March 13th, 2018
The Lown Institute Vignette Competition challenges medical students and trainees to shine a light on everyday overuse and underuse – common practices that either give patients unnecessary tests and procedures, or that fail to give patients necessary care. Sharing stories of the downstream consequences of overuse can be a powerful counterbalance to the ‘more is better’ culture and can help clinicians recognize and avoid overuse.
This year, we received vignette submissions from students and trainees all over the country (and internationally!) on topics from avoiding polypharmacy to inappropriate stenting to navigating clinical guidelines.
We’re publishing the top vignettes on our website. Learn more about the competition and read all the vignettes here.
Valeria Chew, MD Candidate, Drexel University College of Medicine
Jian Liang Tan, MD, Crozer-Chester Medical Center
Kshitij Thakur, MD, Crozer-Chester Medical Center
A 63-year-old female with history of glaucoma, well-controlled hypertension and diabetes mellitus type II was at her primary care physician office for a preoperative evaluation prior to her left eye glaucoma surgery. She was well and had no functional limitation at baseline. Physical examination was unremarkable. Complete blood count and Complete metabolic panel (CMP) were ordered by ophthalmologist as part of the preoperative evaluation. An electrocardiogram (ECG) was performed which revealed sinus bradycardia with a heart rate of 47 beats per minute. The nurse practitioner who was evaluating the patient decided to refer her to the cardiologist for further evaluation prior to the surgery. The patient was evaluated by her cardiologist and was reassured multiple times that the ECG finding was benign and warranted no further investigation. She proceeded with the glaucoma surgery the following month and had an uneventful recovery.
Preoperative evaluation for noncardiac surgery is one of the most common assessment routinely performed by primary care physicians in the outpatient setting. The goals of the assessment are to stratify risk, optimize patient condition preoperative and minimize postoperative complications. Physician often tends to overorder medical tests on a low-risk patient during the preoperative evaluation with the perception that more care is better care, or even that less care is subpar. A survey conducted by Heather Lyu et al revealed that close to 20% of the medical care was deemed unnecessary, with ¼ of them fell in the category of unnecessary tests, and majority of the respondents cited fear of malpractice and patient pressure or request.1
Preoperative risk assessment consists of history, physical examination, perioperative cardiac risk stratification, and appropriate perioperative testing. A focused history and physical examination are the very first step to identify any undiagnosed or underlying decompensated conditions that may warrant further clinical investigations.2 The Ophthalmology Society Choosing Wisely Guidelines recommend against routine medical tests prior to eye surgery in an otherwise asymptomatic patient, unless the history or physical examination indicates the need for a test. A recent study looking at preoperative testing prior to cataract surgery had shown that unnecessary preoperative testing cost Medicare around $45.4 million annually, albeit the recommendations against preoperative testing before low-risk surgeries.3
Various risk models were used to estimate the perioperative risk of major adverse cardiac event (MACE) and guide laboratory testing.2 The revised Cardiac Risk Index, an externally validated tool, is commonly used to predict the risk of MACE. Our patient has a low-risk of MACE as her estimated risk was at 0.9%. The guidelines recommend against preoperative cardiac testing (cardiac stress test, echocardiography, 24-hour ambulatory monitoring) in low cardiac risk patient and patient may proceed with the surgery without further cardiac tests.2 It is also important to determine the type of surgery during the preoperative risk assessment as high-risk surgical procedure (major vascular surgery, major abdominal surgery, pneumonectomy, esophagectomy, adrenal resection or lung, liver or pancreas transplantation) often has greater surgical adverse events and it may require a comprehensive workup prior to the surgical procedure. The converse is true for eye surgery, where it is categorized as a low-risk surgical procedure, (breast, dental, thyroid, endoscopic or superficial surgery) which is often performed as in the outpatient setting. The American College of Cardiology Choosing Wisely Guidelines and American Family Physician recommend against routine ECG screening as part of preoperative evaluation in an asymptomatic low cardiac risk patient undergoing low-risk procedure.4 Our case is a good example to illustrate the extensive use of unnecessary workups (CBC, CMP, and ECG) in asymptomatic low cardiac risk patient who was evaluated in the clinic prior to her low-risk surgical procedure.
Unnecessary tests can be burdensome to the patients as well as the healthcare cost as they often cause false alarms and anxiety which may lead to overdiagnosis and overtreatment. These may inadvertently cause patient harm due to unnecessary imaging (radiation exposure), consultations/referrals or procedures (non-invasive and invasive) and delay in operative plans. According to Mark Smith et al, a 50% reduction in unnecessary tests and procedures could potentially save $105 billion annually (approximately 4% of the total national healthcare spending).5
In summary, reducing unnecessary tests and procedures in preoperative risk assessment among patient undergoing surgical procedure aim to provide cost-effective and high-value care for our patients. Remember that “less is more.”