De-implementation Background & Research

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 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:

National Recommendations

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

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

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

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 

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:

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