A Clinical Process Change and Educational Intervention to Reduce the Use of Unnecessary Preoperative Tests

Abstract

Background Internal medicine residents receive limited training on how to be good stewards of health care dollars while preserving high-quality care. Intervention We implemented a clinical process change and an educational intervention focused on the appropriate use of preoperative diagnostic testing by residents at a Veterans Administration (VA) medical center. Methods The clinical process change consisted of reducing routine ordering of preoperative tests in the absence of specific indications. Residents received a short didactic session, which included algorithms for determining the appropriate use of perioperative diagnostic testing. One outcome was the average cost savings on preoperative testing for a continuous cohort of patients referred for elective knee or hip surgery. Resident knowledge and confidence prior to and after the intervention was measured by pre- and posttest. Results The mean cost of preoperative testing decreased from $74 to $28 per patient after the dual intervention (P < .001). The bulk of cost savings came from elimination of unnecessary blood and urine tests, as well as reduced numbers of electrocardiograms and chest radiographs. Among residents who completed the pretest and posttest, the mean score on the pretest was 54%, compared with 80% on the posttest (P = .027). Following the educational intervention, 70% of residents stated they felt “very comfortable” ordering appropriate preoperative testing (P = .006). Conclusions This initiative required few resources, and it simultaneously improved the educational experience for residents and reduced costs. Other institutions may be able to adopt or adapt this intervention to reduce unnecessary diagnostic expenditures.

Intervention Descriptions in Medical Education: What Can Be Improved? A Systematic Review and Checklist

“…We could not find the additional material for 5 articles (mean score: 13.8 [SD 3.1]). 18,19,44,48,83 For the remaining 19 articles, 22,23,25,35,39,41,50,51,74,78,81,91–93,98,104,110,116,119 scoring included the supplementary material. The mean score of these 19 articles was 18.3 (SD 3.7; range 13–25), significantly higher than the mean score of 15.5 (SD 4.0) for the 81 articles without additional information ( P = .007; 95% CI on the observed difference = 0.8–4.8).…”

Cost of Low-Value Imaging Worldwide: A Systematic Review

“…When introducing an intervention to reduce the routine/daily use of CXR in the ICU, four studies showed a cost reduction of 20‒66% without affecting quality of care [ 25 , 35 , 36 , 54 ]. Furthermore, the reduction of preoperative routine CXR reduced costs by 88% in one study [ 45 ]. For X-rays of ankle injuries, two studies found that using the guidelines could reduce costs by 7‒49% [ 48 , 93 ].…”

An Economic Evaluation of the Preoperative Investigations for Elective Surgical Patients at a Caribbean Tertiary Care Teaching Hospital

“…The current clinical guidelines to guide preoperative evaluation available in the study hospital were formulated and published in 2002. Strides have been made throughout the world in these two decades as to the evidence available and subsequent clinical publications that advise on appropriate preoperative investigations [ 11 ]. One significant change noted in both the US and the UK is that they have eliminated age as an independent factor used to dictate which investigations should be performed.…”