Many Pre-Surgery Tests Are Useless, So Why Are They Still Done?

By Dennis Thompson
HealthDay reporter

THURSDAY, May 27, 2021 (HealthDay News) – Patients facing relatively simple outpatient surgeries are nonetheless asked to undergo a number of preoperative tests that are simply not necessary, according to a new study.

More than half of a group of patients facing low-risk outpatient surgery had one or more tests – blood test, urinalysis, electrocardiogram (ECG), chest x-ray – before their operation.

One-third of patients had at least two tests, and about 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 Health Policy. and innovation.

These tests are still in demand even though “we have known for almost a decade that there is a fairly broad consensus that preoperative testing before low-risk surgery does not provide any benefit to patients,” Berlin said. “We have no reason to believe this improves patient outcomes. It is simply unnecessary waste in our health care system.”

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Unnecessary care that does not contribute to patient well-being accounts for an estimated $ 75 billion to $ 100 billion in unnecessary health care spending in the United States each year, Berlin said.

But researchers don’t think hospitals are ordering these tests to make quick money.

The study found that the most common unnecessary tests were an EKG or blood tests to check blood cell counts or provide a baseline metabolic panel for the patient. Two more expensive tests, cardiac stress and lung function tests, were relatively rare in patients undergoing easy surgeries.

“The tests that we look at individually are not that expensive,” Berlin said.

Instead, these tests are likely done out of habit, glut of care, or to cover the hospital in case of a lawsuit, said Dr Stephen Esper, anesthesiologist at the University of Pittsburgh Medical Center and the centers medical director. UPMC. for perioperative care.

“This is not an attempt for another gain by the doctor’s office,” said Esper, who was not part of the study. “The intention is to do good by the patient.”

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Wide variability

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

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

The researchers looked at three specific outpatient surgeries that shouldn’t require testing before 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, the researchers found.

“In some hospitals, tests have only been done in 20-30% of patients, which may suggest that there has been some improvement over time and that some hospitals are implementing strategies to reduce unnecessary testing “said Berlin. “But in other hospitals it happens over 80% of the time, so you see this great variability between hospitals in the frequency of testing.”

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

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

These preoperative tests “are really a marker for other things happening that are also unnecessary,” Berlin said. “They can trigger a series of events.”

Confusion about the order

Why are these tests always ordered, then?

It could be a habit for the surgeon or anesthesiologist, Esper said, or because the lack of preoperative testing could arise in a malpractice lawsuit, Esper said.

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

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“There is a web of factors that are at play here, including things like confusion over who wants tests and the inability to stop ordering tests because you think it’s something someone’s. one else wants, “Berlin said.

Inertia is another potential factor.

“People recognize that these tests aren’t necessary, but then they wonder if it’s really worth reducing it if the overall impact is so much less than individual surgery? Surgeons might say that my surgery is much more expensive and impactful than this test, so why should we focus on one test? “Said Berlin.

Since the guidelines don’t have a major impact, scaling back those testing could come down to making it a dollar and penny proposition, Berlin said.

Decreasing insurance reimbursement for these tests could cause healthcare providers to order them less often, Berlin said. On the flip side, the increased cost-sharing for patients might make them wonder if they really need these tests before surgery.

“These unnecessary preoperative tests are a prime example of the defects underlying [the] Payment for health care in the United States is structured, largely based on fee-for-service where a provider is reimbursed for each service they provide, rather than being reimbursed based on continued maintenance. health of its patients, ”said Sophia Tripoli, director of health innovations. for Families USA, a nonprofit healthcare consumer advocacy group.

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“The result of fee-for-service not only raises costs for the entire healthcare system and for consumers, but also causes the relationship between providers and patients to be a business transaction rather than a business transaction. inspire providers to build relationships with their patients and respond appropriately to the full range of their patients’ health needs, ”Tripoli said.

There’s one thing for sure, Esper added: Patients love it when they’re told they don’t need further testing before surgery.

“They’re happy, because they don’t have to get stuck with a needle, they don’t need to be irradiated, they don’t need to take their shirts off and go through all of that,” Esper said.

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More information

The US National Institutes of Health has more on preoperative testing.

SOURCES: Nicholas Berlin, MD, MPH, surgeon and health policy expert, University of Michigan Institute for Health 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, Healthcare Innovations, Families USA; JAMA Internal Medicine, May 17, 2021

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