Many Resting Echocardiograms Done Before Noncardiac Surgery May Be Unnecessary

By Lorraine L. Janeczko

October 07, 2021

NEW YORK (Reuters Health) - Many of the preoperative resting echocardiograms often performed before non-cardiac surgery appear to be unnecessary, a new study suggests.

"Pre-op cardiac testing is typically overused," senior author Dr. Daniel S. Rubin of the University of Chicago told Reuters Health by email. "In our study, almost 1/3 of preoperative echocardiograms ordered were considered 'rarely appropriate.' That means they probably should not have been ordered, as they would have been unlikely to improve patient outcomes."

"Overtesting can lead to patient harm, such as unnecessary interventions. Overtesting also leads to increased healthcare costs that don't lead to improved health," he added.

As reported in Anesthesiology, Dr. Rubin and his colleagues examined de-identified insurance records of more than 230,000 patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases who underwent major abdominal surgery over an eight-year period. The research team searched for patients with outpatient claims for resting transthoracic echocardiography within 60 days before surgery.

Procedure appropriateness was determined by the International Classification of Diseases, with procedures classified as "appropriate," "rarely appropriate," or "unclassifiable" using the Appropriate Use Criteria for Echocardiography.

Preoperative resting transthoracic echocardiography was performed in 13,936 patients (6.0%). Ninety-one percent of these were classifiable by the Appropriate Use Criteria for Echocardiography, and 1,298 (9%) could not be classified.

Of the classifiable studies, 71% were considered "appropriate," and 29% were "rarely appropriate." Surveillance of chronic ischemic heart disease and uncomplicated hypertension were involved in 43% of "rarely appropriate" echocardiograms.

"We need to evaluate what should be considered rarely appropriate in this context, and this is the first step," Dr. Rubin said.

Beginning in 2022, the Center for Medicare and Medicaid Services will require providers to justify the advanced imaging studies they order.

"I commend the authors on studying an important question on a clearly defined population," said Dr. Matthew D. McEvoy, professor of anesthesiology and surgery and director of the perioperative consult service of the Department of Anesthesiology at Vanderbilt University Medical Center in Nashville, Tennessee.

"Although only 6% of patients underwent preoperative resting echocardiography, this level of testing represents significant healthcare cost when multiplied across the entire population of patients undergoing major abdominal surgery each year in the United States and globally," Dr. McEvoy, who was not involved in the study, told Reuters Health by email.

"This study highlights an education gap that needs to be addressed," he said. "For instance, it is interesting to note that the most common reason for 'rarely appropriate' resting echocardiography was 'surveillance of chronic ischemic heart disease,' a condition for which stress testing, not resting echocardiography, could be considered, according to the 2014 ACC/AHA (American College of Cardiology/American Heart Association) Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery."

"Overall, I agree with the authors' conclusions that continued efforts are needed to address overuse of preoperative testing," Dr. McAvoy said. "This should be pursued while also addressing efforts to ensure that patients who do meet appropriate use criteria for testing receive such evaluation, as this can lead to better perioperative risk stratification, shared decision-making, and perioperative care coordination."

The research team is conducting further related research. Their unanswered questions include whether a small number of providers order most of the unnecessary tests, and whether the preoperative tests lead to further interventions that may have adverse effects.

SOURCE: Anesthesiology, online September 20, 2021.