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Anesthesiologists Identify Five Tests and Procedures Patients Should Avoid
Five specific tests or procedures commonly performed in anesthesiology that may not be necessary or that should be avoided in some cases were published online June 16 in JAMA Internal Medicine. This “Top Five” list was created by the American Society of Anesthesiologists (ASA) for inclusion in the ABIM Foundation’s “Choosing Wisely” campaign.
According to the article, unnecessary health spending in the U.S. 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 often 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, and procedures by conducting a literature review using the ASA’s current practice parameters. Criteria for inclusion included common clinical practices 1) for which avoidance would lead to improved quality of care or reduced costs; 2) for which there is little or no evidence of benefit to patients, or 3) whose 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 to generate a “Top Five” list of preoperative and intraoperative activities to be questioned. This 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:
- Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) who are undergoing low-risk surgery — specifically, complete blood count, basic or comprehensive metabolic panel, and coagulation studies when blood loss or fluid shifts are expected to be minimal.
- Don’t obtain baseline diagnostic cardiac testing (trans-thoracic or trans-esophageal echocardiography [TTE/TEE]) or cardiac stress testing in asymptomatic, stable patients with known cardiac disease (e.g., coronary artery disease or valvular disease) undergoing low- or moderate-risk non-cardiac surgery.
- Don’t use pulmonary artery catheters routinely for cardiac surgery in patients with a low risk of hemodynamic complications (especially with the concomitant use of alternative diagnostic tools, such as TEE).
- Don’t administer packed red blood cells in a young, healthy patient without ongoing blood loss and hemoglobin of 6 g/dL or greater, unless the patient is symptomatic or hemodynamically unstable.
- Don’t routinely administer colloids (dextrans, hydroxylethyl starches, or albumin) for volume resuscitation without appropriate indications.
The ASA’s initial "Choosing Wisely" list on anesthesiology was released in October 2013, and a second list of pain medicine was published in January 2014.
Source: ASA; June 16, 2014.