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  • Posted May 27, 2021

Many Pre-Surgery Tests Are Useless, So Why Are Hospitals Still Using Them?

Patients facing relatively simple outpatient surgeries are nonetheless being told to undergo a number of preoperative tests that just aren't necessary, a new study reports.

More than half of a group of patients facing low-risk outpatient surgery received one or more tests -- blood work, urinalysis, an electrocardiogram (EKG), a chest X-ray -- prior to their operation.

One-third of patients underwent at least two tests, and roughly 1 in 7 patients had three or more tests before their simple surgery, said lead researcher Dr. Nicholas Berlin, a surgeon and health policy expert at the University of Michigan Institute for Healthcare Policy and Innovation.

These tests are still being requested even though "we've known for almost a decade that there's pretty broad consensus that preoperative testing before low-risk surgery provides no benefit to patients," Berlin said. "We have no reason to believe that's improving patient outcomes. It's just unnecessary waste in our health care system."

Wasteful care that doesn't contribute to the patient's well-being accounts for an estimated $75 billion to $100 billion of unnecessary health care expenditures in the United States each year, Berlin said.

But the researchers don't think hospitals are ordering these tests to make a quick buck.

The most common unnecessary tests were an EKG or blood work to either check for blood cell counts or provide a basic metabolic panel for the patient, the study found. Two more expensive tests, cardiac stress and lung function testing, were relatively uncommon among patients slated for easy surgeries.

"The tests we're looking at individually are not that expensive," Berlin said.

Instead, these tests are likely being performed out of habit, an overabundance of care, or to cover the hospital in case of a lawsuit, said Dr. Stephen Esper, an anesthesiologist with the University of Pittsburgh Medical Center and medical director of the UPMC Centers for Perioperative Care.

"It is not an attempt for any other gain by the physician's office," said Esper, who wasn't part of the study. "The intention is to do right by the patient."

Wide variability

Many professional medical societies have issued guidelines urging hospitals and doctors to not order unnecessary tests, which also unnecessarily expose the patient to potential harm, Berlin said.

To see if these guidelines have had any effect, Berlin and his colleagues reviewed insurance claim data from a Blue Cross Blue Shield of Michigan-funded statewide collaborative quality initiative. They published their findings recently in the journal JAMA Internal Medicine.

The researchers looked at three specific outpatient surgeries that shouldn't require any tests prior to the procedure -- lumpectomy to remove abnormal tissue from a breast, keyhole surgery to remove the gallbladder, and keyhole surgery to repair a hernia.

Even though the surgeries were so simple that patients did not need to be admitted to the hospital, more than half still had to undergo at least one unnecessary test, researchers found.

"At some hospitals, testing was done in only 20% to 30% of patients, which may suggest that there's been some improvement over time and some of the hospitals are implementing strategies to reduce unnecessary testing," Berlin said. "But in other hospitals it's happening over 80% of the time, so you see this wide variability between hospitals in how often testing is performed."

The problem is that these tests add up over time, and can cause patients inconvenience and potential harm if an abnormal result on one test leads to more follow-up testing, Berlin and Esper said.

"We know that in other studies of patients having cataract surgery, even what seems to be an inexpensive test like an EKG on average leads to these downstream cascades of care that on average will cost about $1,300 per patient," Berlin said.

These preoperative tests "are really a marker for other things that happen that are unnecessary as well," Berlin said. "They can trigger a series of events."

Confusion over ordering

Why are these tests still being ordered, then?

It might be out of habit for the surgeon or the anesthesiologist, Esper said, or because the lack of preoperative testing might come up in a malpractice suit, Esper said.

There also remains a lot of confusion about which tests are required for which procedure by which doctor or insurer or hospital, Berlin said.

"There's a web of factors that are at play here, including things like confusion about who wants tests and the inability to stop ordering tests because you think it's something wanted by someone else," Berlin said.

Inertia is another potential factor.

"People acknowledge that these tests are unnecessary but then they question, is it really worth reducing it if the overall impact is so much less than the individual surgery? Surgeons might say, my surgery is much more expensive and impactful than this test, so why should we focus on a test?" Berlin said.

Since guidelines are not having a major impact, cutting back on these tests might come down to making it a dollars-and-cents proposition, Berlin said.

Decreasing insurance reimbursement for these tests might prompt health care providers to order them less often, Berlin said. On the other side, increasing cost-sharing for patients might cause them to question whether they really need these tests before surgery.

"These unnecessary preoperative tests are a prime example of the underlying flaws with how [the] U.S. health care payment is structured, which is largely based on fee-for-service payment where a provider is reimbursed for each service they deliver, rather than being reimbursed based on keeping their patients healthy," said Sophia Tripoli, director of health care innovations for Families USA, a nonprofit health care consumer advocacy group.

"The result of fee-for-service payment not only drives up costs for the entire health care system and for consumers, but also incentivizes the relationship between providers and patients to be a business transaction rather than incentivizing providers to build relationships with their patients and appropriately address the full spectrum of their patients' health needs," Tripoli said.

There's one thing for certain, Esper added -- patients love it when they're told they don't need extra tests done before a surgical procedure.

"They're happy, because they don't have to get stuck by a needle, they don't have to get irradiated, they don't have to take off their shirt and go through all that," Esper said.

More information

The U.S. National Institutes of Health has more about preoperative tests.

SOURCES: Nicholas Berlin, MD, MPH, surgeon and health policy expert, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor; Stephen Esper, MD, MBA, anesthesiologist, University of Pittsburgh Medical Center, and medical director, UPMC Centers for Perioperative Care; Sophia Tripoli, MPH, director, health care innovations, Families USA; JAMA Internal Medicine, May 17, 2021

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