How can we cut wasteful pre-surgery testing?

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For many patients, getting ready to have surgery means getting their blood drawn, their heart rhythm checked, or having other tests in the weeks leading up to their operation.

But not all patients need all those tests – especially if the results won’t change how their surgical team treats them or how well they do afterward.

Now, a study shows how hospitals can focus the use of such tests on the patients who truly need them, while safely reducing unnecessary testing in others.

The result: less wasted money and resources for each test, and less wasted time for patients and clinical staff.

The study, published in JAMA Surgery by a team from the University of Michigan and Brigham and Women’s Hospital, tested a program designed to reduce unneeded preoperative tests at U-M Health.

It focused on reducing four tests in low-risk patients having breast lumps or diseased gallbladders removed, or hernias fixed, in outpatient operations.

Before the intervention, 37% of such patients had at least one unnecessary test. By the end of the study, that rate dropped to 14%.

Overall testing – the percentage of all patients receiving the four tests before having these operations – dropped from 51% to 27%.

At the same time, preoperative testing didn’t change for patients who needed it, based on their health status and surgical risk.

And rates of emergency department visits and hospitalizations stayed the same in the weeks after patients had their operations, suggesting that reducing unnecessary testing didn’t worsen surgical safety or outcomes.

The study shows that during the time when U-M Health reduced unnecessary testing and overall testing, the use of the same tests in similar patients stayed the same at dozens of other hospitals in the state.

Making change together, and measuring its effect

The study’s leader says it’s not just the drop in unnecessary testing, but the way the team achieved it and measured it that makes the study different.

The intervention focused on educating clinicians on the evidence that they could safely reduce testing in some patients, and involving them in how they did so, says senior author and U-M Health surgeon Lesly Dossett, M.D., M.P.H.

“If we truly want to reduce wasteful testing, the kind that provides no value and won’t change care, we need to help team members understand the rationale, to base our intervention on what we know about creating lasting positive change, and to provide easy-to-use tools to support clinical decisions,” said Dossett.

“We’re excited by what we were able to achieve at our preop clinics, and look forward to testing this in hospitals statewide.”

Dossett co-leads the Michigan Program on Value Enhancement, or MPrOVE, through which the new study was conducted.

MPrOVE teams the clinical quality improvement efforts of U-M Health with the rigorous research methods of the U-M Institute for Healthcare Policy and Innovation.

It’s funded by Michigan Medicine, U-M’s academic medical center.

More about the study

The study involved 1,143 patients with an average age of 58 seen at U-M Health’s three preop clinics for outpatient surgery sites from June 2022 to the end of August 2023.

U-M Health had high levels of preop testing (both necessary and unnecessary) in a previous study of 63 hospitals across Michigan published in 2021, so it was a key area for improvement.

During the intervention period, the surgeons and physician assistants involved in the preop clinics had multiple sessions with the study team, and worked to build consensus around which patients needed which tests and which did not.

In the end, the clinicians were asked to follow a flow chart and grid – called decision support documents – to determine which tests a patient should have before surgery, based on their individual characteristics. 

The tests in question were selected because years of research and recommendations from national and international health care quality groups have deemed them unnecessary for certain patients. 

Blood tests called complete blood cell counts, basic metabolic panels and comprehensive metabolic panels were targeted, as were electrocardiograms.

Each patient was scored on a standard scale used by anesthesia professionals to rate the risk of a patient suffering a complication during anesthesia.

Those on the lowest two rungs were able to forego all four tests unless a specialist had specifically ordered it.

But even patients at the higher end of this scale, called the ASA Physical Status, were able to avoid certain tests depending on what other conditions they had.

Alexis Antunez, M.D., M.S., is a U-M Medical School alumna and the study’s first author.

She was a visiting surgical research resident at Michigan Medicine at the time of the study and is now at the Brigham and Women’s Department of Surgery.

MPrOVE program manager Tony Cuttitta, M.P.H., notes that several U-M Medical School students worked on the study design and data analysis.

He also explains that the U-M team is working to scale up the number of surgical specialties using the approach and evaluate the impacts.

The effort was so successful that the U-M team is partnering with 16 other hospitals across Michigan to repeat the same intervention that spurred the change.

The statewide study, which is funded by a grant from the federal Agency for Healthcare Research and Quality, is now under way.

It involves hospitals taking part in collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan and will test whether the model that succeeded at U-M Health is generalizable to other care settings. It will also analyze the financial impact of avoiding unnecessary tests.

Additional authors: In addition to Dossett, Antunez and Cuttita, the study's authors are Ruby J. Kazemi, B.A.; Caroline Richburg, MD; Cecilia Pesavento, M.D., M.B.A.; Andrew Vastardis, M.S.; Erin Kim, B.S.; Abigail L. Kappelman, M.A.; Devak Nanua, M.S.; Hiba Pediyakkal, B.A.; Faelan Jacobson-Davies, M.A.; Shawna N. Smith, Ph.D.; James Henderson, Ph.D.; Valerie Gavrila, M.P.H.; and Hari Nathan, M.D., Ph.D. 

Dossett, Nathan, Smith and Henderson are members of IHPI; several authors are members of the Center for Healthcare Outcomes and Policy, and the Michigan Value Collaborative.

Funding/disclosures: The study was funded by the National Institutes of Health (T32CA009672), the Agency for Healthcare Research and Quality (R01HS029306-01A1) and Blue Cross Blue Shield of Michigan's support for the Michigan Value Collaborative as part of the BCBSM Value Partnerships program.

Paper cited: “Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing,” JAMA Surgery. DOI: 10.1001/jamasurg.2024.6063