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|(L-R) Dr. Korenstein, Dr. Hentel, Dr. Heimann, Dr. Frost, Dr. Janjigian, Dr. Rauch|
The overuse of pre-operative testing in low-risk patients has become a major concern across medical specialties. On April 30, five NYAM sections came together to start a dialogue on the issue. Dr. Michael Cantor, an internist at NYU Medical Center and a member of the Section on Evidence Based Health Care, moderated a panel of experts representing different specialties. Each panelist highlighted research relating to the outcomes of excessive pre-operative testing and shared initiatives aimed at decreasing overuse in this area.
“We are very excited that the combination of expertise in evidence based practice, engagement of stakeholders from clinical specialties, and a timely issue within the health care environment was able to generate this level of excitement and interest,” said Dr. Peter Wyer, Co-Chair of the Section on Evidence Based Health Care. “The concept was generated between our section and the Section on Anesthesiology and Resuscitation chaired by Dr. Elizabeth Frost, who also served as a member of the speaker panel. We took advantage of the unique networking capacity of the Academy to reach out to the other specialties and to publicize the event.”
Deborah Korenstein, MD, of the American College of Physicians shared findings from two studies that 50 to 52 percent of low-risk patients received unnecessary pre-operative testing.
“This is a frequent and a big problem in practice,” Dr. Kornstein said.
Elizabeth A.M. Frost, MD, Department of Anaesthesiology, Icahn School of Medicine at Mount Sinai and Chair of the NYAM Section on Anesthesiology and Resuscitation, focused on the financial costs of overusing pre-operative testing. Dr. Frost cited that routine preanesthetic tests cost more than $60 billion annually, and that an estimated total of $750 billion per year spent on unnecessary tests and hospitalization. As an alternative, Dr. Frost recommended focusing on the patient’s medical history and physical exam, and establishing clearer guidelines on testing driven by their history, the results of the physical, and surgical risk.
“Needless tests cause expense, delays, and complications,” Dr. Frost said. “Improved standardization is needed.”
Daniel A Rauch, MD, Icahn School of Medicine at Mount Sinai and Department of Pediatrics at Elmhurst Hospital Center in Queens, provided the pediatric perspective on pre-operative testing. His presentation debunked the assertions that several common pediatric pre-operative tests are necessary, and instead echoed Dr. Frost’s recommendations regarding medical history and physical exams—when possible, he said, these should be conducted well in advance of the procedure.
“Testing should be done as indicated by the pre-operative visit or occasionally as necessitated by the procedure,” Dr. Rauch said.
Keith Hentel, MD, Department of Radiology, Weill-Cornell Medical Center, said, “There is no evidence to support a policy of performing routine pre-operative chest x-rays.” He emphasized Clinical Decision Support as one mechanism that has been utilized to reduce avoidable imaging.
Tomas Heimann, MD, Chief of Surgery, James J. Peters VA Medical Center, Bronx, and Professor of Surgery, Icahn School of Medicine at Mount Sinai, provided the surgical perspective, reviewing issues in pre-operative evaluations for prevention of surgery and for prevention of post-operative events.
“It’s not that we don’t need testing, it’s that we’re sometimes doing the wrong testing and can’t always do the ones we need,” Dr. Heimann said.
Michael Janjigian, MD, Director of Inpatient General Medicine at Bellevue Hospital, spoke of his imperative to limit which patients are coming to the clinic and to appropriately assess who should be seen by internal medicine. He briefly shared some of Bellevue’s hospital-wide policies that limit the overuse of pre-operative testing, including a one-page pre-operative referral sheet and limited use of stress tests.
“Everyone at Bellevue is pretty much on the same page,” Dr. Janjigian said. “With another round of education and feedback, we would likely make more ground.”
View the panelists' presentations here:
Dr. Janjigian - "Medical Preoperative Referral Sheet"
This program was co-sponsored by the NYAM sections on Anesthesiology and Resuscitation, Evidence Based Health Care, Radiology, Pediatrics, and Urology, and supported in part by a generous contribution from the ABIM Foundation.
Posted on May 5, 2014
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Department of Health Policy and Management at the Harvard School of Public Health
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