Sometimes, a preoperative testing of questionable value can result in unexpected complications. As was the case with a man in his 50s who was to have a very painful hernia repaired. Two Colorado doctors reported in 2014 that the man’s lab tests and physical exam were normal. A chest X-ray was ordered, as he had mild asthma and a history. It showed that he had a nodule in his lung.
Doctors delayed surgery until he had a CT scan. Although it didn’t confirm a lung cancer, it did reveal one in his adrenal gland. Doctors delayed surgery again to examine the adrenal nodule. This was eventually found to be benign. After six months of suffering from severe pain and anxiety, the man finally had his hernia fixed.
Doctors are making progress. In 2019 in JAMA Internal Medicine, Dr. John N. Mafi, an internist at the David Geffen School of Medicine at the University of California, Los Angeles, and his colleagues described an effort to reduce “low-value preoperative care” for patients about to have cataract surgery. A new protocol was recommended by a specially trained quality improvement nurse to surgeons. The result, as assessed in a controlled clinical trial of 1,054 patients, was a dramatic decline in preoperative testing, a significant projected cost saving after the first year and “no measurable adverse effects” on the patients’ surgery, he said.
Cardiac stress tests reveal that over-testing continues.
A cardiac stress test is one of the most common preoperative procedures. It measures blood flow to the body while patients exercise. Dr. Alana E. Sigmund, an internal medicine physician at the Hospital for Special Surgery in New York who has studied physicians’ responses to preoperative guidelines, said in an interview, “Cardiac stress testing is over-ordered. If there’s no indication of a heart problem, like shortness of breath, there’s no reason to do this test prior to surgery.”
The American College of Cardiology (and the American Heart Association) have issued new guidelines in 2014. They advise that patients without symptoms suggesting heart disease should not undergo a cardiac stress testing before surgery. The guidelines leave the decision to test up to the doctor, and you might think it’s better to rule out a possible heart problem before surgery. The evidence is not strong enough to prove that a preoperative stress test can save lives or prevent cardiac problems.
Source: NY Times
