The consensus in preoperative testing: less is more

Family physicians are often asked for preoperative consultations prior to elective surgical procedures. Traditionally, the process of "clearing" patients for surgery has included performing an electrocardiogram, chest x-ray, and numerous laboratory tests. However, as Dr. Molly Feely and colleagues point out in the cover article of American Family Physician's March 15th issue, there is little evidence that routine preoperative testing is beneficial: "these tests often do not change perioperative management, may lead to follow-up testing with results that are often normal, and can unnecessarily delay surgery, all of which increase the cost of care." Instead, current guidelines recommend selective testing based on risk factors identified during the history or physical examination.

The following Choosing Wisely campaign recommendations from several medical specialty groups identify unwarranted preoperative tests to reduce waste and prevent harm to patients:

1. Avoid routine preoperative testing for low-risk surgeries without a clinical indication.
2. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
3. Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to noncardiac thoracic surgery.
4. Avoid cardiovascular stress testing for patients undergoing low-risk surgery.
5. Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.
6. Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk.
7. Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.
8. Prior to cardiac surgery there is no need for pulmonary function testing in the absence of respiratory symptoms.

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The above post first appeared on the AFP Community Blog. A list of primary care-relevant Choosing Wisely recommendations organized by medical discipline is available on the AFP website.

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from February and March:

1) The role of whistleblowing in health care (2/25/13)

2) Unintended consequences of "pregnancy prevention" (2/5/13)

3) Concerns about calcium supplements (2/8/13)

4) Choosing Wisely's curious omissions (3/3/13)

5) Do practice culture and clinician stress affect patient safety in primary care? (3/6/13)

If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!

Dangers of the incidentaloma: how CT scans can hurt you

Mrs. Smith (not her real name) fidgeted in her chair in my examination room as I scanned the radiology report she had given me. She had visited the emergency room the previous evening with severe abdominal pain that had eventually been diagnosed as gastritis, or swelling of the stomach lining due to a virus. During her evaluation, the ER physician had ordered a CT scan of her abdomen and pelvis. Although Mrs. Smith's liver and intestines appeared normal, the radiologist had noted a tiny mass on one of her kidneys.

The report stated that the mass was consistent with a harmless cyst, but concluded with a statement that was all too familiar to me: "Cannot rule out malignancy. Clinical correlation required." Translation: it was almost certainly nothing serious, but there was a very small chance that it might be cancer, and now it was my job to make sure it wasn't. But further investigation of this incidental finding, which had no relationship to Mrs. Smith's original symptoms, would involve a painful biopsy, and if the biopsy was inconclusive, surgery to remove her kidney. In similar situations with other patients, I had suggested the alternative of regular monitoring with additional scans to make sure that the mass wasn't growing; however, this option requires that a patient live each day with the anxiety of not knowing if she has cancer.

That episode happened a decade ago, but the dilemma that my patient faced is, if anything, much more common today. A study published recently in the journal Radiology found that children visiting U.S. emergency rooms had five times as many CT scans in 2008 as in 1995. By 2008, 6 percent of pediatric ER visits involved a CT scan. The same research group, led by Dr. David Larson at Cincinnati Children's Hospital Medical Center, previously found an even greater rise in scanning during adult ER visits, with 25 percent of patients age 65 and older, and 12 to 16 percent of younger adults, getting a CT scan in 2007.

In addition to increasing risks associated with radiation exposure, all of those CT scans turn up an awful lot of "incidentalomas," the term that doctors use for incidental findings that could be (but probably aren't) cancer. A study in the journal Archives of Internal Medicine found that nearly 40 percent of CT and MRI scans performed for research purposes at the Mayo Clinic from January through March 2004 turned up at least 1 incidental finding. In the 35 patients in whom doctors took further action (additional testing, specialist consultation, or surgery), only 6 were judged by researchers to have clearly benefited from an investigation, while in the rest there was no clear benefit or clear harm, such as complications from surgery for a benign tumor. Of all types of scans, CT of the abdomen and pelvis - the very same scan that my patient got - was the most likely to turn up an incidental finding.

In fact, the American College of Radiology has become so concerned about the problem of incidentalomas on CT scans of the abdomen and pelvis that they have published detailed guidance for clinicians about how to approach such findings. "Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures," the radiology group warns, advising that doctors carefully consider an individual patient's risk for cancer in deciding whether or not to recommend further evaluation.

So what can you do to reduce the chance you will be harmed by an incidentaloma? Three experts in diagnostic medicine at the the Dartmouth Institute for Health Policy and Clinical Practice recommended that patients who are told about an incidental finding always seek a second opinion to verify that the radiologist's interpretation of their scan is correct, and understand that clinical observation of an incidentaloma is often a safer option than more testing or surgery. Also, they advise that patients adopt a "healthy skepticism" about testing and only consent to scans that are absolutely necessary to establish a diagnosis or plan of action, rather than ordered “just to be sure.”

To be honest, I don’t remember what Mrs. Smith chose to do about her incidentaloma. If I saw her as a patient today, I would definitely consult a second radiologist to be sure that the kidney mass was actually there. If it was, I would probably recommend a wait-and-see approach, given that additional testing could create more risk than reward.

And if I had the power to turn back to clock and warn my patient before she arrived in the ER, I’d advise her to ask the physician there if the CT scan was really needed at all.

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A slightly different version of the above post originally appeared in my Healthcare Headaches blog at USNews.com and in Common Sense Family Doctor in April, 2011.

Preventive health advice for the new Pope

Congratulations to Cardinal Jorge Bergoglio from Argentina, who yesterday became Pope Francis, the new leader of the worldwide Catholic Church. The new Pope is 76 years old and in apparently good health. To ensure a long and productive reign, Pope Francis's personal physician would be wise to provide age-appropriate preventive care, which includes yearly influenza vaccination and a one-time dose of the pneumococcal vaccine if he hasn't already received it. He should forgo the PSA test for prostate cancer screening, which would cause more harm than good in a man of his age (or any age), and think carefully about continuing colorectal cancer screening, which adults between 76 and 85 years of age should not undergo routinely due to the close balance between benefits and harms, such as complications from anesthesia. If the Pope chooses to have a colonoscopy, he should select a specialist who will adhere to evidence-based guidelines on screening intervals, to avoid the practice of too-frequent colonoscopy that is unfortunately widespread in the United States.

Although Pope Francis is now a world leader with the status of monarchs and Presidents, he should decline any sort of Presidential Physical that includes screenings that are nonbeneficial (such as the aforementioned PSA test) or have insufficient supporting evidence. In fact, I would encourage him to use the pulpit of the Papacy to challenge the absurd notion that undergoing screening tests in men and women his age is "morally obligatory," which a recent study found is commonly held among U.S. seniors. Pope Francis could call into question the morality of for-profit companies, such as Life Life Screening, that prey on vulnerable seniors in their houses of worship by selling questionable or totally worthless tests outside of the context of the physician-patient relationship. Perhaps a Papal edict banning such groups from advertising in the bulletins of Catholic churches worldwide? Better yet, he could lead an inter-denominational campaign against such abuses in people of all faiths.

Extra diagnostic tests don't reassure: another reason to Choose Wisely

Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality primary care. The March 1st issue of American Family Physician includes two articles that reflect this philosophy as embodied in the American Board of Internal Medicine Foundation's Choosing Wisely campaign. Four of the American Geriatrics Society's "Five Things Patients and Physicians Should Question" refer to medications that can be harmful to older patients in certain settings: antipsychotics, hypoglycemics, benzodiazepines, and antibiotics. Dr. Richard Pretorius and colleagues echo this advice and provide additional guidance and systematic approaches to reducing the risk of adverse drug events in older adults.

Sudden hearing loss is a distressing symptom that may prompt a physician to order a CT scan to look for a brain tumor or other cranial mass lesion. However, the American Academy of Otolaryngology - Head and Neck Surgery Foundation advises against ordering this diagnostic test in patients without focal neurologic findings, since the CT scan provides no useful information and exposes the patient to radiation and an expensive medical bill. More information on the evaluation and management of sudden hearing loss is available in AFP's Practice Guidelines summary of the AAO-HNSF's recent clinical guideline.

One reason that clinicians often give for ordering diagnostic tests in patients with a low pretest probability of serious disease is to "reassure the patient." This rationale is used to justify performing endoscopy in patients with dyspepsia but no alarm symptoms; x-rays or magnetic resonance imaging in patients with uncomplicated low back pain; or electrocardiography in patients with chest pain and a low likelihood of cardiac disease. It turns out, though, that negative tests aren't reassuring at all. A recent systematic review and meta-analysis of 14 randomized trials in JAMA Internal Medicine found that diagnostic tests did not reduce patients' illness worry, nonspecific anxiety, or symptom persistence. The only effect of the tests was a small reduction in subsequent primary care visits. Given the adverse effects of diagnostic testing in general, including false positives and overdiagnosis, this "benefit" does not warrant making unwise choices about non-indicated medical tests.

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The above post was first published on the AFP Community Blog.

Do practice culture and clinician stress affect patient safety in primary care?

Initiatives to reduce medical errors in inpatient settings have found that sustained improvements in safety cannot be achieved by simply exhorting health professionals to “try harder” or making evidence-based care protocols widely available (1, 2). One obstacle to implementing changes is a toxic “blame and shame” culture that discourages physicians and staff from identifying or admitting medical errors, and therefore resists strategies to isolate and address their causes (3). To overcome this obstacle, leaders need to find ways to systematically change the culture. For example, Pronovost and colleagues incorporated interventions to create a “culture of safety” in the Comprehensive Unit-Based Safety Program that reduced medication errors, lengths of stay, and bloodstream infections in intensive care units at Johns Hopkins Hospital (4) and throughout the state of Michigan (5).

Patient safety studies in outpatient settings have mostly concentrated on minimizing prescribing errors through computerized order entry and improving communication between providers about abnormal test results (6). Compared to the inpatient setting, there are significant gaps in our understanding of what elements of primary care practice cultures and/or organizational climates may affect the incidence of medical errors.

The most ambitious observational study of the impact of organizational climate and physician stress on medical errors and care quality was the Minimizing Error, Maximizing Outcomes (MEMO) study (7, 8). MEMO was a 3-year longitudinal study of 119 practices in New York, Chicago, and Wisconsin that involved collecting data from more than 400 primary care physicians. Investigators used a 4-item scale derived to assess working conditions and organizational climate of primary care practices, and asked physicians about past errors and the likelihood of making future errors. Data from 1795 adult patients with diabetes, hypertension, or heart failure (1 to 8 patients per physician) was reviewed and analyzed for associations between care quality, medical errors (defined as missing recommended processes of care), practice culture, and physician satisfaction.

Although chaotic work environments and low control over their work were strongly associated with physician dissatisfaction, stress, and burnout in the MEMO study, and physicians perceived these factors as increasing their likelihood of making errors in the future (7), organizational climate had no consistent relationship with care quality or medical error scores (8). There are several possible explanations for the lack of association between organizational climate and patient outcomes in this study, including an overly restrictive definition of a medical error, too few patients analyzed per physician, and, of course, the possibility that practice culture did not affect the patient outcomes that were measured. Indeed, the MEMO investigators suggest that ”one interpretation of our findings is that physicians act as buffers between adverse work conditions and patient care – adverse working conditions affect them strongly, but their reactions do not translate into lower-quality care.”

There is considerably greater variation in size and structure among primary care practices than among intensive care units in the U.S., and that variation will likely make it more challenging to implement a “Comprehensive Primary Care-Based Safety Program” even if it proves possible to identify practice cultures that are more conducive to systematic interventions to reduce medical errors in outpatient settings. Nonetheless, several potential strategies have merit:

1) Experimenting with ways to permit primary care patients to report mistakes they observe in processes of care, no matter how inconsequential, so that practices can benefit from their additional perspectives.

2) Designing better systems, electronic or otherwise, to track pending test results to reduce harms associated with the failure to report abnormal results, such as delayed diagnoses.

3) Paying closer attention to adverse effects of clinicians’ chaotic work environments and sense of control (or lack thereof) over their work, two factors that track closely with career satisfaction.

4) Expanding the definition of a medical error in future studies to include not only acts of omission (e.g., not ordering a recommended test), but commission (e.g., unnecessary tests, drugs, or procedures).

5) Examining sources of variation in primary care culture across multiple practices and practice-based research networks.

Pronovost and Sexton observed several years ago about inpatient culture, “We must understand these sources of variation in order to target who to measure, how to score, where to focus efforts to improve culture, and [whom] to hold accountable for improving culture” (9). The same could certainly be said about the culture of primary care, where the science of patient safety is only beginning to move from making controlled observations of medical errors to designing interventions.

References
1. Woodward HI, Mytton OT, Lemer C, et al. What have we learned about interventions to reduce medical errors? Annu Rev Public Health 2010;31:479-97.
2. Curry LA, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? Ann Intern Med 2011;154:384-90.
3. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-49.
4. Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005;1:33-40.
5. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med 2011;39:934-39.
6. Gandhi TK, Lee TH. Patient safety beyond the hospital. N Engl J Med 2010;363:1001-3.
7. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev 2007;32:203-12.
8. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med 2009;151:28-36.
9. Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Safe Health Care 2005;14:231-33.

Choosing Wisely's curious omissions

Last month, the American Board of Internal Medicine Foundation's Choosing Wisely Initiative announced the release of a second round of lists of 5 things that physicians and patients should question, based on evidence that certain tests or procedures are not beneficial in specific clinical situations. American Family Physician will soon be updating its list of primary care-relevant items from the Choosing Wisely campaign, and its Facebook and Twitter accounts will highlight old and new entries daily over the next few months. This AAFP News Now article provides more information about the American Academy of Family Physicians' most recent items, which include elective labor inductions and unnecessary cervical cancer screenings.

Notably absent from the lists of the primary care specialty societies and the American Urological Association is routine prostate-specific antigen (PSA) testing, which both the Cochrane Collaboration and the U.S. Preventive Services Task Force have concluded does not improve men's health outcomes. Even though the American Cancer Society and the AUA still support selective use of the PSA test in older men who have been adequately informed of its potential harms, no medical group supports the still-common practice of ordering PSA screening without first discussing it with the patient.

Another curious omission from the top 5 lists of cardiology and thoracic surgery organizations is angioplasty or coronary artery bypass surgery for stable coronary artery disease, which are frequently performed in the U.S. but have no clinical advantages over initial medical management.

From a population health perspective, curtailing prostate cancer overdiagnosis and unnecessary cardiac interventions would be worthy goals to add to a "don't do" list that collectively includes more than one hundred items. Instead, these omissions say quite a bit about the persistence of perverse financial and medicolegal incentives in primary and subspecialty medicine. After all, no one ever sued a doctor for diagnosing cancer (even if it didn't need to be diagnosed) or placing a stent in a partially occluded coronary artery (even if it didn't need to be placed), and insurers rarely (if ever) decline to pay for these wasteful tests and procedures.

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A shortened version of the above post first appeared on the AFP Community Blog.