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The Medical Professionalism Blog

Defining Appropriate Use System-Wide

A number of specialty organizations have identified preoperative testing (i.e., lab tests, x-rays and cardiac testing) in healthy patients undergoing low-risk surgery as a frequently overused service and have included it on their Choosing Wisely® lists of tests and procedures that may be unnecessary. As preoperative testing may be ordered or requested by a multiple groups of physicians—surgeons, anesthesiologists, general internists or pediatricians or medical specialists—ensuring its appropriateness is complex. On April 30, the New York Academy of Medicine (NYAM) and the ABIM Foundation sponsored a multispecialty panel discussion to define appropriate preoperative testing and to discuss:

  • potential harms of overtesting;
  • reasons why overtesting is common; and,
  • strategies to optimize testing.

Panelists and attendees included internists, pediatricians, anesthesiologists and surgeons. Many attendees used the event as a springboard for revising policies around preoperative testing at their hospital or practice. In keeping with guidelines from the American Society of Anesthesiologists and the American College of Cardiology/American Heart Association, panelists from all specialties agreed that healthy patients undergoing low-risk surgery should undergo little or no testing. Beyond that important agreement, several notable points emerged from the discussion:

  1. Testing decisions must be individualized for patients with chronic medical conditions and for those undergoing higher-risk surgery. The group did note the lack of evidence or guidelines for how to do that.
  2. Several policies and strategies can facilitate appropriate testing, including centralized preoperative clinics. Such clinics can then work with multiple stakeholders to establish practice norms, and policies issued by the anesthesia departments can serve to disseminate information through the institution. Dr. Michael Janjigian from Bellevue Hospital discussed the process and impact of using a pre-op clinic to reduce unnecessary testing and Dr. Elizabeth A.M. Frost discussed anesthesia policies at Mount Sinai.
  3. Feedback on ordering appropriately, in a variety of contexts, must be given to providers.
  4. Good communication to optimize this process across departments, including communication among providers of patient care and between providers and the patient, is important in managing expectations and avoiding unnecessary testing.

The event successfully facilitated constructive conversation among participants from diverse institutions and specialties to work toward minimizing this important overuse of resources. It also emphasized the multifactorial drivers of inappropriate care, the complexity of reducing it and the need for consensus-building and strong interprofessional communication when working to optimize care.

NYAM hopes to provide a forum for additional cross-specialty discussion related to this and other issues in the future.

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