Study Suggests Routine Preoperative Screening Tests for Very Low-Risk Procedures are Common and Costly for VA

BACKGROUND:
For patients undergoing low-risk procedures, preoperative screening tests often do not change clinical management and sometimes lead to unnecessary follow-up testing and interventions that may delay surgery. Even though guidance to avoid preoperative testing has been available for years, low-value preoperative tests continue to be a major contributor to unnecessary healthcare spending in the US. While previous studies have shown that there has been some low-value preoperative screening in the VA healthcare system (i.e., prior to cataract surgery), it is unknown if these patterns of low-value testing generalize to a variety of other minor procedures. Therefore, this study sought to determine the frequency and costs of potentially low-value preoperative screening tests among VA patients undergoing low-risk procedures. Using VA data, investigators identified 148,728 Veterans who underwent low-risk procedures (i.e., carpal tunnel release, cyst excision) without general anesthesia during FY2019 – and then assessed the overall national and facility-level rates and costs of nine common tests received in the 30 days prior to the procedure. Tests that were examined included: complete blood count, basic metabolic panel, coagulation tests, urinalysis, electro-cardiography, pulmonary function tests, trans-thoracic echocardiograms, cardiac stress tests, and chest x-rays. Patient demographics and comorbidities, as well as facility characteristics, also were assessed.

FINDINGS:

• Routine preoperative screening tests for very low risk procedures were common and costly in some VA facilities: 86,327 of 178,775 low risk procedures (49%) were preceded by 321,917 potentially low-value screening tests. This may represent more than $11 million in low-value care.
• Complete blood count was the most common test (33% of procedures), followed by basic metabolic profile (32%), urinalysis (26%), electrocardiography (19%), and pulmonary function test (12%).
• Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing.
• The top quartile of VA facilities with the highest testing cost accounted for 57% of total costs.

IMPLICATIONS:

• One way to address low-value preoperative testing is to develop quality measures of low-value care that could be integrated into VA’s extensive quality monitoring infrastructure. Further, by identifying facilities with the highest burden of low-value care, then seeking to identify its root causes, interventions can be designed and implemented to improve the quality of care by providing less of it.

LIMITATIONS:

• There is no way to be sure that tests ordered in the 30 days prior to a low-risk procedure were ordered for preoperative screening purposes. In addition, some tests that are generally low value may be justified by individual factors.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 16-216), and Dr. Harris is supported by an HSR&D Research Career Scientist award. Drs. Harris, Bowe, Hawn, Eisenberg, Finlay, and Mudumbai are part of HSR&D’s Center for Innovation to Implementation (Ci2i): Fostering High-Value Care in Palo Alto, CA.

Harris A, Bowe T, Kamal R, et al. Frequency and Costs of Low-Value Preoperative Tests for Patients Undergoing Low-Risk Procedures in the Veterans Health Administration. Perioperative Medicine. September 13, 2022;11(1):33.