The study examined whether two sets of guidelines released concurrently, in 2002, by the American College of Cardiology/American Heart Association and the American Society of Anesthesiologists led to changes in preoperative testing patterns. Both organisations made their recommendations about appropriate testing and treatment strategies to discourage preoperative tests ordered “in absence of a specific clinical indication or purpose.” The researchers found no significant decline in use of:
- plain radiography, or x-rays done without contrast
- haematocrit, or the measurement of the percentage of red blood cells
- urinalysis, and
- cardiac stress testing
There was, however, a decline in pre-surgical electrocardiograms.
The researchers say the costs of such tests may be considerable, given that 30 million Americans undergo surgery each year, and 60 percent of patients undergo ambulatory procedures — which are performed on an outpatient basis.
“While it’s important to ensure patients can safely undergo surgical procedures, many of these procedures are low-risk, and the tests rarely improve patient management,” says the study’s senior investigator Joseph Ladapo, MD, PhD, an assistant professor in the Department of Population Health at NYU Langone.
The NYU Langone team reviewed national data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1997 through 2010. These two surveys, conducted annually by the U.S. Centers for Disease Control and Prevention and the National Center for Health Statistics, examine preoperative visits at office-based physician practices, hospital-based outpatient clinics, and emergency departments in the U.S.
Although overall rates of routine testing declined across several categories over the 14-year period, the declines after accounting for overall changes in physicians’ ordering practices were not statistically significant, notes the research team.
The NYU Langone researchers believe the 2002 guidelines may have had little effect for several reasons.
“Evidence suggests physicians are more likely to follow guidelines that add rather than eliminate a test or procedure,” according to Dr. Ladapo. "In addition, physicians may not have been aware of the recommendations or may not have believed they applied to their patients. They also may have been unduly influenced by reimbursement practices.”
Dr. Ladapo and colleagues acknowledge that their study was somewhat limited in that it was not able to adjust for surgery type or identify patients who were referred for high-risk surgery. However, they found that the distribution of high-risk surgical procedures during the period after the guideline recommendations saw little change.
Dr. Ladapo adds: “Routine preoperative testing is part of the culture of many residency training programmes, and shifting toward medically-appropriate testing while physicians are still in training may be one way to break the cycle.”
Source: NYU Langone Medical Center
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