Frequency and Predictors of Preoperative Cardiac Testing Overuse in Low-Risk Patients Before Laparoscopic Bariatric Surgery

King, Steven A.; Calisi, Olivia; Caldwell, Catherine; Berger, Daniel; Rich, Alyson M.; Dan, Yongwook; Qureshi, Umer; Ramedani, Shayann; Peterson, Brandon

doi:10.1016/j.amjcard.2022.09.024

Cited by 4 publications

(13 citation statements)

References 13 publications

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“…We expected that use of low‐value preoperative cardiac testing is a function of provider and system characteristics, specifically incentives and processes of care. Indeed, we found that a higher regional density of cardiologists, 30,46 a preoperative cardiology referral, 34 and a visit to a preoperative clinic rather than a primary care clinic 47 were associated with more preoperative testing. These findings are consistent with previous work studying low‐value care more generally, which showed that a higher ratio of specialists to primary care physicians was associated with more low‐value care 2 and that a higher regional concentration of cardiologists was associated with more low‐value cardiac testing 50 …”

Section: Discussionmentioning

confidence: 75%

“…Two studies were focused on Veterans 42,49 . Only a minority of studies had specific cardiac exclusion criteria 24,30,34,38,40,43,49 . Most of the included studies were observational using either cross‐sectional 22,24–26,28,34,40,41,45,46,48 or retrospective cohort designs (Table 1).…”

Section: Resultsmentioning

confidence: 99%

“…Fourteen of the 28 studies had a moderate risk of bias 22,24,25,27–29,31–34,36,41,43,49 . Nine had a low risk of bias, 30,38–40,42,44–47 and five had a high risk of bias (Table 1; Supporting Information: Tables ) 23,26,35,37,48 …”

Section: Resultsmentioning

confidence: 99%

“…Patients visiting a preoperative clinic, compared to a primary care clinic, 47 or those having a preoperative referral to a cardiologist 34 had more testing (Table 2; Supporting Information: Table ). A single‐center, quality improvement (QI) project demonstrated that when the hospitalist alone was tasked with determining the necessity of a preoperative echocardiogram, rather than the hospitalist, cardiologist, and anesthesiologist together, fewer echocardiograms were ordered 29 .…”

Section: Resultsmentioning

confidence: 99%

“…42,49 Only a minority of studies had specific cardiac exclusion criteria. 24,30,34,38,40,43,49 Most of the included studies were observational using either cross-sectional 22,[24][25][26]28,34,40,41,45,46,48 or retrospective cohort designs (Table 1). 27,30,32,33,37,38,[42][43][44]47,49 Of those with an intervention, 23,29,31,35,36,39 none was a randomized controlled trials although one was a nonrandomized controlled trial (Supporting Information: Table 8).…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

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Patient, provider, and system‐level factors associated with preoperative cardiac testing: A systematic review

Ellenbogen,

Drmanovic,

Segal

et al. 2023

Journal of Hospital Medicine

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BackgroundOveruse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system‐level factors associated with variation in testing have not been systematically studied.ObjectiveTo conduct a systematic review to better delineate the patient, provider, and system‐level factors associated with variation in preoperative cardiac testing.MethodsWe included studies of an adult US population evaluating a patient, provider, or system‐level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle–Ottawa Scale and Evidence Project Risk of Bias tool.ResultsTwenty‐eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher‐intensity testing. The evidence for provider and system‐level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low‐value testing can be successful.ConclusionsThere is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well‐defined. Further work should aim to better understand these factors.

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Section: Discussionmentioning

confidence: 75%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

See 3 more Smart Citations

Patient, provider, and system‐level factors associated with preoperative cardiac testing: A systematic review

Ellenbogen,

Drmanovic,

Segal

et al. 2023

Journal of Hospital Medicine

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Assessment and modification of cardiovascular risk in non-cardiac surgery. Clinical guidelines 2023

Sumin,

Duplyakov,

Belyalov

et al. 2023

Russ J Cardiol

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Association of a Novel Electronic Form for Preoperative Cardiac Risk Assessment With Reduction in Cardiac Consultations and Testing: Retrospective Cohort Study

Kumar,

Wilkinson,

et al. 2024

JMIR Perioper Med

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Background Preoperative cardiac risk assessment is an integral part of preoperative evaluation; however, there is significant variation among providers, leading to inappropriate referrals for cardiology consultation or excessive low-value cardiac testing. We implemented a novel electronic medical record (EMR) form in our preoperative clinics to decrease variation. Objective This study aimed to investigate the impact of the EMR form on the preoperative utilization of cardiology consultation and cardiac diagnostic testing (echocardiograms, stress tests, and cardiac catheterization) and evaluate postoperative outcomes. Methods A retrospective cohort study was conducted. Patients who underwent outpatient preoperative evaluation prior to an elective surgery over 2 years were divided into 2 cohorts: from July 1, 2021, to June 30, 2022 (pre–EMR form implementation), and from July 1, 2022, to June 30, 2023 (post–EMR form implementation). Demographics, comorbidities, resource utilization, and surgical characteristics were analyzed. Propensity score matching was used to adjust for differences between the 2 cohorts. The primary outcomes were the utilization of preoperative cardiology consultation, cardiac testing, and 30-day postoperative major adverse cardiac events (MACE). Results A total of 25,484 patients met the inclusion criteria. Propensity score matching yielded 11,645 well-matched pairs. The post–EMR form, matched cohort had lower cardiology consultation (pre–EMR form: n=2698, 23.2% vs post–EMR form: n=2088, 17.9%; P<.001) and echocardiogram (pre–EMR form: n=808, 6.9% vs post–EMR form: n=591, 5.1%; P<.001) utilization. There were no significant differences in the 30-day postoperative outcomes, including MACE (all P>.05). While patients with “possible indications” for cardiology consultation had higher MACE rates, the consultations did not reduce MACE risk. Most algorithm end points, except for active cardiac conditions, had MACE rates <1%. Conclusions In this cohort study, preoperative cardiac risk assessment using a novel EMR form was associated with a significant decrease in cardiology consultation and testing utilization, with no adverse impact on postoperative outcomes. Adopting this approach may assist perioperative medicine clinicians and anesthesiologists in efficiently decreasing unnecessary preoperative resource utilization without compromising patient safety or quality of care.

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Frequency and Predictors of Preoperative Cardiac Testing Overuse in Low-Risk Patients Before Laparoscopic Bariatric Surgery

Cited by 4 publications

References 13 publications

Patient, provider, and system‐level factors associated with preoperative cardiac testing: A systematic review

Patient, provider, and system‐level factors associated with preoperative cardiac testing: A systematic review

Assessment and modification of cardiovascular risk in non-cardiac surgery. Clinical guidelines 2023

Association of a Novel Electronic Form for Preoperative Cardiac Risk Assessment With Reduction in Cardiac Consultations and Testing: Retrospective Cohort Study

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