Proving that less really is more, five specific tests or procedures commonly performed in anesthesiology that may not be necessary and, in some cases should be avoided, will be published online June 16 in JAMA Internal Medicine. The "Top-five" list was created by the American Society of Anesthesiologists® (ASA®) for inclusion in the ABIM Foundation's Choosing Wisely® campaign.
"The Top-five list of activities to question in anesthesiology was developed in an effort to reduce unnecessary, costly procedures and improve patient care," said Onyi Onuoha, M.D., M.P.H., lead author and assistant professor of the Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania. "The Choosing Wisely list can help patients and doctors save time, money and prevent possible harm by avoiding medical treatments or tests that may not be required. Therefore, it is important for patients to talk with and ask questions of their primary care physicians, surgeons and physician anesthesiologists about their medical care to better determine which tests and procedures are truly needed."
According to the article, unnecessary health spending in the United States was estimated at $765 billion in 2009, of which one-quarter or, $210 billion, was applied to the overuse of services, including those that are provided more frequently than necessary or that cost more but are no more beneficial than lower-cost alternatives.
Initially, the authors identified 18 low-value anesthesia-related tests, treatments, or procedures by conducting a literature review and using ASA's current practice parameters. Criteria for inclusion included 1) common clinical practices for which 2) avoidance would lead to improved quality of care or 3) reduced costs, 4) there is little or no evidence of benefit to patients, and 5) implementation of avoidance would be feasible to achieve. Candidate items were restricted to common preoperative and intraoperative practices in anesthesia; postoperative practices and pain services were excluded.
Next, a multi-step survey of physician anesthesiologists in mostly the academic sector was conducted and analyzed in order to generate a "Top-five" list of preoperative and intraoperative activities to be questioned. The "Top-five" list was reviewed by ASA committees of jurisdiction, section chairs and division chairs. Finally, the list was endorsed by ASA leadership.
Physician anesthesiologists identified the following five recommendations:
1. Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery -- specifically, complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
2. Don't obtain baseline diagnostic cardiac testing (trans-thoracic/esophageal echocardiography -- [TTE/TEE]) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low- or moderate-risk non-cardiac surgery.
3. Don't use pulmonary artery catheters (PACs) routinely for cardiac surgery in patients with a low risk of hemodynamic complications (especially with the concomitant use of alternative diagnostic tools (e.g., TEE).
4. Don't administer packed red blood cells (PRBCs) in a young healthy patient without ongoing blood loss and hemoglobin of ≥ 6 g/dL unless symptomatic or hemodynamically unstable.
5. Don't routinely administer colloid (dextrans, hydroxylethyl starches, albumin) for volume resuscitation without appropriate indications.
"Given the challenge of translating guidelines into practice, evaluating the ability of physician anesthesiologists to actually implement these items was an important part of the survey," said Lee Fleisher, M.D., senior author and chair of the Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania. "A majority of respondents indicated the inability to implement these recommendations in isolation. With physicians from multiple specialties cooperating in perioperative care, a multidisciplinary approach involving the primary care physician, surgeon and physician anesthesiologist is needed to ensure these recommendations are implemented."
To date, nearly 100 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the conversations about appropriate care. With the release of these new lists, the Choosing Wisely campaign will have covered more than 250 tests and procedures that the specialty society partners say are overused and inappropriate, and that physicians and patients should discuss. The ASA's initial Choosing Wisely list on anesthesiology was released in October 2013 and a second list on pain medicine/chronic pain was published in January 2014.
- Onyi C. Onuoha, Valerie A. Arkoosh, Lee A. Fleisher. Choosing Wisely in Anesthesiology. JAMA Internal Medicine, 2014; DOI: 10.1001/jamainternmed.2014.2309
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