Peoperative testing often unnecessary for low-risk surgeries: JAMA

Yet plenty of evidence suggests that preoperative testing is often unnecessary for low-risk surgeries.

At best, it's costly and doesn't usually improve outcomes for patients. At worst, it can lead to more invasive testing and delay surgery, which can create complications that could have been avoided if the tests weren't done.

"There aren't that many areas in medicine where the data is pretty definitive that something is low-value," says Lesly Dossett, M.D., the division chief of surgical oncology at Michigan Medicine and the co-director of MPrOVE, "but preoperative testing before low-risk surgeries is certainly one of them."

Professional organizations ranging from the American College of Surgeons and the Society of General Internal Medicine to the American Society of Anesthesiologists have identified routine preoperative testing as a low-value type of care that should be reduced whenever possible.

In 2012, the American Board of Internal Medicine Foundation even launched an initiative called the Choosing Wisely campaign that promotes conversations between health care providers and patients about unnecessary medical tests and procedures.

But, almost a decade later, preoperative tests continue to be ordered.

Of about 40,000 patients in the U-M study who had surgery to either remove the gall bladder, repair a groin hernia, or remove cancerous breast tissue, close to a third underwent two or more tests beforehand, and about 13% had three or more.

The most common tests were a complete blood count, an electrocardiogram and a basic metabolic panel, all of which aren't inherently necessary before these surgeries.

"It's one thing to say that this is well recognized in the literature," says Hari Nathan, M.D., Ph.D., who happens to be the division chief of hepato-pancreato-biliary surgery at Michigan Medicine as well as the director of the MVC, "but it's a different thing to put it in the hands of the clinicians who are at the bedside in an easy-to-read, easy-to-understand and convenient-to-carry-around format."

Patients who had a complete medical history and physical done during a visit that was separately billed were more likely to have had preoperative testing as were those who were older or had more than one medical condition.

"I could see those two latter factors being in the background, hypothetically giving some pressure to do more testing," says Nicholas Berlin, M.D., M.P.H., a plastic surgery resident at Michigan Medicine and the first author of the study. "That's not to suggest there's an age threshold or a comorbidity that requires preoperative testing every single time. There's not."

A small number of people who fall into these categories may actually benefit from having these tests done, although it's difficult to know exactly how many based on this data, the researchers say. Yet, when they adjusted their model to account for that issue, they still found the overuse of testing.

The data also revealed wide variations in testing, not only between the 63 hospitals studied but also within health systems for the same procedures, pointing to the need for more research to drill down further into the origins of the problem.

"We have more work to do on our end to figure out what's driving these differences within and between hospitals," says Berlin, who's also a National Clinician Scholar at the University of Michigan Institute for Healthcare Policy and Innovation. "This is signaling to other projects in the future between MPrOVE and statewide quality collaboratives that use more of an on-the-ground approach."