Many checks earlier than surgical procedure are ineffective. Why are they nonetheless being carried out?

By Dennis Thompson
HealthDay reporter

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

More than half of a group of patients who faced low-risk outpatient surgery received one or more tests – blood tests, urine tests, an electrocardiogram (EKG), a chest x-ray, before their surgery.

A third of patients had at least two tests, and roughly one in seven patients had three or more tests before their simple surgery, said lead researcher Dr. Nicholas Berlin, surgeon and health policy expert at the University of Michigan Department of Health Policy and Innovation.

These tests are still being requested, although “we have known for almost a decade that there is a fairly broad consensus that preoperative testing before low-risk surgery is of no benefit to patients,” Berlin said. “We have no reason to believe that this will improve patient outcomes. It’s just unnecessary waste in our healthcare system.”

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Wasteful care that doesn’t contribute to patient wellbeing causes an estimated $ 75 billion to $ 100 billion in unnecessary health care spending in the U.S. each year, Berlin said.

However, the researchers don’t believe that hospitals will order these tests to make money quickly.

The most common unnecessary tests were an EKG or blood test, either to check blood cell counts or to provide the patient with a basic metabolic panel, the study said. Two more expensive tests, cardiac stress and pulmonary function tests, were relatively rare in patients scheduled for simple surgery.

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

Instead, these tests are likely done out of habit, out of excess care, or to cover the hospital in case of a lawsuit, said Dr. Stephen Esper, anesthetist at the University of Pittsburgh Medical Center and Medical Director of the UPMC Centers for Perioperative Care.

“It’s not an attempt at any other benefit from the doctor’s office,” said Esper, who was not part of the study. “The intention is to please the patient.”

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Great variability

Many medical societies have issued guidelines urging hospitals and doctors not to order unnecessary tests that unnecessarily expose patients to potential harm, Berlin said.

To determine whether these guidelines had had any effect, Berlin and his colleagues reviewed insurance claims data from a nationwide quality initiative funded by Blue Cross Blue Shield, Michigan. They recently published their results in the journal JAMA Internal Medicine.

Researchers looked at three specific outpatient surgeries that shouldn’t require testing before the procedure – lumpectomy to remove abnormal tissue from the breast, keyhole surgery to remove the gallbladder, and keyhole surgery to repair an inguinal hernia.

Although the operations were so simple that patients didn’t have to be hospitalized, more than half still had to go through at least one unnecessary test, the researchers found.

“In some hospitals, tests were only carried out on 20 to 30% of patients, which could indicate that there have been some improvements over time and some hospitals are implementing strategies to reduce unnecessary testing,” said Berlin. “But in other hospitals it happens 80% of the time. So you see this huge variability between hospitals in how often tests are done.”

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

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

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

Confusion about the order

Then why are these tests still being ordered?

It could be a habit for the surgeon or the anesthesiologist, Esper said, or because the lack of preoperative testing could occur in a misbehavior suit, Esper said.

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

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“A number of factors play a role here, including confusion about who wants tests and the inability to stop ordering tests because you think someone else wants it,” Berlin said.

Inertia is another possible factor.

“People acknowledge that these tests are unnecessary, but then wonder if it is really worth reducing them when the overall effect is so much less than the individual surgery? Surgeons might say my surgery is much more expensive as well more effective than this test. So why? ” should we focus on one test? “Berlin said.

Since the guidelines don’t have much of an impact, restricting these tests could turn them into a dollar-and-cent deal, Berlin said.

A reduction in insurance costs for these tests could encourage healthcare providers to order them less often, Berlin said. On the other hand, increasing cost sharing for patients could lead them to wonder whether they really need these pre-operative tests.

“These unnecessary preoperative tests are a great example of the underlying flaws in the process [the] US Healthcare Payment is structured and based largely on the payment of service fees where a provider is reimbursed for every service they provide, rather than reimbursement based on the health of their patients, “said Sophia Tripoli, director of innovation in Healthcare for Families USA, a nonprofit advocacy group for health care consumers.

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“The outcome of paying service fees not only increases costs to the entire healthcare system and consumers, it is also an incentive for the relationship between providers and patients to be a business transaction rather than for providers to develop relationships with their patients adequately address the full range of their patients’ health needs, “Tripoli said.

One thing is certain, Esper added: Patients love to be told they don’t need additional testing before surgery.

“They’re happy because they don’t have to get stuck on a needle, have no radiation, take off their shirts and go through it all,” said Esper.

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More information

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

SOURCES: Dr. med. Nicholas Berlin, MPH, Surgeon and Health Policy Expert, University of Michigan Health Policy and Innovation Institute, Ann Arbor; Stephen Esper, MD, MBA, anesthetist, 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