ABSTRACT
BACKGROUND: Significant heterogeneity exists in practice patterns and algorithms used for cardiac screening before kidney transplant. Cardiorespiratory fitness, as measured by peak oxygen uptake (VO2peak), is an established validated predictor of future cardiovascular morbidity and mortality in both healthy and diseased populations. The literature supports its use among asymptomatic patients in abrogating the need for further cardiac testing. METHODS AND RESULTS: We outlined a pre-renal transplant screening algorithm to incorporate VO2peak testing among a population of asymptomatic high-risk patients (with diabetes mellitus and/or >50 years of age). Only those with VO2peak <17 mL/kg per minute (equivalent to <5 metabolic equivalents) underwent further noninvasive cardiac screening tests. We conducted a retrospective study of the a priori dichotomization of the VO2peak <17 versus ≥17 mL/kg per minute to determine negative and positive predictive value of future cardiac events and all-cause mortality. We report a high (>90%) negative predictive value, indicating that VO2peak ≥17 mL/kg per minute is effective to rule out future cardiac events and all-cause mortality. However, lower VO2peak had low positive predictive value and should not be used as a reliable metric to predict future cardiac events and/or mortality. In addition, a simple mathematical calculation documented a cost savings of ≈$272 600 in the cardiac screening among our study cohort of 637 patients undergoing evaluation for kidney and/or pancreas transplant. CONCLUSIONS: We conclude that incorporating an objective measure of cardiorespiratory fitness with VO2peak is safe and allows for a cost savings in the cardiovascular screening protocol among higher-risk phenotype (with diabetes mellitus and >50 years of age) being evaluated for kidney transplant.
Subject(s)
Cardiorespiratory Fitness , Cardiovascular Diseases/diagnosis , Exercise Test , Kidney Failure, Chronic/surgery , Kidney Transplantation , Oxygen Consumption , Surgical Clearance/methods , Adult , Aged , Cardiovascular Diseases/physiopathology , Cost-Benefit Analysis , Exercise Test/economics , Female , Health Care Costs , Humans , Kidney Failure, Chronic/diagnosis , Kidney Failure, Chronic/physiopathology , Kidney Transplantation/adverse effects , Male , Middle Aged , Predictive Value of Tests , Retrospective Studies , Risk Assessment , Risk Factors , Surgical Clearance/economicsABSTRACT
INTRODUCCIÓN: Con el propósito de disminuir la variabilidad en la petición de pruebas preoperatorias y facilitar la toma de decisiones, nuestro centro ha establecido un protocolo de pruebas preoperatorias para pacientes ASA I y ASA II tratados mediante cirugía mayor ambulatoria (CMA). El objetivo del estudio fue calcular el impacto económico relacionado con la falta de adherencia de los profesionales al protocolo establecido. MÉTODOS: Estudio de costes retrospectivo con un muestreo aleatorizado simple de 353 pacientes atendidos en la consulta de anestesia durante un año. Se analizaron aspectos relacionados con los costes, así como el perfil de pacientes y especialidades según el grado de cumplimiento del protocolo establecido. RESULTADOS: La falta de adherencia al protocolo fue del 70%. Se realizaron 138 radiografías de tórax y 218 electrocardiogramas no indicados, lo que supuso un exceso de coste medio de 34 € por paciente. Teniendo en cuenta el coste de ambas pruebas y la población atendida en CMA durante el año evaluado, la falta de adherencia al protocolo supuso un exceso de coste anual para el centro entre 69.337 € y 84.727 €. CONCLUSIONES: Es preciso reducir la variabilidad clínica y favorecer la creación de sinergias entre los diferentes servicios para adecuar la petición de pruebas complementarias, disminuir los costos de la atención y mejorar la calidad asistencial
BACKGROUND: With the purpose of decreasing the existing variability in the criteria of preoperative evaluation and facilitating the clinical decision-making process, our hospital has a protocol of preoperative tests to use with ASA I and ASA II patients. The aim of the study was to calculate the economic impact caused by clinicians' non-adherence to the protocol for the anaesthesiological evaluation of ASA 1 and ASA II patients. METHODS: A retrospective study of costs with a random sample of 353 patients that were seen in the consultation for Anesthesiology over a period of one year. Aspects related to the costs, patient's profiles and specialties were analysed, according to the degree of fulfillment of the protocol. RESULTS: The lack of adherence to the the protocol was 70%. 130 chest X-rays and 218 ECG were performed without indication. This generated an excess costs of 34 € per patient. Taking into account the expenses of both tests and the attended population undergoing ambulatory surgery during the one-year period, an excess spending for the hospital of between 69.164 € and 83.312 € was estimated. CONCLUSIONS: Clinical variability should be reduced and the creation of synergies between the different departments should be enhanced in order to adjust the request for unnecessary complementary tests to decrease health care and to improve the quality of patient care
