The appropriateness of preoperative blood testing: A retrospective evaluation and cost analysis

Background. Inappropriate preoperative blood testing can negatively contribute to healthcare costs.Objective. To determine the extent and cost implications of inappropriate preoperative blood testing in adult patients booked for orthopaedic, general or trauma surgical procedures at a regional hospital in KwaZulu-Natal Province, South Africa (SA).Methods. We undertook a retrospective observational study using routine clinical data collected from eligible patient charts. The appropriateness of preoperative blood tests was evaluated against locally published guidelines on testing for elective and non-elective surgery. The cost of the relevant blood tests was determined using the National Health Laboratory Service 2014 State Pricing List.Results. A total of 320 eligible patient charts were reviewed over a 4-week period. Preoperative blood testing was performed in 318 patients. There was poor compliance with current departmental guidelines, with an estimated over-expenditure of ZAR81 019. Non-compliance was particularly prevalent in younger patients, patients graded as American Society of Anesthesiologists 1 and 2, and low-risk surgery groups.Conclusion. Inappropriate preoperative blood testing is common in our hospital, particularly in low-risk patients. This is associated with an increase in healthcare costs, and highlights the need for SA doctors to become more cost-conscious in their approach to blood testing practices

The Development of a Scoring Tool for the Measurement of Performance in Managing Hypotension and Intra-Operative Cardiac Arrest during Spinal Anaesthesia for Caesarean Section

Background: At level one hospitals in South Africa a high annual number of maternal deaths occur due to the unrecognised/ untreated complications of spinal anaesthesia. The authors developed a clinical scenario and scoring system to measure intern performance in managing hypotension and cardiac arrest during spinal anaesthesia for caesarean section on a human patient simulator. This system was then subjected to tests of validity and reliability.Methods: The simulator-based clinical scenario was developed by two specialist anaesthesiologists. A modified Delphi technique was used to achieve consensus among 10 anaesthetic specialists regarding a standardised scoring system. A total of 20 medical officers with a Diploma in Anaesthesiology and 20 interns completed the scenario and were scored by two senior anaesthesiologists.Results: Medical officers scored an average of 252 and 246 points, whereas interns scored an average of 216 and 215 points (p = 0.005 and p = 0.013, respectively). The scoring instrument demonstrated high inter-assessor reliability with an intra-class correlation coefficient of 0.983.Conclusions: The scoring tool was shown to be valid and reliable. It offers a standardised assessment process and may be used to refine institutional intern training programmes, with a view to improving anaesthesia skills in community service medical officers.Keywords: Anaesthesia Spinal, Caesarean Section, Internship, Residency, Simulation, Simulato

Taking an idea to a research protocol

We present a nine-step process to assist with developing an idea into a research protocol. This process ensures that evidence-based medicine practice is followed to prevent redundant research questions. The first step is to identify broad research ideas with a potentially “weak” evidence base, rather than starting with a specific research question. The second step is to identify the knowledge gap within the intended field of research by examining the background literature. Thirdly, the focus will be on the “foreground knowledge” needed to frame a potential research question. The fourth step uses this potential research question to conduct a comprehensive literature research, and aims to determine whether or not the question has been asked before. The fifth step entails writing a study one-page summary which provides a succinct summary of what is intended. The sixth step involves writing the protocol. The rigid process of protocol writing will ensure that a number of important practical study issues are dealt with timeously. The seventh step is to discuss the protocol with experts. Their input will make the protocol more robust. The eighth step necessitates making a “social contract” that requires public commitment to the project. The final step is to write a grant application for the study. This serves to allow the researcher to identify the funding priorities of potential grant-funding agencies, thereby allowing the researcher to frame his or her research in such a manner that the financial support necessary for the success of the project will hopefully be ensured.Keywords: research; anaesthesia; protoco

The appropriateness of preoperative blood testing: A retrospective evaluation and cost analysis

Background. Inappropriate preoperative blood testing can negatively contribute to healthcare costs.Objective. To determine the extent and cost implications of inappropriate preoperative blood testing in adult patients booked for orthopaedic, general or trauma surgical procedures at a regional hospital in KwaZulu-Natal Province, South Africa (SA).Methods. We undertook a retrospective observational study using routine clinical data collected from eligible patient charts. The appropriateness of preoperative blood tests was evaluated against locally published guidelines on testing for elective and non-elective surgery. The cost of the relevant blood tests was determined using the National Health Laboratory Service 2014 State Pricing List.Results. A total of 320 eligible patient charts were reviewed over a 4-week period. Preoperative blood testing was performed in 318 patients. There was poor compliance with current departmental guidelines, with an estimated over-expenditure of ZAR81 019. Non-compliance was particularly prevalent in younger patients, patients graded as American Society of Anesthesiologists 1 and 2, and low-risk surgery groups.Conclusion. Inappropriate preoperative blood testing is common in our hospital, particularly in low-risk patients. This is associated with an increase in healthcare costs, and highlights the need for SA doctors to become more cost-conscious in their approach to blood testing practices

Bibliometrics to assess the productivity and impact of medical research

Background: Bibliometrics is the use of statistical and mathematical analysis to assess research production and quality. These metrics provide important insights into the quality and impact of research by applying standardised metrics. However, there are inherent limitations in their application. Objective: We aimed to review existing bibliometric indices and assess their comparative utility in the assessment of medical researchers. We specifically aimed to evaluate the utility of the h-index in identifying young or developing medical researchers with future research potential. Method: We conducted a focussed literature review on commonly used bibliometrics. To explore the utility of these metrics we then used them to evaluate a sample of researchers from a South African medical school faculty. Researchers were ranked with the following metrics: number of publications; h-index; citations per paper; citations per paper per year; and m-index. The h-index, citations and publication counts were drawn from ResearchGate and, if not available, from Google Scholar. The top 20 researchers, based on publication count, were then analysed further. Results: We identified 145 researchers for analysis of which 37 were excluded due to an inability to obtain additional information. Higher time-dependent metrics (publication count, citation count, h-index) were directly proportional to years since first publication. Indices that corrected for time, such as the m-index, provided more insight and better discrimination in identifying younger researchers with greater research potential. Conclusion: Bibliometrics have utility as part of the assessment of academic output but may be subject to time-dependent bias. Research quality is best measured using the h-index, g-index and m-index. The h-index is limited by being time dependent and field specific and overlooks highly cited papers. Bibliometrics that account for time, such as the m-index, should be considered in the early identification of young researchers, ideally accompanied by critical peer review

Postoperative atrial fibrillation in patients on statins undergoing isolated cardiac valve surgery: a meta-analysis

Introduction: The efficacy of perioperative statin therapy in decreasing postoperative morbidity in patients undergoing valve replacements and repairs is unknown. The aim of our study was to determine whether or not the literature supports the hypothesis that statins decrease postoperative atrial fibrillation (AF), and hence improve short-term postoperative outcomes in patients undergoing isolated cardiac valve surgery.Method: We conducted a meta-analysis of studies on postoperative outcomes associated with statin therapy following isolated valve replacement or repair. The data was taken from published studies on valvular heart surgery patients. Participants were patients who underwent either isolated cardiac valve replacement or repair. Patients in the intervention group received statins prior to their surgery. Three databases were searched: Ovid Healthstar, 1966 to April 2012; Ovid Medline, 1946 to 31 May 2012; and Embase, 1974 to 30 May 2012. The meta-analysis was conducted using Review Manager® version 5.1.Results: Statins did not decrease the incidence of postoperative AF in patients undergoing isolated cardiac valve surgery [odds ratio (OR) 1.19, 95% confidence interval (CI): 0.80– 1.77)], although there was significant heterogeneity for the outcome of postoperative AF (I2 55%, 95% CI: 27–72). Statins were associated with a decrease in 30-day mortality (OR 0.43, 95% CI: 0.24–0.75).Conclusion: Although this meta-analysis suggests that chronic statin therapy did not prevent postoperative AF in unselected valvular heart surgical patients, the heterogeneity indicates that this outcome should be viewed with caution and further research is recommended.Keywords: atrial fibrillation, cardiac surgery, statin

Obstetric spinal hypotension: Preoperative risk factors and the development of a preliminary risk score – the PRAM score

Background. Obstetric spinal hypotension is a common and important problem during caesarean delivery. Identifying patients at risk for hypotension may guide clinical decision-making and allow timeous referral.Objective. Using preoperative risk factors, to develop a simple scoring system to predict systolic hypotension.Methods. This prospective, single-centre, observational study of patients undergoing elective or urgent caesarean delivery assessed body mass index, baseline heart rate, baseline mean arterial pressure (MAP), maternal age, urgency of surgery (elective v. non-elective) and preoperative haemoglobin concentration as predictors of spinal hypotension (systolic blood pressure <90 mmHg). We used empirical cut-point estimations in a logistic regression model to develop a scoring system for prediction of hypotension.Results. From 504 eligible patients, preoperative heart rate (odds ratio (OR) 1.02, 95% confidence interval (CI) 1.00 - 1.03; p=0.012), preoperative MAP (OR 0.97, 95% CI 0.95 - 0.98; p<0.001) and maternal age (OR 1.05, 95% CI 1.02 - 1.08; p=0.002) were found to be predictors of hypotension. We derived a preliminary scoring system (pulse rate >90 bpm, age >25 years, MAP <90 mmHg – the PRAM score) for the prediction of systolic hypotension following obstetric spinal anaesthesia. Patients with three factors had a 53% chance of developing hypotension, compared with the overall incidence of 30%. The PRAM score showed good discrimination, with a c-statistic of 0.626 (95% CI 0.576 - 0.676) and good calibration.Conclusions. Preoperative heart rate, preoperative MAP and maternal age were predictive of hypotension in elective and emergency caesarean delivery. The PRAM score shows promise as a simple, practical means to identify these patients preoperatively, but requires prospective validation.

A prospective observational study of preoperative natriuretic peptide testing in adult non-cardiac surgical patients in hospitals in Western Cape Province, South Africa

Background. International guidelines recommend risk stratification to identify high-risk non-cardiac surgical patients. It is also recommended that all patients aged ≥45 years with significant cardiovascular disease should have preoperative natriuretic peptide (NP) testing. Abnormal preoperative B-type NPs have a strong association with postoperative cardiac complications. In South African hospitals, it is not known how many patients with significant cardiovascular disease scheduled for intermediate- to high-risk surgery will have raised NPs.Objectives. To determine the prevalence of abnormal (raised) NPs in non-cardiac surgical patients with cardiac clinical risk factors. A secondary objective was to develop a model to identify surgical patients who may benefit from preoperative NP screening.Methods. The inclusion criteria were patients aged ≥45 years presenting for elective, non-obstetric, intermediate- to high-risk non-cardiac surgery with at least one of the following cardiovascular risk factors: a history of ischaemic heart disease or peripheral vascular disease (coronary equivalent); a history of stroke or transient ischaemic attack; a history of congestive cardiac failure; diabetes mellitus currently on an oral hypoglycaemic agent or insulin; and serum creatinine level >175 µmol/L (>2.0 mg/dL). Blood samples for N-terminal-prohormone B-type NP (NT-proBNP) were collected before induction of anaesthesia. The preoperative prognostic threshold for abnormal (raised) NT-proBNP was ≥300 pg/mL. A generalised linear mixed model was used to determine the association between the risk factors and an abnormal NT-proBNP level.Results. Of 172 patients, 63 (37%) had an elevated preoperative NT-proBNP level. The comorbidities independently associated with elevated preoperative NT-proBNP were coronary artery disease or peripheral vascular disease, congestive cardiac failure, diabetes mellitus, and a creatinine level >175 µmol/L.Conclusions. We strongly recommend that non-cardiac surgical patients aged ≥45 years undergoing intermediate- or high-risk non-cardiac surgery with a history of coronary artery disease/peripheral vascular disease, congestive cardiac failure, diabetes mellitus or elevated creatinine have preoperative NP testing as part of risk stratification