Abstract
BackgroundA substantial fraction of all American healthcare expenditures are potentially wasted, and practices that are not evidence-based could contribute to such waste. We sought to characterize whether Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) tests of preoperative patients are used in a way unsupported by evidence and potentially wasteful.Methods and FindingsWe evaluated prospectively-collected patient data from 19 major teaching hospitals and 8 hospital-affiliated surgical centers in 7 states (Delaware, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania) and the District of Columbia. A total of 1,053,472 consecutive patients represented every patient admitted for elective surgery from 2009 to 2012 at all 27 settings. A subset of 682,049 patients (64.7%) had one or both tests done and history and physical (H&P) records available for analysis. Unnecessary tests for bleeding risk were defined as: PT tests done on patients with no history of abnormal bleeding, warfarin therapy, vitamin K-dependent clotting factor deficiency, or liver disease; or aPTT tests done on patients with no history of heparin treatment, hemophilia, lupus anticoagulant antibodies, or von Willebrand disease. We assessed the proportion of patients who received PT or aPTT tests who lacked evidence-based reasons for testing.ConclusionsThis study sought to bring the availability of big data together with applied comparative effectiveness research. Among preoperative patients, 26.2% received PT tests, and 94.3% of tests were unnecessary, given the absence of findings on H&P. Similarly, 23.3% of preoperative patients received aPTT tests, of which 99.9% were unnecessary. Among patients with no H&P findings suggestive of bleeding risk, 6.6% of PT tests and 7.1% of aPTT tests were either a false positive or a true positive (i.e. indicative of a previously-undiagnosed potential bleeding risk). Both PT and aPTT, designed as diagnostic tests, are apparently used as screening tests. Use of unnecessary screening tests raises concerns for the costs of such testing and the consequences of false positive results.
Highlights
Estimates suggest that 20% to 30% of total American healthcare expenditures may be unnecessary. [1,2,3,4] Over-diagnosis of disease has been described as a modern epidemic in high-income countries.[5]
26.2% received prothrombin time (PT) tests, and 94.3% of tests were unnecessary, given the absence of findings on history and physical (H&P)
Among the 682,049 H&Ps, we found 411,998 associated with PT and activated partial thromboplastin time (aPTT) tests (60.4%) (Fig 2)
Summary
Estimates suggest that 20% to 30% of total American healthcare expenditures may be unnecessary. [1,2,3,4] Over-diagnosis of disease has been described as a modern epidemic in high-income countries.[5]. There has been a focus on using objective evidence to combat over-diagnosis and over-treatment of disease.[7] This strategy is motivated by the need to contain medical costs as mandated by the Affordable Care Act; but, derives from a sense that there are human as well as economic costs to consider when allocating treatment.[8]. Factors that potentially could contribute to higher medical costs include practices that have persisted in medicine and surgery without objective validation of their efficacy. One such practice may be ordering a panel of pre-operative tests that include a prothrombin time (PT) test and/or an activated partial thromboplastin time (aPTT) test prior to surgery to determine whether bleeding is a potential surgical risk.[9,10,11]
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