Executive Summary
Providers continue to order several preoperative tests, even though professional physician associations say certain routine tests are high cost and offer low value.
- The tests rarely improve patient management, according to the study’s senior investigator.
- Protocols Are Critical. (Editor’s Note: One Is Included With The Online Issue.)
New study: They aren’t following guidance from their professional groups
By Joy Daughtery Dickinson
Routine preoperative testing before elective surgery can cause anxiety for patients, delays or cancellations of procedures, expenses, and even potential harm when the results are false-negative or false-positive, says Girish P. Joshi, MBBS, MD, FFARCSI, professor of anesthesiology and pain management, University of Texas Southwestern Medical Center, Dallas.
However, several of those tests still are being ordered, despite the fact that professional physician associations consider certain routine tests to be of low value and high cost, and they’ve tried to discourage their use, according to new research from NYU Langone Medical Center in New York City, published June 8, 2015, in JAMA Internal Medicine. The study is believed to be the first to look at the long-term national effect of specific professional guidelines across a range of tests and surgery types. Guidance has been issued by the American Society of Anesthesiologists (ASA) and the American College of Cardiologists/American Heart Association (ACC/AHA). (To see the abstract for doi:10.1001/jamainternmed.2015.2081, go to http://bit.ly/1IqD1nb. For a copy of the ASA guidance, go to http://bit.ly/1I2RM1n. For a copy of the ACC/AHA guidance, go to http://bit.ly/1ev5YF2)
“Our findings suggest that professional guidance aimed at improving quality and reducing waste has had little effect on physician or hospital practice,” says Alana E. Sigmund, MD, the lead investigator and an assistant professor in the Department of Medicine at NYU Langone.
The researchers saw no significant decline in use of the following routine tests before elective surgery:
- plain radiography;
- hematocrit;
- urinalysis;
- cardiac stress testing.
The researchers did see a decline in pre-surgical electrocardiograms (ECGs). (See details of the study included in this issue.) Joshi said, “It is possible that the strict requirements by CMS [the Centers for Medicare and Medicaid Services] and insurance companies for reimbursement for ECG may have reduced this test.”
The study’s senior investigator, Joseph Ladapo, MD, PhD, an assistant professor in the Department of Population Health at NYU Langone, said, “While it’s important to ensure patients can safely undergo surgical procedures, many of these procedures are low-risk, and the tests rarely improve patient management.”
The overall rates of routine testing declined across several categories over the 14-year period that was studied. However, after accounting for overall changes in physicians’ ordering practices, the declines were not statistically significant, the researchers say. They give several reasons. “Evidence suggests physicians are more likely to follow guidelines that add rather than eliminate a test or procedure,” Ladapo said.
Physicians interviewed by Same-Day Surgery agree. “This reflects other physician practices in which it is easier to intervene than ‘hold back,’” Joshi says.
Also agreeing is the president of the American Society of Anesthesiologists, J.P. Abenstein, MSEE, MD, associate professor of anesthesiology at Mayo College of Medicine, Rochester, MN. “Adding gives me more information,” Abenstein says. “Eliminating means I have less information. Who would be opposed to more information?”
Ladapo says physicians might not have been aware of the recommendations from national groups, or they might not have believed those recommendations applied to their patients.
Joshi agrees. Even those such as preoperative clinic physicians and surgeons “who are familiar with the guidelines order unnecessary tests with the concern that the anesthesiologist may postpone the surgical procedure due to lack of a certain test, and so it is easier to obtain ALL tests,” he says.
Ladapo also says that reimbursement practices might have had an impact, but that belief is dismissed by Abenstein. “I disagree, in the context of physician anesthesiologists,” he says. “We don’t have an economic self-interest in ordering an additional test.”
Fear of liability might be a different story, he says. “There may be some incentive related to litigation, e.g., ‘if I order a test, and if something goes wrong, this might protect me,’ but no direct reimbursement issues,” Abenstein says.
Details of Study
The study from NYU Langone Medical Center in New York City, published June 8, 2015, in JAMA Internal Medicine, looked at whether two sets of guidelines released concurrently, in 2002, by the American College of Cardiology/American Heart Association and the American Society of Anesthesiologists, led to changes in preoperative testing patterns. Both organizations made their recommendations about appropriate testing and treatment strategies to discourage preoperative tests ordered “in absence of a specific clinical indication or purpose.” The NYU Langone researchers analyzed national data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1997 through 2010. These two surveys, conducted annually by the Centers for Disease Control and Prevention and the National Center for Health Statistics, examine preoperative visits at office-based physician practices, hospital-based outpatient clinics, and emergency departments in the United States.
The researchers acknowledge that the study was somewhat limited in that it was not able to adjust for surgery type or identify patients who were referred for high-risk surgery. However, they found that the distribution of high-risk surgical procedures after the guideline recommendations saw little change.
Joshi agrees that physicians are concerned about their liability. “I believe that the most important reason for anesthesiologists to continue ordering unnecessary tests is fear of litigation and a concern that they may miss something that may come to haunt them just in case things went sour,” he says.
So what can be done? First, we must determine who is ordering unnecessary preop tests, Joshi says. “The problem is that most studies, including this one, are limited, as they do not provide the information that is critical, that is, who — i.e., anesthesiologists, surgeons, or internal medicine/primary care physicians — is ordering the preoperative tests,” he says.
The change should start at training, Ladapo says. “Routine preoperative testing is part of the culture of many residency training programs, and shifting toward medically appropriate testing while physicians are still in training may be one way to break the cycle,” he says.
Protocols are critical, sources say.
Joshi says, “Several anesthesiology practices use a table to standardize the approach to preoperative testing and avoid unnecessary testing.” [Click here to see the table that Joshi uses.]
Such tables are developed from research, as well as recommendations of the ASA and the National Institute for Health and Care Excellence, London, England (http://www.nice.org.uk/Guidance/CG3).
The problem with routine preoperative testing extends beyond elective surgery, Joshi says. “Although this was a study in ambulatory surgical population, the problems are even worse in hospitalized patients,” he says. “It is my observation that in the [public] hospital I practice, there is significant emphasis on reducing unnecessary tests, and we have protocols in place for over a decade” that guide anesthesiologists and surgeons.
Future healthcare changes might resolve the issue, Joshi says. “I am hopeful that once the perioperative services payments are ‘bundled’ and physicians/hospitals receive a fixed amount for a certain surgical procedure, and we have tort reform to prevent frivolous litigation, practices will changes,” he says.
Joshi also points to the growing popularity of having a “perioperative surgical home” for patients. In this process, the surgeon decides that the patient needs surgery, and the patient agrees. Then, “the rest of the care is transferred to the anesthesiologist, who would decide the need for tests, and referral to another specialist would prevent unnecessary testing and unnecessary referral,” Joshi says. “This should significantly reduce surgical-related healthcare costs.” (For more on this topic, see “Medicare patients undergo unnecessary tests before cataract surgery, study finds,” SDS, June 2015. Also see story in this issue about one type of preop testing that provides a modest reduction in surgical site infections.)
Routine preoperative testing before elective surgery can cause anxiety for patients, delays or cancellations of procedures, expenses, and even potential harm when the results are false-negative or false-positive, says Girish P. Joshi, MBBS, MD, FFARCSI, professor of anesthesiology and pain management, University of Texas Southwestern Medical Center, Dallas.
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