002
(within 30 days)

BMI, body mass index; NSQIP, National Surgical Quality Improvement Program.
36.7%, P < .0001). A total of 57.1% underwent hematol-
ogy tests, 38.1% chemistry, 20.4% LFT, and 20.8%
coagulation.
Factors Associated With Testing
Tables 5 and 6 summarize the multivariate regression
analyses that assess independently associated factors
related to preoperative testing. The analysis demonstrated
that use of preoperative testing was associated with older
age, ASA physical status >2, Hispanic or African American
race, body contouring procedures, epidural or spinal pro-
cedures, and diabetes, hypertension, or cancer.
With respect to race, Hispanics were more likely to
undergo CBC, chemistry, LFT, and coagulation testing
(Table 5). African Americans also more frequently under-
went all types of testing except LFT. Patients undergoing
body contouring procedures more frequently underwent all
types of laboratory testing, whereas those undergoing hand
or face surgery less frequently underwent all types of test-
ing. Interestingly, patients receiving epidural or spinal anes-
thesia more frequently received all types of preoperative
tests. Older patients also underwent all types of testing at
higher rates. Diabetic patients more frequently underwent
chemistry, patients with bleeding disorders more frequently
underwent coagulation testing, and those with known alco-
hol use more often underwent LFT (Table 6).
Outcomes
The use of preoperative testing was not associated with
major postoperative complications (0.42% vs 0.21%, P =
.178) or wound complications (2.1% vs 1.7%, P = .150)
(Table 7). Multivariate logistic regression analysis analyz-
ing specific laboratory tests demonstrated that neither
the performance of preoperative testing nor the presence
of abnormal results was associated with postoperative
complications. Interestingly, patients who underwent pre-
operative laboratory testing were more likely to stay for
>24 hours postoperatively (2.7% vs 1.5%, P < .001).
Furthermore, abnormal preoperative hematologic (odds
138 Aesthetic Surgery Journal 34(1)

Table 5.  Summary of Patient and Procedural Characteristics Associated With Specific Preoperative Laboratory Tests
OR (95% CI)

Any Testing CBC Chemistry LFT Coagulation

Race

 White Reference

 Black 1.500 (1.29-1.75) 1.45 (1.25-1.68) 1.56 (1.35-1.81) NS 1.28 (1.07-1.52)

 Hispanic 5.8 (3.66-9.15) 6.11 (3.93-9.50) 1.58 (1.16-2.15) 1.61 (1.14-2.29) 4.36 (3.19-5.95)

Procedure

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 Breast Reference

  Body contour 2.14 (1.73-2.65) 2.19 (1.78-2.70) 1.28 (1.07-1.53) 1.49 (1.22-1.81) 1.41 (1.16-1.72)

 Face 0.65 (0.52-0.81) 0.59 (0.47-0.73) NS NS NS

 Hand 0.55 (0.47-0.64) 0.50 (0.43-0.58) 0.65 (0.55-0.77) 0.48 (0.39-0.60) 0.38 (0.30-0.48)

  LE reconstruction NS 0.81 (0.68-0.96) NS 0.81 (0.66-0.99) 0.71 (0.57-0.89)

Anesthesia

 General Reference

 Epidural/spinal 3.65 (1.78-7.49) 3.52 (1.78-6.99) 3.06 (1.81-5.19) 0.30 (0.13-0.70) 3.85 (2.35-6.28)

 Local/regional 0.56 (0.43-0.74) 0.61 (0.46-0.80) 0.48 (0.36-0.65) 0.61 (0.40-0.92) NS

 MAC 0.75 (0.59-0.94) 0.72 (0.57-0.91) 0.62 (0.48-0.79) 0.60 (0.43-0.83) NS

CBC, complete blood count; CI, confidence interval; LE, lower extremity; LFT, liver function tests; MAC, monitored anesthesia care; NS, not significant; OR, odds ratio.

ratio [OR], 1.45; P < .001) and LFT (OR, 1.63; P < .001)
results were associated with higher rates of >24-hour
hospital admission (Table 8).
Discussion
This study represents the first population-based assess-
ment of preoperative laboratory use in ambulatory plastic
surgery patients. Using a prospective, national registry of
patient data compiled by the NSQIP over a 5-year period,
we assessed 8645 plastic surgery patients undergoing low-
risk ambulatory procedures and determined that 62.0% of
these patients underwent preoperative laboratory tests.
Even in study patients with no defined comorbid condi-
tions, a majority (59.4%) underwent preoperative testing.
These summary statistics highlight the inefficient, non–
evidence-based utilization patterns of preoperative labora-
tory testing.
Several recent well-designed studies, including meta-
analyses and randomized controlled trials, have been
performed assessing the utility of preoperative testing in
low-risk ambulatory surgery patients, as well as those
with stable underlying comorbid conditions. These studies
have failed to demonstrate any clinical utility or predictive
value to testing.1,11,12,14-16 The primary indication for utili-
zation of a test is its potential ability to alter clinical decision
making and care.17 Current recommendations for labora-
tory testing in the United States are derived from the 2002
ASA task force and are based on observational studies and
expert opinions,18 and this has recently been updated with
the practice advisory published in Anesthesiology.19 These
expert opinions make it clear that there are no perfect and
unambiguous or uniform recommendations in place due
to a significant lack of robust literature on preanesthesia
testing.
The practice advisory suggests that a preoperative elec-
trocardiogram be considered when there is underlying car-
diopulmonary disease or the procedure has a potentially
significant degree of invasiveness.19 There is no current
consensus about an age cutoff. Chest x-ray should be con-
sidered in patients with underlying cardiopulmonary dis-
ease, recent upper respiratory tract infections, and chronic
lung diseases. Routine preoperative hemoglobin testing is
not indicated unless there is significant procedural risk,
liver disease, known anemia, or bleeding or hematologic
disorder. Preoperative coagulation testing is best reserved
for patients undergoing more invasive operations and in
those with significant hepatic or renal dysfunction or in
cases of known bleeding disorders. Last, routine serum
chemistries are reserved for those with underlying hepatic
or renal disease and in those with known endocrinopathies
or those currently on medications that might alter normal
values, such as those on diuretics.
Fischer et al 139

Table 6.  Summary of Patient Characteristics Associated With Specific Preoperative Laboratory Tests
OR (95% CI)

Any Testing CBC Chemistry LFT Coagulation

ASA classification

  ASA 2 NS NS 1.26 (1.10-1.44) 1.51 (1.27-1.78) NS

  ASA 3 1.28 (1.06-1.54) NS 1.65 (1.38-1.98) 1.68 (1.35-2.10) 1.47 (1.25-1.72)

  Age (per year) 1.013 (1.010-1.017) 1.008 (1.005-1.012) 1.023 (1.020-1.027) 1.020 (1.016-1.024) 1.006 (1.002-1.010)

Comorbidities

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 Diabetes 1.23 (1.06-1.43) NS 1.40 (1.22-1.61) NS NS

 Hypertension 1.31 (1.06-1.61) 1.14 (1.03-1.32) 1.84 (1.64-2.08) 1.16 (1.01-1.33) NS

 Cancer 5.85 (1.36-25.1) 4.05 (1.37-11.96) NS 3.40 (1.56-7.43) NS

 Smoking NS 0.88 (0.78-0.99) NS NS NS

 Chemotherapy NS 1.51 (1.02-2.25) 1.81 (1.25-2.63) 1.71 (1.17-2.51) NS

  Bleeding disorder NS NS NS NS 3.65 (2.34-5.68)

  ETOH use NS NS NS 1.17 (1.05-1.31) NS

 Obesity NS NS NS 0.87 (0.77-0.98) 0.71 (0.63-0.81)

ASA, American Society of Anesthesiologists; CBC, complete blood count; CI, confidence interval; ETOH use, alcohol use; LFT, liver function tests; NS, not significant; OR, odds ratio.

Table 7.  Summary of Patient Characteristics Associated With Specific these results may not alter management. Furthermore, the
Preoperative Laboratory Tests incidence of major complications in this study cohort was
No. (%)
only 0.34%. Using multivariate logistic regression, neither
the use of testing nor the occurrence of an abnormal labo-
Preoperative No Preoperative ratory value was shown to be of significant predictive
Overall Testing Testing P Value
clinical value, with respect to major complications or
Major complication 29 (0.34) 22 (0.42) 7 (0.21) .178 wound complications.
In assessing which populations more frequently under-
Wound complication 169 (2.0) 114 (2.1) 55 (1.7) .150 went testing, several notable trends were apparent. First,
Any complication 187 (2.2) 127 (2.4) 60 (1.8) .087 ethnic minorities were more frequently tested and those
patients undergoing body contouring procedures (specifi-
>24-Hour stay 192 (2.2) 144 (2.7) 48 (1.5) .0001 cally abdominoplasty/panniculectomy) were more likely
to undergo testing. Patients undergoing body contouring
procedures may often have underlying laboratory abnor-
malities related to prior weight loss, which may account
There are also no consistent recommendations regard- for the observed increase in laboratory testing.20,21 Older
ing the timing of preoperative testing, but if there have patients were also more likely to be tested. Those patients
been no significant clinical changes in history or examina- with defined comorbidities, including diabetes and hyper-
tion with 6 months, testing can be omitted.1,19 In brief, the tension, were more likely to be tested, as well as those
practice guidelines provided by the ASA task force are with cancer. Interestingly, patients not receiving general
clear that routine preoperative testing is not advisable; anesthesia were more often tested. Similar patterns were
rather, selective testing that might be used to guide or noted by Benarroch-Gampel et al1 in their evaluation of
further optimize perioperative management is currently the utility of preoperative testing in ambulatory hernia
recommended. repairs.
One of the important aspects of preoperative testing is Subgroup analysis did reveal several significant findings.
how it affects decision making and management. Thus, Patients who underwent coagulation testing and patients
while these data do not allow us to determine the rate at with abnormal hematologic or LFT tests were more often
which abnormal results led to procedure cancellation, the admitted for >24-hour hospital stay. Overall, patients who
fact that a significant number (36.7%) of patients pro- underwent any preoperative laboratory testing were more
ceeded to surgery despite abnormal tests suggests that likely to be admitted for >24-hour hospital stay (2.7% vs
140 Aesthetic Surgery Journal 34(1)
Table 8.  Predictive Value of General and Specific Laboratory Testing
With Respect to Complications and Admission
OR (95% CI)
Wound Major
Complications Complications
Overall cohort (test vs no test)
 Hematology 1.47 (0.72-3.20) 1.69 (0.60-4.76)
 Chemistry 0.81 (0.53-1.25) 0.67 (0.22-2.03)
 Coagulation 0.78 (0.49-1.25) 0.30 (0.08-1.07)
  Liver function test 0.75 (0.53-1.21) 2.34 (0.83-6.62)
Overall cohort (abnormal vs normal)
 Hematology 1.06 (0.67-1.66) 1.05 (0.79-8.49)
 Chemistry 1.03 (0.58-1.83) 2.05 (0.60-6.93)
 Coagulation 1.12 (0.32-3.86) 1.34 (0.25-7.36)
  Liver function test 0.95 (0.50-1.81) 1.29 (0.48-3.47)
CI, confidence interval; OR, odds ratio.
1.5%, P = .0001). It is likely that these patients were not
admitted secondary to their abnormal laboratory finding but
because of underlying comorbid conditions necessitating
further observation rather than immediate discharge.
Unfortunately, due to the nature of this data set, we are
unable to determine the reason or rationale for the admis-
sion. These findings show that laboratory testing was associ-
ated in some instances with rescheduling from outpatient to
inpatient, as reflected by a stay >24 hours. Testing was not
predictive of complications, nor was abnormal findings. This
finding has been confirmed by several other large stud-
ies.16,22,23 Additionally, in patients who underwent same-day
testing with abnormal findings, the surgery proceeded as
planned, further confirming the limited scope of clinical util-
ity of testing in low-risk ambulatory patients.
In the preoperative workup, a comprehensive history
and physical examination are paramount, with selective
laboratory tests helping to complete the picture of preop-
erative risk. The data suggest a role of selective, evidence-
based preoperative laboratory testing in an effort to
minimize risk of patient morbidity and to better reduce
cost and resource allocation.24 Although preoperative lab-
oratory tests may be perceived as a vehicle for assessing
overall fitness for anesthesia and surgery, this assumption
is likely not true in the low-risk ambulatory surgery
patient.11 As demonstrated in this study, the overuse of
testing is likely an inferior substitute for a comprehensive
history and physical examination in the low-risk ambula-
tory patient, further adding to the existing data on this
topic.7 Such overused, unnecessary testing is costly, incon-
venient, and of limited clinical utility.3,7
Several steps must occur before effecting change that
reaches beyond the scope of this study. First and foremost,
practitioners must recognize that laboratory testing is not
indicated in the vast majority of elective, ambulatory surgery
patients. However, this is only part of the solution. Looking
beyond the patient, practitioners often order laboratory tests
for a variety of reasons. Recent data suggest several com-
24-Hour Stay
monly cited reasons for obtaining a preoperative laboratory
workup: fear of litigation, risk for cancellation of case, prac-
tice tradition, lack of understanding of guidelines, and belief
1.08 (0.70-1.67)
that other practitioners also would want testing.2 Clearly,
1.16 (0.74-1.81) many of these reasons are not evidence based. A comprehen-
sive understanding of the reasons for obtaining testing is
1.65 (1.15-2.38) needed to optimally effect change and conformance with
evidence-based practices. As this occurs, strategies that
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1.35 (0.92-1.99)
incorporate evidence-based decision making and include
interdisciplinary collaboration with anesthesiologists and
primary care physicians may be an opportunity to improve
1.45 (1.11-2.17)
care and cut costs with appropriate preoperative workup and
1.09 (0.65-1.81) laboratory utilization.23,25,26
This study is not without limitations. First, the ACS-
1.77 (0.78-4.03) NSQIP includes only 30-day outcomes and thus may not
1.63 (1.01-2.63)
capture the true picture of postoperative complications or
long-term outcomes. Additionally, this study suffers from
a significant selection bias, as patients who underwent
testing had a higher rate of comorbidities. The greatest
limitation of this study is that it lacks the ability to deter-
mine the thought process or rationale for testing. Clinical
evaluation of a patient and the gestalt of performance
status may represent a variable that cannot be captured
and may be used in the experienced clinicians’ decision
tree. Furthermore, the occurrence of an intraoperative
complication cannot be directly assessed from this data
set, which further limits the clinical utility of the out-
comes. Also, the lack of direct cost data or individual
institutional criteria for defining a laboratory abnormality
may somewhat limit the generalizability of these data.
Finally, there is a strong selection bias for hospital-based,
reconstructive procedures using the NSQIP data sets, and
for this reason, these data may not directly translate into
practice for the ambulatory, outpatient surgery center
patient. It is worth noting, however, that these data in
relatively more complex patients undergoing a reconstruc-
tive procedure show limited predictive value for preopera-
tive testing; thus, in lower risk ambulatory patients, there
would likely be even less benefit derived from testing.
Overall, this large population-based assessment of pre-
operative laboratory use patterns in low-risk ambulatory
plastic surgery patients highlights the overuse of testing
and its clinical inefficiency as a reliable indicator of perio-
perative morbidity. These data can be used to effect
change in practice patterns of laboratory testing with the
ultimate goal of improving patient care, experience, and
minimizing extraneous costs.
Conclusions
This study highlights the overuse of preoperative laboratory
testing and the inability of either preoperative laboratory test-
ing or abnormal values to be of significant predictive value
Fischer et al 141
with regard to postoperative morbidity. The inefficient use of
preoperative laboratory testing in low-risk ambulatory
patients represents a potential area for evidence-based inter-
ventions to reduce costs. Interestingly, testing and abnormal
findings were associated with >24-hour stays. In conclusion,
in low-risk ambulatory plastic surgery patients, preoperative
laboratory testing is costly, associated with limited clinical
benefit, and may be eliminated with significant cost savings.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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