Routine Preoperative Testing Still Common Before Low-Risk Surgery, Study Finds

Routine preoperative testing before low-risk surgery is widely viewed as having low value.

A new research article indicates that routine preoperative testing before low-risk surgery is common despite having low value.

Over the past decade, healthcare reformers have called on the industry to reduce unnecessary tests. For example, the Choosing Wisely campaign was launched in 2012 to spur conversations between clinicians and patients about care that is truly necessary.

The new research article, which was published by JAMA Internal Medicine, is based on an analysis of administrative claims data in Michigan from January 2015 to June 2019. The researchers examined routine preoperative testing for three low-risk ambulatory surgeries: lumpectomy, gall bladder removal, and groin hernia repair. The surgeries were conducted on 40,000 patients.

The research was the result of collaboration between the University of Michigan-based Michigan Program on Value Enhancement (MPrOVE) and the Michigan Value Collaborative, which focuses on medical and surgical quality improvement.

The study includes three key findings.

• 51.6% of the patients underwent one or more preoperative tests, 29.4% of patients had two or more tests, and 13.5% of patients had three or more tests
   
• The most common tests were complete blood cell count (33.1%), electrocardiograms (25.2%), and basic metabolic panel (11.3%)
   
• Older patients and patients with comorbidities were more likely to undergo preoperative testing

"In this study of patients undergoing three common low-risk surgical procedures, preoperative testing was common, with approximately 52% of patients undergoing at least one test and 29% undergoing two or more tests," the research article's co-authors wrote.

Interpreting the research

This kind of testing clearly generates little value, Lesly Dossett, MD, division chief of surgical oncology at Michigan Medicine and the co-director of MPrOVE said in a prepared statement. "There aren't that many areas in medicine where the data is pretty definitive that something is low-value, but preoperative testing before low-risk surgeries is certainly one of them."

For most patients, preoperative testing before low-risk surgery should be a relic of the past, she said. "There was probably a time when some of the testing did reduce adverse events. But now there's been so many advances in surgery—complication rates are so low—that a lot of these tests are not necessarily helpful anymore."

Older patients and patients with comorbidities may require preoperative testing for low-risk surgery, but even those circumstances can result in unnecessary testing, said Nicholas Berlin, MD, MPH, a Michigan Medicine plastic surgery resident and lead author of the research article. "That's not to suggest there's an age threshold or a comorbidity that requires preoperative testing every single time. There's not."

Conducting preoperative tests generates revenue for hospitals, so there is an economic incentive for low-value preoperative tests to continue. But the country cannot afford the status quo, said Hari Nathan, MD, PhD, division chief of hepato-pancreato-biliary surgery at Michigan Medicine and director of the Michigan Value Cooperative.

"At the end of the day, we all recognize that as a society, we need to find ways to curb healthcare costs. That's in everybody's interest. Even if, on your balance sheet, you think it makes sense to do more tests just to make money, as healthcare providers and as a nation, it does not make sense. It is unsustainable."