PREOPERATIVE PERSISTENCE
Doctors continue to order tests before surgeries despite growing research many waste time, money and can result in complications
Let’s say you’re scheduled for a common and relatively low-risk operation, such as a cataract removal, hernia repair, or a hip or knee replacement. It’s normal to feel anxious about any surgery.
But what if one of the presurgical tests your doctor orders — for example, a chest X-ray or cardiac stress test — turns up something unexpected, such as a suspicious nodule or a mild heart abnormality? Now you have even more reason to worry, and your surgery will probably be delayed until further tests assure the doctor it would be safe to operate.
Experts say that presurgical testing is often unjustified for many common operations. Many of these tests are a waste of time and money, a growing body of research shows, and the tests themselves can sometimes result in complications.
For more than two decades, experts in various medical specialties — including cardiology, ophthalmology and anesthesiology — have issued guidelines directed at reducing preoperative tests that rarely provide findings relevant to a patient’s surgical risk. Yet practicing doctors often do not follow this advice. Guidelines published in 2002 from the American College of Cardiology, the American Heart Association and the American Society of Anesthesiologists resulted in almost no change in doctors’ presurgical orders nearly a decade later, according to a report in JAMA Internal Medicine. The only exception was a decline in the use of electrocardiograms, or EKGS, a noninvasive test that checks heart function at rest.
Sometimes a preoperative test of questionable value results in unanticipated complications, as happened to a man in his 50s scheduled for repair of a painful hernia. Two Colorado doctors reported in 2014 that the man’s lab tests and physical exam were normal. But a chest X-ray, ordered because he had a history of mild asthma, suggested he had a nodule on a lung. Doctors delayed the surgery until he got a CT scan, which did not confirm a lung nodule but did find one on an adrenal gland. Again, doctors postponed surgery to allow for further work-up of the adrenal nodule, which was found to be benign. The man finally had his hernia repaired after six additional months of debilitating pain and repeated anxiety over incidental test findings suggesting he could have cancer.
However, doctors are making some headway. In 2019 in JAMA Internal Medicine, Dr. John Mafi, an internist at the University of California, Los Angeles, and his colleagues described an effort to reduce “low-value preoperative care” for patients about to have cataract surgery. New guidelines were issued, and a specially trained quality improvement nurse advised the surgeons about the new recommended protocol. The result, as assessed in a controlled clinical trial of 1,054 patients, was a dramatic decline in preoperative testing, a significant projected cost saving after the first year and “no measurable adverse effects” on the patients’ surgery, he said.
Perhaps most problematic among common preoperative procedures is a cardiac stress test, which assesses blood flow to the heart while patients exercise. Dr. Alana Sigmund, an internal medicine physician at the Hospital for Special Surgery in New York who has studied physicians’ responses to preoperative guidelines, said, “Cardiac stress testing is overordered. If there’s no indication of a heart problem, like shortness of breath, there’s no reason to do this test prior to surgery.”
The latest guidelines, which the American College of Cardiology and American Heart Association issued in 2014, advise that a cardiac stress test before surgery is generally not recommended for patients lacking symptoms suggestive of heart disease. The guidelines leave the decision to test up to the doctor. Existing evidence shows no health or lifesaving benefit from a preoperative stress test when the patient lacks cardiac symptoms or has fewer than two major risk factors for having a heart attack, such as high blood pressure and smoking, especially when the prospective surgery itself is low risk.
Yet despite these guidelines and a national campaign called Choosing Wisely, aimed at curbing unnecessary tests and procedures, a recent study by Dr. Daniel Rubin and his colleagues at the University of Chicago found that many doctors persist in ordering preoperative stress tests among patients at very low risk for cardiac complications. The study, published in JAMA Cardiology in January, looked at more than 800,000 patients having a hip or knee replaced, which is usually considered a low-risk surgery. It found that nearly half the patients who were given a preoperative stress test had no cardiac risk factors that might justify its use. Furthermore, the stress test did not lessen the risk of suffering a heart attack or cardiac arrest during or immediately after surgery, even among patients with one or more cardiac risk factors.
In fact, the stress test might have been counterproductive. For reasons Rubin could not explain, patients without risk factors who were given a cardiac stress test had double the surgical-complication rate experienced by comparable patients who did not have one.
Experts suggest you ask whether prescribed tests would reveal anything relevant to your surgical risk that the doctor could not determine by asking you a few questions during a routine physical. For example, answering a simple question such as “Do you get out of breath climbing a flight of stairs or walking four city blocks?” might provide a quick assessment of whether you might be having heart symptoms.
Mafi suggested that patients can help by questioning what a particular test might show and whether it’s really needed. Also helpful, he said, is to choose a doctor “who’s thoughtful, takes time to listen and is judicious about testing. You don’t have to order 100 tests if just one test will do.”
Experts suggest you ask whether prescribed tests would reveal anything relevant to your surgical risk that the doctor could not determine by asking you a few questions during a routine physical.