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Implementation of evidence-based presurgical testing guidelines for endometrial cancer patients in the ambulatory setting is both safe and cost-effective, a study showed.

The overuse of preoperative testing has been described in several single-institution studies in the low-risk ambulatory setting. In a recent study, Ginger Gardner, MD, and colleagues at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City developed evidence-based presurgical testing guidelines. A multidisciplinary team from gynecologic oncology, anesthesiology, perioperative nursing, hospital operations, and operations analytics was assembled to review the available literature and establish oncology-specific presurgical testing guidelines.

The analysis compared all patients with a diagnosis of endometrial pathology who underwent ambulatory surgery before the guidelines were implemented (July 2014-Dec. 2015) to after guidelines implementation (July 2016-Dec. 2017). The team then compared the rates of completed presurgical tests and perioperative adverse events between the time periods. Cost savings related to the reduction in presurgical testing were calculated using the direct cost of testing and reported in percentage cost reduction.

The following Q&A discusses the details of the study, published in . (The researchers did not respond to requests for comment, and the answers here are from the text of the report.)

What does the study add to the literature?

Surgical resection with staging is the cornerstone of management of newly diagnosed endometrial cancer, typically including hysterectomy. At many institutions, the standard of care is a minimally invasive approach, which allows for treatment in the ambulatory surgical setting.

The incidence of endometrial cancer is increasing, creating an opportunity for careful consideration of preoperative testing with the potential of large cost savings. The aim of the study was to evaluate the safety and cost savings of implementing presurgical testing guidelines for patients undergoing hysterectomy for endometrial cancer at a comprehensive cancer center.

A total of 749 hysterectomies were completed in the period before implementation of the guidelines and 775 hysterectomies in the period after. After implementation of presurgical treatment guidelines, complete blood counts, coagulation testing, comprehensive metabolic panels, chest x-rays, and electrocardiograms were all significantly reduced, by 13.4%, 78.1%, 36.8%, 39%, and 15.5%, respectively.

The rates of perioperative cardiopulmonary adverse events (0% vs 0%) and hematologic adverse events (3.3% vs 2%) were stable between the time periods.

Our study focused on an intermediate-risk procedure, and there were no deaths or cardiopulmonary adverse events in either time period within 90 days of surgery. There was a 41.4% reduction in direct costs related to presurgical testing in the period after implementation of the guidelines.

What is the typical surgical management of early-stage endometrial cancer?

The standard of care for surgical management of early-stage endometrial cancer includes minimally invasive hysterectomy with staging. All patients undergoing surgery at MSKCC are assessed by an advanced practice provider specialized in preoperative evaluation. For appropriate patients, surgery can be performed at an ambulatory surgical center, typically representing a lower-risk population.

Before the intervention, presurgical testing for hysterectomy was the same for patients who underwent ambulatory surgery and those requiring a higher level of care. This presented an opportunity for quality improvement through evidence-based reduction of presurgical testing in the lower-risk ambulatory population.

Why is presurgical testing controversial?

Standardized guidelines for presurgical testing and clearance are available in the literature, but evidence consistently suggests that the majority of preoperative testing is unnecessary. As of 2012, the was $3 billion to $18 billion U.S. dollars annually. Excessive presurgical testing causes increased patient anxiety and may lead to nonspecific findings requiring additional patient visits and work-up.

How may your guidelines serve as a template for expanded use in other areas of health care?

First, a team approach with multidisciplinary expertise was essential for guideline development and implementation. By including all parties involved in the preoperative and postoperative workflow, we were able to anticipate potential problems and have leaders within each group to champion the initiative.

Second, to promote standardization and ease of use for providers, we created a single document that stratified procedures on the basis of risk. To accomplish this, we reviewed common patient risk modifiers and anesthesia-specific modifiers associated with presurgical tests, as well as how close to surgery the tests were needed.

Third, the broad dissemination of the guidelines across the gynecologic surgery service allowed for standardization of practice.

What is the main message for practicing oncologists?

We believe that the use of streamlined evidence-based testing guidelines is feasible and crucial, as quality metrics and alternative payment models have become central to the current landscape for healthcare policy and reimbursement.

Read the study here.