Abstract
BackgroundDespite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery. Using a single-center retrospective cohort study, we aimed to quantify the incidence of un-indicated preoperative testing in an academic ambulatory center by utilizing recommendations by the recently developed American Society of Anesthesiology (ASA) “Choosing Wisely” Top-5 list.MethodsWe utilized data from the EPIC medical records of 3111 patients who had ambulatory surgery at the Hospital of the University of Pennsylvania during a 6-month period. Data were abstracted from laboratory studies— complete blood count, electrolyte panel, coagulation studies, and cardiac studies—stress test, and echocardiogram obtained within 30 days prior to surgery. Preoperative tests obtained from each patient were categorized into “indicated” (ASA ≥ 3) and “un-indicated” (ASA 1 and 2) tests, and percentages were reported.ResultsDuring the study period, 52.9 % (95 % confidence interval (CI) 37.6–66.4) of all patients had at least one un-indicated laboratory test performed preoperatively. Further analysis revealed variation in the incidence of preoperative ordering between tests; 73 % of all complete blood counts (CBCs), 70 % of all metabolic panels, and 49 % of all coagulation studies were considered un-indicated by “Top-5 List” criteria. Stated differently, of the patients included in the sample, 51 % of patients received an un-indicated CBC, 41 % an un-indicated metabolic panel, and 16 % un-indicated coagulation studies. Twelve percent of “any un-indicated preoperative test” were obtained from ASA 1 healthy patients. Of the 587 patients less than 36 years old, 331 (56 %) had at least one test that was deemed un-indicated. Forty-one patients had either an echocardiogram or stress test ordered and performed within 30 days of surgery. Of these, eight (19.5 %) studies were un-indicated as determined by chart review.ConclusionsThe incidence of ordering “at least one un-indicated preoperative test” in low-risk patients undergoing low-risk surgery remains high even in academic tertiary institutions. In the emerging era of optimizing patient safety and financial accountability, further studies are needed to better understand the problem of overuse while identifying modifiable attitudes and institutional influences on perioperative practices among all stakeholders involved. Such information would drive the development of feasible interventions.
Highlights
Despite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery
With the release of the “Choosing Wisely” Top-5 lists of activities to avoid in 20131 (Onuoha et al 2014a), the American Society of Anesthesiologists (ASA) identified five diagnostic tests or treatments that are commonly practiced in the perioperative setting but offer limited to no benefits to patients according to evidence-based studies and may incur significant costs to the health system1 (Onuoha et al 2014a; Onuoha et al 2014b)
Of the patients included in the sample, 51 % of patients obtained an un-indicated complete blood count (CBC), 41 % an un-indicated metabolic panel, and 16 % unindicated coagulation studies (Fig. 1)
Summary
Despite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery. Despite existing evidence-based guidelines advising the contrary, a battery of preoperative tests continue to be performed in low-risk patients undergoing low-risk ambulatory surgery (Benarroch-Gampel et al 2012; Brown and Brown 2011; Fleisher LA 2013; Richman 2010; Schein et al 2000; Soares Dde et al 2013; Vogt and Henson 1997). With the combination of routine preoperative testing in the setting of an increasing prevalence of ambulatory surgery, the elimination of un-indicated tests in low-risk patients would promote patient safety, better quality of care, and result in substantial cost savings (Brown and Brown 2011; Fleisher LA 2013; Schein et al 2000)
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