Preoperative evaluation can lead to unnecessary tests and may waste money

What’s one of the biggest culprits for the rise of unnecessary medical testing?

Preoperative evaluation.

Before most patients undergo surgery or an invasive procedure, they are normally sent to their primary care physicians for a “preoperative evaluation.”  This is a visit to determine if they are medically stable enough to undergo the operation.

Tests like bloodwork, an EKG, or a chest x-ray are frequently ordered.  For those with suspicion of coronary artery disease, a stress test is sometimes considered, based on the patient’s symptoms.

According to a recent study, however, may of these tests may be unwarranted.  Not only do they waste money, they also can potentiate further, more invasive, studies that stem from incidentilomas.

Published in Obstetrics & Gynecology, researchers,

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.

There are several reasons.  Of course, malpractice worry is at the back of most doctors’ minds.  As the chief author puts it, “‘Number one, certainly, a lot of this is medicolegal’ — meaning, basically, doctors don’t want to get sued for not having a test done.”

Also, the entire medical team needs to be on the same page.  Meaning, the preoperative guidelines for the primary care doctor, surgeon, and anesthesiologist has to be the same.

If I don’t feel like a certain preoperative test is necessary, for instance, it shouldn’t be ordered by a consultant. This is difficult in most practices, where the preoperative doctor, surgeon and anesthesiologist operate under separate auspices.

Having everyone under the same roof, such as in a large, integrative practice, can help in consolidating the recommendations and, perhaps, reduce $3 billion wasted on unnecessary preoperative tests.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    I routinely receive requests for preoperative examinations on my elderly primary care patients. Many of the tests and requirements are dictated by the surgeon and by the hospital with little or no consideration of the literature on the subject. Outpatient surgical clearances are even worse. We will have surgeons ordering HiV tests and Hepatitis screening for no apparent reason. In order to assess risk you must know the health of the patient. That requries taking a history thoroughly and doing a physical examination. Knowing the risk category of the patient and the risk category of the type of surgery allows you to assess risk and make recommendations. Unfortunately most of the time that an inappropriate or unnecessary test is ordered by the surgical team or required by the hospital you are in a position of seeing that it gets done or the patient doesnt get to have the procedure.

  • L.

    My recent experience bears this out. At the so-called “America’s #1 Hospital” I have had and several recent surgeries. Interestingly, the SECRETARY ordered the tests, when I scheduled my surgery – not the doctor – reading off a sheet created years ago, most likely – When I questioned the SURGEON – he said – oh, you don’t need that – while the SECRETARY – made it sound as if the surgeon would refuse to operate if I refused a chest x-ray. I’ve had enough radiation, (reached my life-time limit) thank you very much – and you better need a darn good reason to order a chest x-ray before you order one for me.

  • Bladedoc

    HIV and hepatitis screens – there are a number of surgeons who feel that they will not do a complicated elective procedure and put themselves at risk for a career-ending chronic illness if at all possible. I myself do so much emergency survey I’ve become blasé but it’s the surgeons’ choice.

    The rest of the stuff is purely medicolegal, change the system or suck it up.

  • Lady Patient

    re: mandatory HIV and hepatitis screens:

    Shouldn’t the patient have the right to know the HIV or hepatitis status of the operating team also? It seems to me that they could be the greater threat for passing along an infection to the patient rather than the other way around.

    • Bladedoc

      Sure, they can request it. I’ll say no and they can find another surgeon. No sweat. Just like they can refuse testing and I can refuse to operate on them. Fair is fair.

      • Lady Patient

        I was really playing devil’s advocate with my question and was hoping for a reasonable explanation why a doctor’s infectious disease status is not the patient’s business. If one of your real patients asked the same question, would you have given the same abrupt response you gave me?

        • Dr.Z

          @ladypatient. Think about it. How long do you think a surgeon or a member of their support team would be allowed to practice if they contracted an infectious disease?

        • BladeDoc

          I would give an answer with the same meaning but clearly brief interactions via blog commentary will be more abrupt and less able to convey nuance and feeling than a person to person conversation.

          BTW I give the same answer to patients who refuse to have residents help with the case, i.e. “this is a teaching hospital, it has been shown that teaching hospitals have a better outcome. It is my routine to have resident assistance during surgery and if you do not want this you need to go to another surgeon.”

  • DoctorZ

    Arguing that preop evaluation leads to unnecessary testing is analogous to argueing that a particular immunization is wasted on those who don’t contract the disease.

  • http://fertilityfile.com IVF-MD

    I often do something that is the equivalent of pre-op testing and that’s obtaining medical clearance before helping a patient get pregnant. The hemodynamic changes that a woman undergoes during pregnancy, labor and delivery rival those of many surgical procedures.

    Sure, if a patient gets pregnant on her own, she would obviously run the same risks. But since it’s my medical treatment that helped her get pregnant, the medicolegal system puts the burden on me to make sure she was reasonably fit to endure pregnancy. Of course, this is not necessary on someone young, with no risk factors.

    Here’s an additional interesting concept. Suppose a husband has hepatitis and has sex with his wife for years and years, exposing her to the risk of contracting it. If instead, however, it’s an IVF procedure which probably presents a much lower risk of transmission, it is mandatory to test (in California) for HIV, hepatitis B and C, VDRL and something called HTLV-1. The couple are forced to pay for this testing even if they wanted to waive it, saying “Well, if we’ve never tested for these in the years we were married, exposing ourselves to the risk of transmission every time we tried to get pregnant naturally, then why should we be forced to do this testing now?”, they would still not be allowed to waive it. Now, having said that, I will share that in 13 years of doing hundreds of these panels that almost all come back negative, there were two cases of undiagnosed HIV-positive husbands who were detected simply by routine pre-IVF screening. True, it was useful in these cases, but then would you make the argument that every couple that is having sex be forced to do these same tests every year or so? After all, if you did that, I’m sure you’d discover many more cases of husbands who were HIV positive and didn’t know it. Is it the patient’s choice of how much risk they are willing to take? Or is it the turf of bureaucrats in entities like OSHA and the FDA to dictate what everyone must be tested at what time for what disease?

  • family practitioner

    There is a bigger problem within this, and that is the bullying of primary care by specialty offices.

    This is what happens:
    1. Telephone call to my office goes like this: “I was just put on Dr. Big Shot Surgeon’s schedule next week for my elective surgery and I need an appointment with you for clearance IMMEDIATELY!, or my surgery with Dr. Big Shot will be delayed! and it WILL BE YOUR FAULT!”
    2. Patient shows up for pre op clearance with a scribbled note on a scrip pad from the surgeon: “Medical clearance for surgery”. So I play detective, try to figure out what and when the surgery is, examine the patient, determine they are ok for the procedure and scribble my own note on a scrip pad: “The patient is medically cleared for the procedure.” Later in day, patient calls and says that the surgeon will not accept the note because I did not write enough.
    3. Or, the patient shows up for pre-op clearance with a 3-4 page H and P form, required by the hospital, even though I am not privileged at the hospital and probably not legally allowed to do the H and P for that patient at that particular hospital.
    4. Or, the patient does not understand that an appointment is required for clearance, and faxes over the form, or drops it off, and then calls a few days later saying, “My surgery with Dr. Big Shot is tomorrow, how come you have not done the forms yet?”
    5. Or, the surgeon demands I do things that are not clearly medically indicated, but I bear the responsibility of medicare maybe not covering it, and face the wrath of an angry, entitled patient.

    Oy vey, enough kvetching already! But all of the above is not the exception, but the norm.

  • surgical resident

    Lots of surgeon bashing here….

    @lady pt. Please show us one case report of an infected surgeon infecting a patient

    I hate “pre-op” clearance which is why I never get one from a pcp. I will get a pulm eval if needed or order whatever test I need. Our biggest problem is anesthesia. We often follow the heart associations pre-op algorithm with beta blockers, etc. We show up to the or and anesthesia wants an echo, which is not indicated and will only delay the case. I also ask them what we will do if it shows a low ef, and they always say it’s nice to know these things. It’s a tremendous waste of money and time.

    I do agree that having an internist write an h&p for you is lazy and irresponsible.

    @doctorz. I think analogy is way off. Pre-op testing is expensive (vaccines aren’t), unnecessary (vaccines aren’t), are not standardized (vaccines are), etc. The stress test is a common waste of cash. You order a test when any intervention is contraindicated due to the need for surgery to take out there cancer, fix their aaa, etc.

    Kevin is right on the money

    • Dr.Z

      @surgical resident… my point was that reason people don’t contract disease is because they were immunized… and the reason that surgical procedures are successful is because preop evaluations screen out those at risk of the procedure they were scheduled to receive.

      What is forthcoming is pressure on specialists to accept the H&P in the referred patient’s EHR and results of tests performed 2 months ago which the PCP requested by a lab unknown to the specialist. While the patient was referred to the specialist … the patient couldn’t get an appointment for 2 months … and insurance will not pay for new test.

      • surgical resident

        Dr. Z,

        I see your point, but I would argue that a surgeon should be able to do some basic screening and physical exam skills ( we did go to medical school). I’ve had referrals from PCP’s for abdominal hernia repairs in 60 yo’s that are anemic and never had colon cancer screening. So of course, we do some screening. I also think that someone should be forced to see a pcp before they see a surgeon or other specialists.

  • Primary Care Internist

    I never understood why I need to get a U/A for a patient undergoing OUTPATIENT CATARECT SURGERY (actually true, major NYC hospital).

    Pre-op testing is 99% administrative bs designed by nurses or administrators, and 1% medicolegal.

  • Primary Care Internist

    oops i meant “CATARACT” not to be confused with cata-rectum

  • Taylor

    What types of surgery are people getting that they need surgery clearance? I had elective surgery (orthognathic surgery) in June 2009 and I didn’t have to do anything except the pre-op phone call with the hospital. I didn’t even have a PCP at the time of my surgery other than my gynecologist, but obviously she would not be consulted for orthognathic surgery!

    • Dennis

      In my town, eye docs won’t do catarat surgery without medical clearance, ekg, cbc and bmp

  • Lady Patient

    surgical resident said:

    Lots of surgeon bashing here….

    Please show us one case report of an infected surgeon infecting a patient

    “““““
    How would any such report be initiated if the operating team has no mandate for testing. Considering the many posts here from doctors who have given their opposition to exposing such things as surgical errors or mistakes, I would think their infectious disease status, and any potential to harm a patient, could be hidden as well.

    just playing devil’s advocate…….

  • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

    As per my blog of August 29, 2010, a recent paper, written by anesthesiologists not surgeons, in Archives of Internal Medicine http://tiny.cc/0asay points out that patients who receive preop consultations have worse outcomes and receive more tests, many of which are unnecessary. You should read the entire paper.

  • ninguem

    Clusters of postoperative infections. They do get picked up.
    http://www.ncbi.nlm.nih.gov/pubmed/7658076 This was candida, tracked to a nurse with frequent candidal infections herself.

    There was another one a while back, again tracked to a scrub nurse, cardiac surgery as I recall. It was a more unusual bug, traced back to the skin and fur of a scrub nurse’s dog. An observed flaw in her scrub technique showed how it could get past the usual operating room scrubs to the patients.

    The only surgeon-to-patient HIV case was that dentist in Florida a decade or so ago, and it looked like what the dentist did was deliberate. Since the HIV-infected dentist is no longer alive, hard to tell. There was suspicion the sicko was deliberately contaminating needles.

    Patient exposed to one surgeon, surgeon exposed to thousands of patients, blood exposure a random event, so every time there’s an encounter, there’s a chance of a needlestick or a glove break with broken skin. Patient encounters one surgeon, while the surgeon encounters thousands of patients, who’s at higher risk of catching a blood-borne disease?

  • ninguem

    Most of the requests for “preoperative evaluation” from surgeons, that come to me about my own patients, are really demands for me to write the H+P for them.

    Mostly orthopedics. Occasionally from the ophthalmologists.

    Often they are at hospitals where I am not on staff. They are “kind” enough to forward information on how to use the dictation system of a hospital I’ve never seen, so the H+P will be sitting on the chart for them. I decline to do that. I send a letter outlining the medical problems the patient has, meds, allergies, the usual medical history. Mention that the medical problems are properly addressed if accurate. Glycemic control and all that. Testing is usually done more for my own patient management rather than surgical protocol, though I make sure to forward a copy of testing to the surgeon. The surgery is a good patient motivation to get in the office to be seen for general medical care.

    I have yet to see such a H+P request from a general surgeon.

  • http://www.sleepapnea.org Edward Grandi, E.D. @ ASAA

    Many thoughtful comments, but pre-operative screening for sleep disordered breathing, obstructive sleep apnea could mean the difference between life and death for the undiagnosed surgical patient. A simple set of questions – STOP-BANG (highly sensitive and specific) could determine the anesthesia protocol and the level of post-operative care.