Unnecessary pre-op tests very common, and costly

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Women scheduled for gynecologic surgery are very likely to undergo unnecessary tests before their operation, new research shows.

While the tests (blood and urine tests, electrocardiograms, and chest X-rays) aren’t harmful, they may be anxiety-producing and inconvenient for patients, and they are certainly costly, says Dr. Jason D. Wright of Columbia University’s College of Physicians and Surgeons in New York City, who led the new study.

He and his colleagues calculated that inappropriate testing of 1,402 patients over a two-year period led to direct costs of over $418,000. What’s more, Wright said, he suspects that overuse of preoperative medical tests is likely going on with other types of surgery as well.

Every year, Wright and his team note, the US health care system spends $3 billion on preoperative lab tests. “An abundance of evidence suggests that the majority of preoperative testing is unnecessary,” they note in the journal Obstetrics & Gynecology.

While guidelines on appropriate testing have been available for years, the researchers say, it’s not clear how many doctors actually use these guidelines when ordering preoperative tests for their patients.

To investigate, Wright and his colleagues reviewed medical records for women who underwent gynecologic surgery at their center between 2005 and 2007. They found that 95 percent of the 1,402 patients received all the recommended testing, but 90 percent had at least one test that was not necessary based on guidelines from the National Institute of Clinical Excellence (NICE).

None of the 749 urine tests, the 407 liver function tests, or the 1,046 tests of blood clotting factors were appropriate, while 99 percent of the 427 chest X-rays ordered were not appropriate. Only 36 percent of the electrocardiograms and 29 percent of complete blood counts were in accordance with “evidence-based” guidelines.

Recommendations for preoperative testing vary depending on the patient and the procedure, Wright explained in an interview. For example, a healthy 35-year-old having her tubes tied would need no testing at all, based on the NICE guidelines; however, a 65-year-old patient with diabetes and heart disease preparing for ovarian cancer surgery would require several different tests.

While his study didn’t look at why inappropriate tests were ordered, “when you look at the literature it seems like there are a number of factors that are probably at play,” Wright said.

“Number one, certainly, a lot of this is medicolegal”—meaning, basically, doctors don’t want to get sued for not having a test done, he said. Surgeons may also be concerned, he added, that if they don’t order a particular test and the anesthesiologist wanted that test done, the anesthesiologist might cancel the surgery. Finally, he noted that “a lot of surgeons aren’t aware that these published guidelines are out there.”

It’s also possible, Wright added, that individual patients in the current study did have valid reasons for having a particular test done.

Based on the findings, Wright said, “Patients should certainly have an informed discussion with their physician about what tests they really need to have before surgery, so they can come to an informed decision with their physician.”

SOURCE:  Obstetrics & Gynecology, September 2010.

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