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Time to Cut Down on Pre-Surgery Testing

Researchers find that doctors haven't heeded professional societies' advice to do less pre-operative testing.
(Photo: Nukamari/Flickr)

(Photo: Nukamari/Flickr)

In the old days, doctors didn't need an MRI or even an X-ray to tell if you'd broken a leg. They just felt around, gently twisted your tibia a bit, and, if you screamed, chances were good you'd broken something. That's not to say advances in medical technology have been bad for patients, but a new study does suggest that doctors are administering some tests too often before they head into the operating room.

Pre-operative diagnostic tests have been on the rise for a while. In 2002, several  professional societies issued recommendations on which specific tests were important, and which ones doctors could safely ignore. Among the tests that doctors were ordering routinely—and unnecessarily: X-rays and other radiology tests; blood and urine analysis; electrocardiograms; and cardiac stress tests. Researchers from the American College of Cardiologists, the American Heart Association, and the American Society of Anesthesiologists argued that while those tests cost money to perform, they yield little useful information for doctors and surgeons. In almost all cases, the societies' reports stated, the tests simply aren't worth it.

In almost all cases, the tests simply aren't worth it.

Whether doctors have actually followed those recommendations, however, is less clear, so New York University School of Medicine assistant professor Alana Sigmund and a few colleagues decided to find out. Rather than ask doctors themselves what tests they'd been ordering, the researchers analyzed data, collected between 1997 and 2010, from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Those data sets cover a random sample of patients' visits to doctors and hospitals throughout the country, including the nature of the visit and what tests were ordered as a result.

While the overall frequency of unnecessary pre-operative tests has gone down a bit since 2002, a closer look at the NAMCS and NHAMCS data suggests things aren't quite so simple. The number of tests ordered during the course of annual check-ups and other regular visits to the doctor, the team found, was also going down, suggesting that the decline in unnecessary pre-op tests might simply be part of a broader decrease in testing. Indeed, when Sigmund and colleagues compared pre- and post-2002 trends in pre-surgery testing to trends in tests ordered during regular visits, they found essentially no change in how often doctors ordered radiology reports, blood and urine tests, and cardiac stress tests. Those results held up even after adjusting for patients' risk factors, insurance coverage, and other variables.

There was one exception to those results: electrocardiograms (ECGs). After accounting for general trends in testing and patient variables, the researchers estimate there was a 6.7 percentage-point drop in the frequency of pre-operative ECGs.

The study has some important limitations—for example, "general medical examinations may not be an adequate control group for preoperative evaluations," the authors write. Still, the researchers write, "our findings suggest that professional guidance aimed at improving quality and reducing waste had little effect on physician practice."

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