Are you throwing away money with unnecessary routine preop tests?
By Joy Daughtery Dickinson, Executive Editor
Are you performing unnecessary preoperative tests? If so, you're wasting expensive staff time required to conduct them and analyze them, as well as supplies needed to conduct them. In addition, you're experiencing potentially unnecessary surgical delays due to false positives. Additionally, patients are wasting time, possibly away from work. All of these costs add up, especially in these tight economic times.
So why is unnecessary testing done? "One of answers, I hear frequently, hear they have a need to practice defensive medicine," says Jeffrey L. Apfelbaum, MD, chair of the American Society of Anesthesiologists' (ASA's) Committee on Standards and Practice Parameters, professor and chair of the Department of Anesthesia and Critical Care at the University of Chicago, and member of the Executive Committee of Pritzker School of Medicine and medical staff of the University of Chicago Hospitals in Chicago. "Having information available is one way to do so," Apfelbaum says.
His opinion is echoed by Michael N. Abrams, MA, co-founder and managing partner of Numerof & Associates Inc. (NAI), a St. Louis, MO-based strategic management consulting firm focused on organizations in rapidly changing industries, including healthcare. "There are other hypothesized factors as well, including: to provide early detection of potentially serious medical conditions; to detect underlying health conditions that, even though rare, could result in complications during or after the scheduled procedure; and to provide peace of mind to the patient/family by reporting that all screening tests were normal."
Electronic records may change the parameters of preoperative testing, because testing at its foundation is about lowering risk, says T. Forcht Dagi, chairman of the Committee on Perioperative Care for the American College of Surgeons. "As we get better at deploying electronic health records, and as we have interchange of data across entire medical systems, it will be easier to know what tests the patient has had and what the results were," Dagi says.
Currently, when a surgeon is doing an operation that needs a chest X-ray, the patient might say he had one done one month ago. When the surgeon asks the result, the patient might say he isn't certain, but he thinks it was OK. "It's easier to get another X-ray then chase down the original results," Dagi says.
So how do you know which preoperative tests to perform? Look to recent developments and research for direction:
• A study published in the September issue of the Annals of Surgery said that preoperative testing is overused in patients undergoing low-risk, ambulatory surgery.
After adjusting for patient and procedure characteristics, neither testing nor abnormal results were associated with postoperative complications in 73,596 patients undergoing elective hernia repair.1
In the study, 63.8% of patients underwent testing, and at least one abnormal test was recorded in 61.6% of patients. In patients with no comorbidities, as defined by the National Surgical Quality Improvement Program, and no clear indication for testing, 54% received at least one test, the researchers said. In addition, 15.3% of tested patients had their lab tests done on the same day as their operations. In this group, surgery was done despite abnormal results in 61.6% of same-day tests. Major complications (reintubation, pulmonary embolus, stroke, renal failure, coma, cardiac arrest, myocardial infarction, septic shock, bleeding, or death) occurred in 0.3% of patients.
On the basis of high rates of testing in healthy patients, the use of preoperative tests should be dictated by physician and/or facility preference, as well as patient condition, the researchers say.
• In 2012, the American Society of Anesthesiologists Committee on Standards and Practice Parameters updated the society's "Practice Advisory for Preanesthesia Evaluation."2
The advisory says that preop tests should not be routinely ordered. "Preoperative tests may be ordered, required, or performed on a selective basis for purposes of guiding or optimizing perioperative management," the advisory says.
There is insufficient evidence for ordering routine preop tests based on clinical characteristics, the advisory says. "However, consideration of selected clinical characteristics may assist the anesthesiologist when deciding to order, require, or perform preoperative tests," it says. Specific tests and their timing should be based on the individual patient and can be based upon information such as the medical record, patient interview, physical examination, and the type and invasiveness of the planned procedure, the advisory states.
The need for selective testing is emphasized by Apfelbaum. "Selecting tests, after you considered information you gathered using medical skills, likely will assist the anesthesiologist in making decisions that will be useful in the preoperative assessment or perioperative management of patient," he says. "That's the take-home message."
• The Agency for Healthcare Research and Quality of the Department of Health and Human Services has a current project on preop testing for patients undergoing elective or ambulatory surgery requiring anesthesia.
This project is providing "excellent guidance," according to Abrams (The guidance can be accessed at http://1.usa.gov/UzN6UP.)
The guidance, which still is in development, says, "[I]t is important look not only at the benefits and harms of preoperative testing in general but also at specific patient and intervention factors that might change the balance between the benefits and harms — namely, the risk of the surgical procedure, the type of anesthesia planned, the indication for surgery, comorbidities, and other patient characteristics."
While the current fee-for service payment model provides little incentive to eliminate preop testing, that model is changing quickly, Abrams emphasizes. Bundled pricing typically includes such testing in a comprehensive price. While the "global surgery package" defined by Medicare doesn't include diagnostic tests and imaging, global payments are likely to evolve to include them as the Affordable Care Act (ACA) is fully implemented, Abrams says. "Savings from using only appropriate testing will make the transition much easier," he says.
For example, Dagi says, if a patient is having a very minor procedure, and the risk of bleeding is very low, and the patient has no history of difficulty with blood clotting and no history of hemorrhage, and the patient is not taking any medications that might affect the ability to coagulate, then under those circumstances you may be able to skip some of preop coagulation tests that would be required for major surgery.
Would care paths be a better approach?
Abrams suggests that providers go beyond simply targeting preoperative testing and instead look at using care paths to reduce costs.
"Significant savings can be realized through minimizing personnel time spent doing tests, assessments, treatments, and procedures so that increased efficiency improves throughput time and staff workload," he says. "The time and effort spent following up on false positive tests must also be considered"
To determine how much you can save, look at your data on staff practice variances, Abrams suggests. "The data elements include such items as test utilization, false positive test rates and associated case cancellation rates, supply use, OR time and staff utilization, complication rates and reimbursement denials," he says.
Effectively using care paths can bring all surgeons up to the level of the best performer's results, or better, Abrams says.
"Since adherence to care paths has been demonstrated to improve outcomes, reduce complications, and improve patient/family satisfaction, care paths contribute to reduced staff time and facility resources to care for post-procedure complications and may secondarily improve patient loyalty and community reputation," he says. (See story about how Abrams helped a surgery center eliminate unnecessary tests with a care path for diagnostic evaluation of prostate cancer, below. For information on how to get physicians on board with reducing preop testing, see story, below. To see how researchers reduced patient charges for common preop tests, see story, below..)
- Benarroch-Gampel J , Sheffield, KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Annals of Surgery 2012; 256(3):518-528. Abstract accessed http://bit.ly/OuIZv6. Doi: 10.1097/SLA.0b013e318265bcdb.
- Committee on Standards and Practice Parameters. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116(3):522-538. Accessed at http://bit.ly/RioTC8. Doi: 10.1097/ALN.0b013e31823c1067.
The DVD-based Manual for Anesthesia Department Organization and Management (MADOM) is free for members of the American Society of Anesthesiologists and $100 plus shipping and handling for non-members. To order, go to http://bit.ly/XK6SxD.
Get physicians on board to reduce preop testing
So if you're convinced that unnecessary preop testing needs to be eliminated, how do you accomplish this feat?
"Eliminating unnecessary preop test ordering and other costly behaviors that a thorough assessment of current practices will reveal involves change management for the entire facility staff, including its physicians," says Michael N. Abrams, MA, co-founder and managing partner of Numerof & Associates Inc. (NAI) in St. Louis, MO. "Providers will be critical for most changes needed, however, since they control much of what is ordered and carried out for the procedures done in the facility."
While getting physicians on board might seem like a daunting task, Abrams points out that physicians, as a group, have attributes that help facilitate acceptance of change. He lists the following: "a desire to provide the highest quality care for their patients, a competitive spirit concerning the quality of their outcomes compared to peers, and a requirement for data to be provided to support change."
Flexibility is an important factor, Abrams says. "Although the smooth, consistent functioning of the entire team that accompanies use of care paths is appreciated, most physicians need to know that variation based on their assessment of individual patients will be allowed — subject to review for appropriateness, of course," he says.
Reducing preop tests as part of a care path
Path targeted diagnostic evaluation of prostate cancer
When one surgery center's care path for diagnostic evaluation of prostate cancer showed routine use of three diagnostic tests, Michael N. Abrams, MA, co-founder and managing partner of Numerof & Associates Inc. (NAI) in St. Louis, MO, took a deeper look.
"The care path under review had indicated that all patients should receive a bone scan, CT scan of the abdomen, and a PET scan," Abrams says. "In this particular instance, the issue came down to differential diagnosis, and reserving such tests for those specific patients whose cases warranted these tests."
The American Urological Association has established clinical practice guidelines for the evaluation of a patient with prostate cancer, which depend on the status of both the patient and status of the cancer. "Preoperative care pathways, therefore, will include the urologist's assessment of the patient as a candidate for surgery depending both on the stage of malignancy and also the anesthesiologist's needs to provide safety during the operation," Abrams says.
Before you consider surgery, the patient must be a good surgical candidate and have a life expectancy of at least 10 years, he says. "The malignancy should be localized to the prostate, so that surgery can provide a high likelihood of clinical success and cure," Abrams says.
According to best practice pathways, men with a presenting prostate-specific antigen (PSA) under 10, and a Gleason score (representing tumor aggressiveness) below 8 have a very low risk of metastatic disease, and no further imaging or testing is indicated, he says. "However, men who are at high risk of harboring extra-prostatic cancer are those with PSA greater than 10 or have a Gleason score equal to or greater than 8," Abrams says. "These men are at a high risk of metastasis and should have further studies including a bone scan and CT scan of the abdomen and pelvis."
If there are still concerns about tumor spread after these studies, then more extensive tests could include PET or Prostascint scanning, he says. "However, these tests would not routinely be given to all prostate cancer patients," Abrams says.
Because the cancer cannot be cured once it is beyond the borders of the prostate gland, these tests determine whether surgery would be curative and should proceed, he explains.
"Once the decision for surgery has been made, immediate pre-operative testing follows standard collaborative guidelines established by both the surgeon and anesthesia, including appropriate blood tests, EKG, etc.," Abrams says. Other consultants, such as cardiology or oncology, also provide input, he says.
At the time of admission and surgery, use cost-efficient programs in choosing antibiotics and in efficient use of hospital resources, Abrams advises. "By establishing evidence-based pathways from the preoperative area to the surgical suite, to post-operative care, patients can oftentimes be discharged after just an overnight stay or even as outpatients," he says. "This can save thousands of dollars per patient and millions of dollars to the healthcare system." (For more information on cost containment in urology, see select references, below.)
Anesthesiologist model of care saves money
Patient charges cut for hip, knee replacements
Using a comprehensive preoperative triage system directed by anesthesiologists, researchers at the Ochsner Medical Center in New Orleans has shown marked reductions in patient charges for common medical tests without sacrificing quality of care and successful outcomes. Their findings were presented at the recent Anesthesiology annual meeting of the American Society of Anesthesiologists.
Patient charges for the seven most common medical tests were reduced by $18,187 for every 100 patients with mild disease and $20,664 for every 100 patients with moderate disease.
Lead study author Sharon Carrillo, MD, MS, and her group used methods of coordinated care in the surgical setting in which facilities "join together like a concerned family to oversee a patient's surgical experience" and create substantive savings in healthcare. "Our premise is that dedicated anesthesiologists likely have more insight into surgical stresses and test requirements than primary care physicians who, with surgeons, still predominantly 'clear' most patients in U.S. clinical practice," said Carrillo.
In the study of nearly 1,400 patients, anesthesiologists at Ochsner reviewed available medical records, ordered tests, and requested appropriate consults for total knee and total hip replacement surgeries. Among several other cost-saving practices, the study authors replaced costlier comprehensive metabolic profile tests with a basic metabolic profile, obtained EKG tests only for healthy patients over 65, and avoided duplicate X-rays by administering them only when called for because of symptoms or previous examination findings.
Interestingly for the Ochsner researchers, their findings were observed during a period in which an external auditor determined that major complications associated with total knee and total hip surgeries at the institution were decreasing.
"We believe that we have successfully reduced the cost passed on to patients without sacrificing successful outcomes," said Carrillo. "Our goal is to expand the triage process to other surgical groups in hopes of further cost containment and improved patient satisfaction at our institution."