Report: Preop labs, annual cardiac screening among most wasteful healthcare services

Those lab tests a physician orders before surgery may seem like just a drop in the bucket of healthcare spending, but over time those routine—often unnecessary—services add up.

The Washington Health Alliance attempted to quantify the cost of wasteful healthcare services over a one-year period (July 2015-June 2016) in Washington state. Researchers studied 47 commonly overused treatments and found more than 45 percent of them were either wasteful or likely wasteful, costing approximately $282 million.

In their Feb. 1 report, the authors point out this is likely an underestimate because it didn’t include subsequent tests, procedures or treatments that stemmed from the initial unnecessary intervention. In addition, they identified 11 particular treatments that accounted for 93 percent of the waste in the report, with cardiovascular services dotting the list.

Here are the cardiovascular treatments that resulted in the most waste, according to the report:

• Unnecessary preoperative baseline lab studies. According to the report, 85 percent of the more than 108,000 patients who received preoperative tests before low-risk surgery didn’t require it. The wasteful tests totaled $86 million. “What is considered wasteful is when baseline studies are indiscriminately ordered for asymptomatic patients who are undergoing low-risk surgery. These types of tests traditionally include a complete blood panel, basic or comprehensive metabolic panel, urine testing and/or coagulation studies when blood loss is expected to be minimal.”
• Annual electrocardiograms (ECGs) or cardiac screening for asymptomatic individuals. Among more than 416,000 patients receiving annual ECGs or cardiac screening, 23 percent of the services were deemed unnecessary, totaling $40 million. The researchers considered the tests appropriate if individuals had two or more risk factors for coronary heart disease (CHD) or had high-risk markers for CHD within two years.
• Cardiac stress testing. Seven percent of these tests were considered wasteful and another 11 percent were deemed “likely wasteful.” Combined, those two categories equaled an estimated cost of $33.4 million. The authors said routine stress testing in asymptomatic patients isn’t recommended and could lead to unnecessary invasive procedures and radiation exposure.
• Preoperative ECG, chest x-ray and pulmonary function testing. The researchers found 20 percent of these services were unnecessary, equaling $6.4 million in waste. “Indiscriminate, routine preoperative testing in asymptomatic patients does not make an important contribution to perioperative assessment; the ordering of preoperative tests should be selective based on existing risk and level of invasiveness of the surgery,” they wrote.

“What is interesting about this list is that it combines services that are both lower cost (less than $500) and higher cost (more than $500), dispelling a belief that overuse only refers to a problem of over-utilizing expensive testing, imaging, etc.,” the authors wrote. “In fact, the problem of overuse is also one of excessive utilization of unnecessary low-cost services. When looked at individually, low-cost services don’t seem to be much of a driver, but when looked at collectively, they add up to a big problem.”

According to the researchers, addressing overuse requires pushing forward with the transition from volume-based payments to value-based models and shared decision-making between providers and patients, with an emphasis on choosing necessary, high-value care.