Evaluation of Choosing Wisely Recommendations on Preprocedural Cardiovascular Testing

Overview

Journal Am Heart J Plus

Specialty Cardiology & Vascular Diseases

Date 2024 Apr 1

PMID 38560075

Authors

Keval Patel

David Winchester

Affiliations

Soon will be listed here.

Abstract

Study Objective: The Choosing Wisely (CW) initiative currently has multiple recommendations focused on avoiding preprocedural testing in asymptomatic patients prior to low-risk surgery. The purpose of this study was to measure the potential impact of the CW recommendations as they relate to preprocedural testing prior to cataract surgery.

Design: Retrospective cohort study.

Setting: Single academic medical center.

Participants: Patients undergoing cataract surgery from 01/02/2018 to 12/31/2018.

Interventions: N/A.

Main Outcome Measures: Prevalence of preprocedural testing in elevated versus low cardiac risk patients as defined by the Revised Cardiac Risk Index (RCRI).

Results: Of a total 909 patients, 90 (9.9%) had some form of preprocedural testing ordered; testing was more common among elevated risk (n = 50/315, 15.9%) compared to low-risk patients (n = 40/594, 6.7%; p < 0.0001). Of the tests ordered, 9 were abnormal (4 in the low-risk cohort, 5 in the elevated risk cohort). ECGs were the vast majority of tests ordered (n = 88/90). No stress test orders or periprocedural adverse cardiovascular (CV) events were observed. Anesthesiology clinicians ordered 95.6% of preprocedural testing. "Routine" was the justification given for the substantial majority of tests ordered in both cohorts (90% low-risk, 86% elevated risk).

Conclusion: Our investigation confirms that cataract surgery has exceptionally low rates of postprocedural CV events. In contemporary practice, preprocedural CV testing for cataract surgery is not highly prevalent, rarely abnormal, and also not well justified by ordering clinicians. Our results may be considered as justification for revisions of some CW recommendations to potentially target higher prevalence areas of low-value care.

References

Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J . Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2008; 42(2):377-81. PMC: 2700030. DOI: 10.1016/j.jbi.2008.08.010. View

Ganguli I, Lupo C, Mainor A, Raymond S, Wang Q, Orav E . Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Intern Med. 2019; 179(9):1211-1219. PMC: 6547245. DOI: 10.1001/jamainternmed.2019.1739. View

Lee T, Marcantonio E, Mangione C, Thomas E, Polanczyk C, Cook E . Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999; 100(10):1043-9. DOI: 10.1161/01.cir.100.10.1043. View

Morden N, Colla C, Sequist T, Rosenthal M . Choosing wisely--the politics and economics of labeling low-value services. N Engl J Med. 2014; 370(7):589-92. PMC: 4104300. DOI: 10.1056/NEJMp1314965. View

Schein O, Katz J, Bass E, Tielsch J, Lubomski L, Feldman M . The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med. 2000; 342(3):168-75. DOI: 10.1056/NEJM200001203420304. View

Greenberg P, Liu J, Wu W, Jiang L, Tseng V, Scott I . Predictors of mortality within 90 days of cataract surgery. Ophthalmology. 2010; 117(10):1894-9, 1899.e1. DOI: 10.1016/j.ophtha.2010.02.009. View

Kline K, Plumb J, Nguyen L, Shaw L, Beyth R, Huo T . Patient and Provider Attitudes on Appropriate Use Criteria for Myocardial Perfusion Imaging. JACC Cardiovasc Imaging. 2016; 10(7):824-825. DOI: 10.1016/j.jcmg.2016.08.013. View

Chen C, Lin G, Bardach N, Clay T, Boscardin W, Gelb A . Preoperative medical testing in Medicare patients undergoing cataract surgery. N Engl J Med. 2015; 372(16):1530-8. PMC: 5536179. DOI: 10.1056/NEJMsa1410846. View

Kirkham K, Wijeysundera D, Pendrith C, Ng R, Tu J, Laupacis A . Preoperative testing before low-risk surgical procedures. CMAJ. 2015; 187(11):E349-E358. PMC: 4527930. DOI: 10.1503/cmaj.150174. View

10.

Cassel C, Guest J . Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012; 307(17):1801-2. DOI: 10.1001/jama.2012.476. View

11.

Korenstein D, Chimonas S, Barrow B, Keyhani S, Troy A, Lipitz-Snyderman A . Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments. JAMA Intern Med. 2018; 178(10):1401-1407. PMC: 7505335. DOI: 10.1001/jamainternmed.2018.3573. View

12.

Rubin D, Hughey R, Gerlach R, Ham S, Ward R, Nagele P . Frequency and Outcomes of Preoperative Stress Testing in Total Hip and Knee Arthroplasty from 2004 to 2017. JAMA Cardiol. 2020; 6(1):13-20. PMC: 7527943. DOI: 10.1001/jamacardio.2020.4311. View