De-Implementation Background Evidence
Wasteful spending in healthcare has been well documented and researched, with the Institute of Medicine estimating at least $210 billion spent on unnecessary medical testing and care in the U.S. each year.
The Washington Alliance estimates that $85.2 million is spent on unnecessary preoperative tests for healthy patients facing low-risk procedures, and many peer-reviewed publications link routine preoperative testing with downstream harm to patients and providers.
Choosing Wisely has assembled hundreds of clinical recommendations that aim to reduce unnecessary testing, are supported by evidence, are free from harm, and are truly necessary. Of these recommendations, Choosing Wisely has a top 12 list, which includes guidelines for preoperative testing in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.
The Choosing Wisely guidelines are based on clinical recommendations put forth by the following professional medical societies:
- American Academy of Ophthalmology
- American College of Physicians
- American College of Radiology
- American College of Surgeons
- American Society of Anesthesiologists
- American Society of Clinical Pathology
- American Society of Echocardiography
- Society of Thoracic Surgeons
NATIONAL RECOMMENDATIONS
RECOMMENDATIONS BY TEST:
Multiple societies have recommended against routine preoperative testing (e.g., laboratory studies, chest x-rays, EKGs, cardiac stress tests, etc.) in low-risk patients prior to low-risk procedures.
BLOOD WORK
American Society of Anesthesiologists – Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) who are undergoing low-risk surgery – specifically, this applies to complete blood count, basic or comprehensive metabolic panel, or coagulation studies when blood loss (or fluid shifts) are expected to be minimal.
CHEST X-RAY
American College of Physicians – Don’t obtain routine preoperative chest radiographies in the absence of a clinical suspicion of intrathoracic pathology.
American College of Radiology, American College of Surgeons – Avoid preoperative chest radiographies for ambulatory patients with unremarkable history and physical exams.
EKG/ECG and ECHO TESTS
American College of Cardiology – Avoid performing electrocardiography (EKG or ECG) screening as part of preoperative cardiovascular risk assessment in asymptomatic patients scheduled for low-risk non-cardiac surgery.
American Society of Echocardiography – Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.
CARDIAC STRESS TESTS
The Society of Thoracic Surgeons – Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery.
American Society of Anesthesiologists – Don’t obtain baseline diagnostic cardiac testing (e.g., echocardiography or cardiac stress testing) in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.