Branden Wright MD¹; Erik Freeland DO^2
1Cooper Medical School of Rowan University
²Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo

Abstract

Purpose
Reducing waste is at the forefront for healthcare administrators, and one area to target is routine pre-operative testing. Despite the availability of professional/societal guidelines, physicians continue to order routine preoperative tests. Preoperative tests rarely influence surgical management, and there is data supporting safety without preoperative testing in low-risk surgeries for healthy patients. These principles can be extrapolated to low-risk orthopedic procedures in healthy patients, such as isolated distal extremity fractures. We believe there will be enough wasted expenditure with unnecessary preoperative workup in isolated orthopedic trauma during a one-year period to warrant change in preoperative management.

Methods
A retrospective analysis of 209 cases of isolated distal radius and ankle fractures from July 2019-July 2020 was conducted. Charts were queried for preoperative tests completed. Each case’s respective series of preoperative tests were compared to what professional/societal guidelines deemed appropriate. A decision-making analysis was performed to assess physician over-ordering. Total number of unnecessary tests was calculated, and cost analysis was completed to determine potential waste.

Results
98% of cases had at least one unnecessary test. Coagulation profiles and blood type tests were the most commonly over-ordered tests at 90% of the time.  Cost analysis revealed $262,624 in potentially wasted expenditure. Blood type tests and chest x-rays represented the largest portion, with $129,654 and $71,694 of wasted expenditure respectively.

Conclusion
We recommend the implementation of multimodal interventions in clinics treating isolated distal radius and isolated ankle fractures. Interventions should include components of provider education, provider audit and feedback, and EMR ordering restrictions to reduce this area of waste. 

Keywords: Cost Analysis, Healthcare Waste, Orthopedic Trauma, Preop Anesthesia Guidelines, Preop Tests

Introduction
Healthcare expenditure is one of the biggest problems facing the medical community today. Reducing waste is at the forefront for healthcare administrators and in 2012 the American Board of Internal Medicine began the Choosing Wisely campaign. One of the five initiatives of the campaign involved reducing unnecessary testing such as complete blood counts and routine chemistries (1). One area to target in reducing unnecessary testing is the preoperative setting. The most common preoperative tests include the Electrocardiogram (ECG), the Chest X-Ray (CXR), Complete Blood Count (CBC), Basic Metabolic Profile (BMP), PT/INR, and Blood type and screen (T&S). There are many societal and professional guidelines available to help guide physicians towards clinically focused and cost-conscious preoperative testing decisions, such as the guidelines published by the American Society of Anesthesiologists (ASA), American Cardiology Association/American Heart Association (ACA/AHA), and British National Institute for Clinical Excellence (NICE) (2–5).  Despite these guidelines, physicians continue to routinely order preoperative testing (6). Often, these tests are ordered habitually without clinical indication and rarely influence management, even when abnormalities are discovered  (7–9). For instance, the incidence of abnormal test results influencing management ranged from 0.0% for abnormal CBCs, to 3% for abnormal CXRs in a systematic review (7). In a climate where evidence-based and cost-conscious clinical decisions are emphasized, one would expect routine preoperative testing to come into question.

In addition to the futility of routine preoperative testing in terms of management, there is evidence suggesting no increase in perioperative complications in the absence of routine preoperative testing in healthy patients undergoing low-risk surgery. A study investigating cataract surgery was among the first to demonstrate no difference in perioperative complications among those who did not undergo routine preoperative testing for cataract surgery (10). Subsequently, other studies have demonstrated safety in the absence of routine testing for similar low-risk surgeries in healthy patients such as for elective abdominal hernia repairs, ambulatory plastic surgery procedures, and ambulatory orthopedic procedures (11–13). We believe this concept can be extrapolated to healthy patients with isolated orthopedic trauma. It is known that isolated wrist and ankle fractures among healthy patients can be safely managed on an outpatient or ambulatory basis (14–17). This classifies these procedures as low-risk (18). Thus, reducing unnecessary preoperative testing in healthy patients with isolated distal extremity fractures could be an area of interest for cost reduction.

This study’s purpose was to do a retrospective cost analysis of current preoperative workup tendencies in healthy patients with isolated wrist and ankle fractures. We believe the expected wasted expenditure will warrant future interventions to implement evidence-based and cost-conscious preoperative testing protocols in emergency rooms and clinics treating these injuries.

Methods and Materials 
Ethical approval for a retrospective chart review was granted by our hospital’s IRB. Permission was granted to waive the need for written consent. Inclusion criteria included all encounters for patients aged 18-65 under the ICD-10 codes S52, S62, S82, and S92 from July 2019 to July 2020 at a level one trauma center. Included fractures were all isolated fractures at the level of the forearm (S.52), at the level of the hand or wrist (S.62), fractures of the lower leg including the ankle (S.82), and fractures of the foot or toe (S.92). Pregnant patients and patients with polytrauma were excluded. Charts were queried for preoperative tests completed, patient comorbidities, active respiratory complications, and medications at the time of injury presentation. Patients were also classified based on the American Society for Anesthesiologists (ASA) classification for preoperative physical grading, which has been used for over 60 years to classify patients’ preoperative health status (19). ASA Grade I and Grade II are considered generally healthy (20). This information was used to assess each patient’s clinical status for comparison with clinical guidelines.

For each case, completed preoperative tests were assessed for indication by comparing patients’ clinical status to clinical guidelines provided by our institution’s anesthesia department (Table I). Guidelines were based on professional and societal suggestions [2-5]. For instance, if a test was completed for a patient but clinical guidelines deemed a test unnecessary for that patient based on their clinical status, it was deemed an unnecessary test. For a test completed that was supported by clinical guidelines, it was considered an indicated test. For situations where a test was indicated but not completed, it was considered missed.

Table I. Anesthesia Guidelines
Outcome measures included a provider decision-making analysis and a cost analysis for theoretical wasted expenditure. The decision-making analysis included calculating the total number of unnecessary versus indicated tests among the patients in our cohort. For the cost analysis, the costs of tests were acquired from publicly available data provided by our institution’s billing department. The number of unnecessary tests was multiplied by the price of each test to determine the theoretical wasted expenditure. A statistician was consulted and deemed statistical analysis unnecessary given there were no comparisons between groups. 

Results
A total of 209 cases were included in the data set. 102 patients were ASA grade I, 73 were ASA grade II, 33 were ASA grade III, and 1 was ASA grade IV. Thus, most of our cohort was considered healthy based on ASA grades. Of these patients, Table II details the decision-making analysis organized by individual testing measures. The last row in Table II gives the percentage of adherence to guidelines stratified by case; representing how often clinicians ordered the correct series of preoperative tests for each fracture case. Coagulation profiles and blood type tests were the most commonly over-ordered tests as 90% of the time they were unnecessary. ECGs had the highest rate of adherence as 50% of cases had the correct ECG decision made. Overall, at least one unnecessary preoperative test was ordered in 98% of cases. 

Discussion
The rate of our physicians ordering unnecessary preoperative tests was high, as expected. Recent studies have proposed explanations for physicians’ tendencies to routinely order preoperative testing despite the availability of professional guidelines for almost 20 years. One study suggested that physicians may be unaware of the guidelines, they may feel their patients do not apply to guideline scenarios, they may feel uncertain that guidelines will improve patient outcomes, and the inertia of existing practice patterns is hard to overcome [6]. In an academic hospital like ours, it is also important to consider resident ordering behavior. In a national survey of internal medicine residents, the main drivers of overuse were deemed to be legal protection, being uncomfortable with diagnostic uncertainty, and the need to satisfy patient demand (21).  

Interventions to address these perceived issues have been successful in other realms of the hospital. A recent study reviewed many of these interventions and provided an evidence-based blueprint to reduce unnecessary testing among hospitalists (22). They found the best interventions were multimodal, including a combination of multi-level provider education, performance feedback on provider ordering habits, and EMR ordering restrictions. Interventions only incorporating singular modes, such as physician education without audit and feedback, have been less effective. Other studies have intervened with additional measures, such as financial incentives and resident social marketing. Successful multimodal interventions with financial arms included sharing 50% of the costs saved within the corresponding department and $400 bonuses for residents if their team reduced their lab ordering by 5% (23,24). Indeed, one would expect these same principles to be effective if implemented among provider teams tasked with the preoperative workup of patients with distal extremity fractures. Small studies with multimodal prospective arms have successfully reduced unnecessary testing and provided confidence that interventions can be successful elsewhere, especially when targeting isolated orthopedic trauma (25).

The cost analysis revealed a significant amount of wasted expenditure over the course of one year for patients with isolated orthopedic trauma at a level I trauma center. When considered on a larger national scale, the waste would certainly be substantial. Not captured in the monetary value is the time wasted before surgery, the time wasted by laboratory services, and the time wasted by technologists. Reducing unnecessary preoperative workup can aid in reducing unnecessary work for other hospital employees, as well as streamline patient care leading to a better overall patient experience. Future research could investigate these areas.

A limitation of this study was the absence of a prospective arm with an intervention to compare testing rates before and after. The COVID-19 pandemic delayed original plans to include a prospective arm in the emergency department, and we hope this data renews interest in a future intervention at our hospital. We also understand our retrospective design should somewhat temper expectations with estimated cost savings. Providers ultimately have clinical autonomy and clinical scenarios arise where guidelines are not followed. Even so, reducing at least 50% of potential waste would have resulted in savings of greater than $100,000 at our hospital over the course of a year. Another limitation that should be noted is professional anesthesia guidelines have been based on lower-level evidence and have been a widespread limitation for investigators looking to reduce preoperative workup [2-4].  

Conclusion 
A retrospective analysis of unnecessary preoperative workup in healthy patients with isolated orthopedic trauma revealed a high rate of physician over-ordering and $262,624 in wasted expenditure over the course of one year. We recommend the implementation of multimodal interventions in departments providing care for these patients, such as orthopedics, emergency medicine, and anesthesia, to address this area of waste. Interventions should include a component of education, such as departmental lectures or emails, that target all levels of providers. Interventions should have a system of auditing provider ordering behavior and administering feedback to providers on their performance. Departments that intervene should work with their EMR liaisons to create order-restriction programs. On an individual basis, providers are encouraged to take accurate histories with patients and to incorporate professional guideline suggestions with sound clinical judgment. Reducing unnecessary preoperative workups in patients with isolated orthopedic trauma is of interest in today’s landscape of cost-conscious and evidence-based medicine.

Table 1 | Table 1a | Table1b | Table II | Table III

Required Disclosures and Declaration

Copyright Information: No Copyright Information Added
IRB Approval Information: Yes
Disclosure Information: No known conflicts of interest

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