Evidence-Based Guideline Adherence to Recommended Preoperative Testing for Women Undergoing Hysterectomy for Uterine Leiomyoma
Authors: Vill Brittany , Chan Joanne , Oshogwemoh Ismail , Maurice Joseph 
Published: July 2024

Background: Previous literature demonstrates that inappropriate preoperative testing in gynecologic surgery can lead to major healthcare expenditures and delayed procedures.1-3 This study aims to investigate adherence to evidence-based preoperative testing recommendations for patients receiving a hysterectomy for uterine leiomyoma at Carle Foundation Hospital (CFH) in Urbana, Illinois. We reviewed chest x-ray (CXR), electrocardiogram (ECG), complete blood count (CBC), basic metabolic panel (BMP), complete metabolic panel (CMP), prothrombin time (PTT), and urinalysis (UA) studies performed three months prior to surgery for patients who received a hysterectomy at CFH from 2011 to 2020. Our aim is to evaluate the adherence to National Institute for Health and Clinical Excellence (NICE) guidelines, based on individual patient’s comorbidities.1 Our hypothesis is that CFH will benefit from review of guidelines to improve preoperative testing adherence and provide cost effective care.

Methods: Retrospective data of women who received a hysterectomy for uterine Leiomyoma at CFH from 2011 to 2020 was reviewed to evaluate adherence to the NICE criteria for the following preoperative tests: CXR, ECG, CBC, BMP, CMP, PTT, and UA. Preoperative tests were included if completed less than three months before the patient’s date of surgery. Past medical and surgical histories were collected to evaluate individual patient comorbidities. Patient comorbidities at time of surgery were utilized to label each preoperative test as indicated or not indicated. We performed logistic regressions to evaluate if age, race, procedure year, or hysterectomy type impacted the likelihood that preoperative tests were appropriately ordered.

Results: Our data demonstrated appropriate adherence to most NICE guidelines. For example, the NICE guidelines recommend that a CBC is indicated for any patient receiving a hysterectomy; 97.5% of patients received a CBC prior to their surgery. As a result of the risk stratification, a BMP was indicated for 183 patients in our sample, and 171 (93.4%) patients received the test. A preoperative ECG was indicated for 267 patients in our sample, yet, only 162 of the 267 patients (60.7%) received an ECG. The NICE preoperative testing guidelines did not recommend a preoperative UA as prior to hysterectomy, but 125 patients in our study (39.1%) received the test. Logistic regression evaluating preoperative UA was compared with hysterectomy type (total abdominal, laparoscopic, vaginal, or robotic). Robotic hysterectomy demonstrated a significantly lower incidence of UA as compared to abdominal 0.56 (95% confidence interval 0.34-0.91). Other procedure comparisons did not demonstrate any significant difference.

Conclusion: Our data demonstrate the need to reevaluate preoperative testing practices as CFH. While tests, such as CBC, BMP, and CMP had good adherence to national guidelines, others like ECG were underutilized. Finally, UA testing was frequently unnecessarily ordered. These variables, however, are moderated by physician practice and utilization of evidence-based preoperative testing guidelines by patient’s primary care providers or the CFH preoperative clinic. Review of evidence-based guidelines regarding preoperative testing is indicated. Continued investigation into evidence-based guideline adherence will provide CFH and other institutions with recommendations to provide appropriate preoperative testing and foster cost-effective care.