The study shows how hospitals can safely reduce unnecessary preoperative testing

The study shows how hospitals can safely reduce unnecessary preoperative testing

For many patients, preparing for surgery means having their blood drawn, checking their heart rhythm, or having other tests done in the weeks before their surgery.

But not all patients need all of these tests — especially if the results don't change how their surgical team treats them or how well they do afterward.

Now, a new study shows how hospitals can focus the use of such tests on the patients who really need them while reducing unnecessary testing for others.

The result: less wasted money and resources on each test and less wasted time for patients and clinical staff.

The study, published inJama operationA team from the University of Michigan and Brigham and Women's Hospital tested a program designed to reduce unnecessary preoperative testing at UM Health.

It focused on reducing four tests in low-risk patients with breast lumps or diseased gallbladders that were removed in outpatient surgeries or hernias were fixed.

Before intervention, 37% of such patients had at least one unnecessary test. At the end of the study, this rate dropped to 14%. Overall testing – the percentage of all patients receiving the four tests before these surgeries decreased from 51% to 27%.

At the same time, preoperative testing in patients who needed it did not change due to their health status and surgical risk. In the weeks following patients' execution, rates of emergency room visits and hospitalizations remained the same, suggesting that reducing unnecessary testing does not worsen surgical safety or outcomes.

The new study shows that during the time that UM Health reduced unnecessary testing and general testing, use of the same tests on similar patients remained the same at dozens of other hospitals in the state.

Make changes together and measure its impact

The study's leader says it's not just the drop in unnecessary testing, but the way the team achieves it that sets the study apart.

The intervention focused on informing clinicians about the evidence that they could safely reduce testing in some patients and their involvement in how they did so, says senior author and UM Health surgeon Lesly Dossett, MD, MPH

If we truly want to reduce wasteful testing that doesn't add value and change care, we need to help team members understand why, base our intervention on what we know about creating lasting positive change, and provide easy-to-use tools to support clinical decisions. We are pleased with what we have been able to achieve in our Preop clinics and look forward to testing this in hospitals nationwide. “

Lesly Dossett, MD, MPH, UM Health Surgeon

Dossett leads the Michigan Value Improvement Program, or Mprove, through which the new study was conducted. Mprove Teams Efforts to improve the clinical quality of UM Health using the rigorous research methodologies of the UM Institute for Health Policy and Innovation. It is funded by Michigan Medicine, UM's Academic Medical Center.

More about the study

The study included 1,143 patients with a median age of 58 years at UM Health's three Preop outpatient surgery clinics from June 2022 to the end of August 2023.

UM Health had high levels of preop testing (both necessary and unnecessary) in a previous study of 63 Michigan hospitals published in 2021.

During the intervention period, the surgeons and physicians involved in the Preop clinics had several meetings with the study team and worked to create a consensus about which tests patients needed and which they did not.

At the end, clinicians were asked to create a flowchart and network - called decision support documents - to determine which tests a patient should have before surgery based on their individual characteristics.

The tests in question were chosen because years of research and recommendations from national and international health groups were deemed unnecessary for certain patients. Blood tests called complete blood cell counts (CBCs), basic metabolic panels (BMPs) and comprehensive metabolic panels (CMPs) were also targeted, as were electrocardiograms.

Each patient was scored on a standard scale used by anesthesiologists to assess a patient's risk of a complication during anesthesia. Those on the lowest two rungs could forego all four tests unless a specialist specifically ordered them. But even patients at the higher end of this scale, known as ASA physical status, could avoid certain tests depending on what other medical conditions they had.

Alexis Antunez, MD, MS, is a UM Medical School alumna and the first author of the study. At the time of the study, she was a visiting surgical research fellow at Michigan Medicine and is now in the Department of Surgery at Brigham and Women.

Tony Cuttitta, Mprove program manager, notes that several UM Medical School students worked on study design and data analysis. He also explains that the UM team is working to scale the number of surgical specialties using the approach and assess the impact.

The effort was so successful that the UM team is collaborating with 16 other hospitals across Michigan to replicate the same intervention that inspired the change.

The nationwide study, funded by a grant from the federal Agency for Healthcare Research and Quality, is now underway. It includes hospitals participating in collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan and will test whether the model that is successful at UM Health is generalizable to other care settings. It will also analyze the financial impact of avoiding unnecessary testing.

In addition to Dossett, Antunez and Cuttita, the study authors are Ruby J. Kazemi, BA; Caroline Richburg, MD; Cecilia Pesavento, MD, MBA; Andrew Vastardis, MS; Erin Kim, BS; Abigail L. Kappelman, MA; Devak Nanua, MS; Hiba Pediyakkal, BA; Faelaner Jacobson-Davies, MA; Shawna N. Smith, PhD; James Henderson, PhD, 10; Valerie Gavrila, MPH; and Hari Nathan, MD, PhD.

Dossett, Nathan, Smith and Henderson are members of IHPI; Several authors are members of the Center for Health Outcomes and Policy and the Michigan Value Collaborative.

The study was funded by the National Institutes of Health (T32CA009672), the Agency for Healthcare Research and Quality (R01HS029306-01A1), and Blue Cross Blue Shield of Michigan Support for the Michigan Value Program as part of the BCBSM Partners Program.

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