De-implementation Background & Research
De-implementation Background & Research
Embedded Files
Wasteful spending in healthcare has been well documented and researched, with the Institute of Medicine estimating at least $210 billion spent on unnecessary medical testing and care in the U.S. each year. The Washington Alliance estimates that $85.2 million is spent on unnecessary preoperative tests for healthy patients facing low-risk procedures.
Wasteful spending in healthcare has been well documented and researched, with the Institute of Medicine estimating at least $210 billion spent on unnecessary medical testing and care in the U.S. each year. The Washington Alliance estimates that $85.2 million is spent on unnecessary preoperative tests for healthy patients facing low-risk procedures.
Choosing Wisely
Choosing Wisely
Choosing Wisely has assembled hundreds of clinical recommendations that aim to reduce unnecessary testing, are supported by evidence, are free from harm, and are truly necessary.
Of these recommendations, Choosing Wisely has a top 12 list, which includes guidelines for preoperative testing in patients scheduled to undergo low- and/or intermediate-risk non-cardiac surgery.
They are based on the recommendations put forth by the following professional societies:
American Academy of Ophthalmology
American College of Physicians
American College of Radiology
American College of Surgeons
American Society of Anesthesiologists
American Society for Clinical Pathology
American Society of Echocardiography and
National Recommendations
National Recommendations
Recommendations by Test:
Recommendations by Test:
Multiple societies have recommended against preoperative testing (e.g., laboratory studies, chest x-rays, EKG, echocardiograms) in low-risk patients prior to low-risk procedures.
Blood Work
Blood Work
American Society of Anesthesiologists - Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, or coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
ECG
ECG
American College of Cardiology - Avoid performing electrocardiography (EKG) screening as part of preoperative cardiovascular risk assessment in asymptomatic patients scheduled for low-risk non-cardiac surgery.
American Society of Echocardiography - Avoid echocardiograms for preoperative/ perioperative assessment of patients with no history or symptoms of heart disease.
Cardiac Stress Testing
Cardiac Stress Testing
The Society of Thoracic Surgeons - Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery.
American Society of Anesthesiologists - Don’t obtain baseline diagnostic cardiac testing (e.g., echocardiography or cardiac stress testing) in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.
Chest X-ray
Chest X-ray
American College of Physicians - Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
American College of Radiology, American College of Surgeons- Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exams.
Statewide Partners:
Statewide Partners:
Three organizations within Michigan have partnered to address unnecessary preoperative testing through a collaborative lens that includes data-driven approaches. While each organization has individual projects underway, these groups also collaborate on the development of strategies and resources for the benefit of their stakeholders.
Michigan Program on Value Enhancement (MPrOVE): Focuses on improving quality and demonstrating the value of care at Michigan Medicine, while at the same time catalyzing collaborative research efforts to inform state and national policy decisions. MPrOVE works to identify, design, and rigorously and rapidly evaluate specific projects focused on improving quality and demonstrating the value of clinical services at Michigan Medicine and beyond.
Michigan Surgical Quality Collaborative (MSQC): A collaborative of Michigan Hospitals dedicated to overall surgical quality improvement, including better patient care and lower costs. They host robust regional registry to analyze the issues, identify the best practices, and disseminate them widely.
Michigan Value Collaborative (MVC): A partnership between Michigan hospitals, physician organizations, and Blue Cross Blue Shield of Michigan/Blue Care Network. MVC's goal is to improve the health of Michigan through sustainable, high-value healthcare. MVC aims to understand variation in healthcare use, identify best practices, and lead interventions for improving care before, during, and after hospitalization. MVC uses its insights to provide members with rigorous performance feedback and coordinates collaborative events for shared learning and practice sharing.
Academic Work
Academic Work
Baskin, A. S., Mansour, A. I., Kawakibi, A. R., Das, P. J., Rios, A. E., Miller, J., ... & Dossett, L. A. (2022). Perceived Barriers to the De-implementation of Routine Preoperative History & Physicals Preceding Low-risk Ambulatory Procedures: A Qualitative Study of Surgeon Perspectives. Journal of Surgical Research, 270, 359-368.
Berlin, N. L., Yost, M. L., Cheng, B., Henderson, J., Kerr, E., Nathan, H., & Dossett, L. A. (2021). Patterns and determinants of low-value preoperative testing in Michigan. JAMA Internal Medicine, 181(8), 1115-1118.
Cuttitta, A., Joseph, S. S., Henderson, J., Portney, D. S., Keedy, J. M., Benedict, W. L., ... & Mian, S. I. (2021). Feasibility of a Risk-Based Approach to Cataract Surgery Preoperative Medical Evaluation. JAMA ophthalmology, 139(12), 1309-1312.
Ganguli I, Simpkin AL, Lupo C, et al. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Network Open. 2019;2(10):e1913325-e1913325.
Katz RI, Dexter F, Rosenfeld K, et al. Survey study of anesthesiologists' and surgeons' ordering of unnecessary preoperative laboratory tests. Anesthesia and analgesia. 2011;112(1):207-212.
Pickering AN, Zhao X, Sileanu FE, et al. Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within the Veterans Health Administration. Journal of general internal medicine. 2022.
Salar O, Holley J, Baker B, Ollivere BJ, Moran CG. Omitting pre-operative coagulation screening tests in hip fracture patients: stopping the financial cascade? Injury. 2014;45(12):1938-1941.
Welch JM, Zhuang T, Shapiro LM, Harris AHS, Baker LC, Kamal RN. Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clinical orthopaedics and related research. 2022.
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