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Factors affecting adherence to recommendations on pre-operative cardiac testing: A cohort study
Alexandra Stroda1, Tanja Sulot, Sebastian Roth
1From the Department of Anaesthesiology, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany (AS, TS, SR, RM, GLB), Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland (EM), Department of Anaesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania (DI), Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland (WS), Department of Anaesthesiology and Peri-operative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Division of Anaesthesiology, Intensive Care, Rescue and Pain Medicine, Kantonsspital St. Gallen, St. Gallen (MF), Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland (BBS), Department of translational medicine, University of Ferrara, Ferrara, Italy (SS), Department of Anaesthesia, Hospital Clinic of Barcelona, Universidad de Barcelona, Spain (PM), Department of Anaesthesiology and ICU, Ankara University Medical School, Ankara, Turkey (SCT), Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands (JvW), Department of Anaesthesiology, Hospital Beatriz Ângelo, Loures, Portugal (FL), Aretaieion University Hospital National and Kapodistrian University of Athens, Athens, Greece (KT), Department of Peri-operative Medicine and Intensive Care, Karolinska Hospital and Institution for Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden (AG), Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany (H-JG), Anaesthesia and Intensive Care Department, University Hospital, Varese, Italy (LG), Department of Anaesthesiology, Intensive Care and Pain Management, Pomeranian Medical University, Szczecin, Poland (KK), Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany (JL), Anaesthesia and Intensive Care Department III, Carol Davila University of Medicine and Pharmacy Bucharest, Central Military Emergency University Hospital 'Dr Carol Davila', Bucharest, Romania (DC), Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom (SJH), and CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Germany (GLB, AS, SR, RM).
Background:
Cardiac risk evaluation prior to noncardiac surgery is fundamental to tailor peri-operative management to patient's estimated risk. Data on the degree of adherence to guidelines in patients at cardiovascular risk in Europe and factors influencing adherence are underexplored.
Objectives:
The aim of this analysis was to describe the degree of adherence to [2014 European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines] recommendations on rest echocardiography [transthoracic echocardiography (TTE)] and to stress imaging prior to noncardiac surgery in a large European sample and to assess factors potentially affecting adherence.
Design:
Secondary analysis of a multicentre, international, prospective cohort study (MET-REPAIR).
Setting:
Twenty-five European centres of all levels of care that enrolled patients between 2017 and 2020.
Patients:
With elevated cardiovascular risk undergoing in-hospital elective, noncardiac surgery.
Main Outcome Measures:
(Non)adherence to each pre-operative TTE and stress imaging recommendations classified as guideline-adherent, overuse and underuse. We performed descriptive analysis. To explore the impact of patients' sex, age, geographical region, and hospital teaching status, we conducted multivariate multinominal regression analysis.
Results:
Out of 15 983 patients, 15 529 were analysed (61% men, mean age 72 ± 8 years). Overuse (conduction in spite of class III) and underuse (nonconduction in spite of class I recommendation) for pre-operative TTE amounted to 16.6% (2542/15 344) and 6.6% (1015/15 344), respectively. Stress imaging overuse and underuse amounted to 1.7% (241/14 202) and 0.4% (52/14 202) respectively. Male sex, some age categories and some geographical regions were significantly associated with TTE overuse. Male sex and some regions were also associated with TTE underuse. Age and regions were associated with overuse of stress imaging. Male sex, age, and some regions were associated with stress imaging underuse.
Conclusion:
Adherence to pre-operative stress imaging recommendation was high. In contrast, adherence to TTE recommendations was moderate. Both patients' and geographical factors affected adherence to joint ESC/ESA guidelines.
Trial Registration:
NCT03016936.
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