Stopping extensive pre-op testing requires malpractice reform

As predictable as the leaves falling this time of year, another paper on the subject of unnecessary preoperative laboratory testing has appeared.

A group from the University of Texas Medical Branch looked at more than 73,000 elective hernia repairs in the National Surgical Quality Improvement Project (NSQIP) database. Almost 2/3 of the patients had preoperative laboratory tests. Of that group, 58.6% had a CBC, 53.5% had electrolytes, 23.7% had liver function studies, 18.7% had coagulation studies and 9.9% had all of the above. Even 54% of patients with no co-morbidities had at least one test.

An abnormal test was found in more than 60% of those tested, of the 7200 patients who had lab tests done on the day of surgery, 61.6% had at least one abnormal test including 23% with a coagulation abnormality, 41% with a chemical abnormality and 33% with an LFT abnormality. Despite these results, the scheduled surgery was done.

Tests did not predict complications in patients without co-morbidities. Obtaining a test (not necessarily an abnormal result) was associated with a higher risk of major complications (0.4% versus 0.2% p < 0.0001) but not wound complications. However, abnormal results did not predict complications.

The authors of the paper recommended that surgical societies establish guidelines for preop testing.

Hernia patients, particularly those without co-morbidities, are similar to normal people. Obtaining lab studies on these patients is analogous to obtaining labs on the next 100 people who walk past the hospital. Few abnormal results will be found, and most of them will be false positives.

This fact has been known for at least 30 years, yet surgeons, who as shown by previous studies order 80% of preop tests, still continue to order them. Some question whether anesthesiologists insist on having the tests done. Is it defensive medicine? Force of habit?

When I was a department chairman and this subject came up for discussion, at least one person always said, “But if you miss one patient with (you fill in the blank), you will get sued.” That type of comment is very difficult to refute because there is a grain of truth to it.

As far as I can tell, “I was following evidence-based guidelines” is not a foolproof defense against a malpractice suit. While there have been some attempts to legislate that following evidence-based guidelines should “immunize” doctors against malpractice suits, to my knowledge, no such laws exist. In 2004, an article in the AMA’s Virtual Mentor journal discusses this point very well as does a paper from the Journal of Law, Medicine & Ethics.

What then is a practicing physician to do? That unnecessary pre-op testing occurs has been understood for many years. The paper points out that the estimated cost of preoperative testing is anywhere from $3 billion to $18 billion. Several esteemed associations and societies have established guidelines which are not followed.

Meanwhile, extensive preoperative testing of ambulatory patients continues at the discretion of the surgeon, anesthesiologist and probably the patient’s primary care doctor too. And the tab mounts.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • karen3

    The risk of avoidable harm to a patient is 25%. The risk of a doctor being sued for no good reason, or for that matter, any reason, by any single patient is near zero. Preventable medical error is the third leading cause of death in this country and I would bet the primary cause of death for those over 65.

    We shouldn’t leave serious injuries uncompensated because of irrational risk aversion by doctors. The way to cut malpractice premiums and the risk of suit is 1) strong state wide removal of incompetent doctors who are malpractice magnets and drive up everyone’s premiums, 2) not being a jerk and 3) reducing errors.

    By the way, malpractice plaintiff attorneys keep lists of doctors that potential plaintiffs complain about and they trade notes. Often, the plaintiffs bar will wait until there is a clear pattern before deciding to take a case against a particular doc. So, if you are a doc who has been sued, and the attorney is a respected one, there are probably a dozen other patients in the wings who could have sued and didn’t. It’s much less risk to the attorney to go after someone who has many complaints because it is more likely that there will be negligence, vs, a mere error or difference of opinion. If you get sued by a reputable firm, figure that you have a problem that you are not recognizing. The docs who get blindsided are like the guys who pay no attention to their unhappy wives and then “didn’t see it coming” when she divorces him.

  • http://twitter.com/Skepticscalpel Skeptical Scalpel

    I’m not sure where you are getting your data but a recent paper from the New England Journal of Medicine (http://www.nejm.org/doi/full/10.1056/NEJMsa1012370#t=articleTop) states the following:

    “Across specialties, 7.4% of physicians annually had a claim, whereas 1.6% made an indemnity payment. There was significant variation across specialties in the probability of facing a claim, ranging annually from 19.1% in neurosurgery, 18.9% in thoracic–cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry.”

    That’s slightly higher than “near zero.”

    You say, “The risk of avoidable harm to a patient is 25%.” In what context? What type of patient? In hospital or not?

    • karen3

      Assuming the doc to be seeing a patient every half hour, that would put a claim incidence rate at about one every 60,000 patient encounters, and a paid claim at about 210,000 patient encounter. That sounds really low to me. The 25% is from the HHS OIG, which physician reviewers making the assessments, for the Medicare population, in the hospital. IOM has come in with similar numbers for the general population. Office based practices are harder to assess. The fear factor is more realistically placed with the patient, not the doctor.

      • http://twitter.com/Skepticscalpel Skeptical Scalpel

        I don’t quite follow your argument. If I, as a general surgeon, have a 15% chance of getting sued annually, that is not a low risk.

  • ninguem

    I don’t know it this is relevant or not.

    I have a preop patient today. He’s got multiple medical problems. On paper, he doesn’t need PSA testing for example, for the planned hand surgery.

    But he needs the test for general health maintenance. Assuming one believes in PSA testing, I know it’s controversial.

    I take the opportunity to get a bunch of housekeeping matters addressed when the patient is here for preop lab work…….none of which is indicated for the anesthesia and surgery planned.

    • http://twitter.com/Skepticscalpel Skeptical Scalpel

      It’s relevant. It could explain some of the seemingly “unnecessary” testing that is done. My question is, “Are any ‘general health maintenance’ blood tests really needed?