SOURCE: American Society of Anesthesiologists (ASA)
Five specific tests or procedures commonly performed in anaesthesiology 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 anaesthesiology was developed in an effort to reduce unnecessary, costly procedures and improve patient care,” said lead author Onyi Onuoha, MD, MPH, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, 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 anaesthesiologists 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 anaesthesia-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 anaesthesia; postoperative practices and pain services were excluded.
Next, a multi-step survey of physician anaesthesiologists in mostly the academic sector was conducted and analysed 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 anaesthesiologists identified the following 5 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/oesophageal 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 routinely for cardiac surgery in patients with a low risk of haemodynamic complications (especially with the concomitant use of alternative diagnostic tools (e.g., TEE).
4. Don’t administer packed red blood cells in a young healthy patient without ongoing blood loss and haemoglobin of greater than 6 g/dL unless symptomatic or haemodynamically 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 anaesthesiologists to actually implement these items was an important part of the survey,” said senior author Lee Fleisher, MD, 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 anaesthesiologist is needed to ensure these recommendations are implemented.”