Low-value preoperative cardiac testing before low-risk surgical procedures: a population-based cohort study

Siavash Zare-Zadeh; Braden J. Manns; Derek S. Chew; Tyrone G. Harrison; Flora Au; Amity E. Quinn

doi:10.9778/cmajo.20220049

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Figure 1:
Flow diagram showing patient selection. Note: RCRI = Revised Cardiac Risk Index.
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Figure 2:
Unadjusted annual number of preoperative noninvasive cardiac tests per 100 operations in the 6 months before surgery, 2011/12–2018/19. Note: ECG = electrocardiography, Echo = echocardiography, EST = exercise stress testing, MPI = myocardial perfusion imaging.
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Figure 3:
Adjusted incidence rate ratio (IRR) (log scale) of noninvasive cardiac testing with characteristics at the patient and temporal level. Reference groups include year 2011/12, age less than 40 years, male sex and urban zone 1. Error bars represent 95% confidence intervals. Note: ECG = electrocardiography.
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Figure 4:
Unadjusted rates of noninvasive cardiac testing by patient and geographic characteristics. Error bars represent 95% confidence intervals. Note: ECG = electrocardiography, Echo = echocardiography, EST = exercise stress testing, MPI = myocardial perfusion imaging.

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Table 1:

Patient and surgical characteristics of adult Albertans at low risk who underwent elective noncardiac surgery between 2011/12 and 2018/19, by preoperative noninvasive cardiac tests within 6 months of the index procedure

Characteristic	No. (%) of patients/operations^*
Characteristic	Overall	Advanced tests only^†	Electrocardiography only	No test
Patients
No. of patients	798 599	21 787	118 923	657 889
Age, mean ± SD, yr	47.9 ± 17.0	58.7 ± 15.3	57.7 ± 14.5	45.8 ± 16.8
Age category, yr
< 40	293 926 (36.8)	2885 (13.2)	14 785 (12.4)	276 256 (42.0)
40–49	144 349 (18.1)	2925 (13.4)	17 699 (14.9)	123 725 (18.8)
50–59	151 177 (18.9)	4987 (22.9)	31 346 (26.4)	114 844 (17.5)
60–69	115 147 (14.2)	5508 (25.3)	31 123 (26.2)	78 516 (11.9)
≥ 70	90 931 (11.4)	5412 (24.8)	23 824 (20.0)	61 695 (9.4)
Missing	3069 (0.4)	70 (0.3)	146 (0.1)	2853 (0.4)
Sex
Female	427 891 (53.6)	12 761 (58.6)	66 358 (55.8)	348 772 (53.0)
Male	367 639 (46.0)	8956 (41.1)	52 419 (44.1)	306 264 (46.6)
Missing	3069 (0.4)	70 (0.3)	146 (0.1)	2853 (0.4)
Income quintile
1st (lowest)	170 481 (21.4)	4701 (21.6)	23 696 (19.9)	142 084 (21.6)
2nd	167 606 (21.0)	4553 (20.9)	25 340 (21.3)	137 713 (20.9)
3rd	153 408 (19.2)	4149 (19.0)	22 471 (18.9)	126 788 (19.3)
4th	146 729 (18.4)	3923 (18.0)	21 962 (18.5)	120 884 (18.4)
5th (highest)	147 012 (18.4)	4140 (19.0)	24 243 (20.4)	118 629 (18.0)
Missing	13 362 (1.6)	321 (1.5)	1211 (1.0)	11 831 (1.8)
Location
Urban	673 992 (84.4)	19 057 (87.5)	110 082 (92.6)	544 854 (82.8)
Rural	119 038 (14.9)	2595 (11.9)	8407 (7.1)	108 036 (16.4)
Missing	5568 (0.7)	135 (0.6)	434 (0.4)	4999 (0.8)
No. of elective noncardiac operations
1	610 625 (76.5)	11 701 (53.7)	73 524 (61.8)	525 400 (79.9)
2	142 935 (17.9)	6521 (29.9)	31 867 (26.8)	104 556 (15.9)
≥ 3	45 039 (5.6)	3574 (16.4)	13 532 (11.4)	27 933 (4.3)
No. of comorbidities^‡
0	349 326 (43.7)	4447 (20.4)	31 763 (26.7)	313 116 (47.6)
1	222 765 (27.9)	6220 (28.6)	37 176 (31.3)	179 369 (27.3)
2	127 074 (15.9)	5377 (24.7)	27 191 (22.9)	94 506 (14.4)
≥ 3	85 200 (10.7)	4783 (22.0)	19 651 (16.5)	60 766 (9.2)
≥ 5	14 234 (1.8)	960 (4.4)	3142 (2.6)	10 132 (1.5)
Surgery	1 045 896	22 297	133 177	890 422
Surgery type
Musculoskeletal	266 454 (25.5)	6470 (29.0)	51 323 (38.5)	208 661 (23.4)
Ophthalmologic	156 233 (14.9)	4366 (19.6)	26 788 (20.1)	125 079 (14.0)
Head and neck	84 946 (8.1)	1544 (6.9)	11 053 (8.3)	72 349 (8.1)
Skin and soft tissue	217 134 (20.8)	2810 (12.6)	11 882 (8.9)	202 442 (22.7)
Thoracic	4498 (0.4)	312 (1.4)	529 (0.4)	3657 (0.4)
Other^§	316 631 (30.3)	6795 (30.5)	31 602 (26.6)	278 234 (31.2)

Note: SD = standard deviation.
↵* Except where noted otherwise.
↵† Echocardiography, exercise stress testing and myocardial perfusion imaging.
↵‡ Alcohol use disorder, asthma, atrial fibrillation, lymphoma, metastatic cancer, nonmetastatic cancer, heart failure, gout, pain, chronic obstructive pulmonary disease, hepatitis B, cirrhosis, dementia, depression, diabetes, epilepsy, hypertension, hyperthyroidism, inflammatory bowel disease, irritable bowel syndrome, multiple sclerosis, myocardial infarction, Parkinson disease, peptic ulcer disease, peripheral vascular disease, psoriasis, arthritis, schizophrenia, constipation and stroke.
↵§ Intra-abdominal, lower urologic/gynecologic, vascular, breast, neurologic, retroperitoneal and anorectal.