Evaluation of choosing wisely recommendations on preprocedural cardiovascular testing

Abstract

Study objective: The Choosing Wisely (CW) initiative currently has multiple recommendations focused on avoiding preprocedural testing in asymptomatic patients prior to low-risk surgery. The purpose of this study was to measure the potential impact of the CW recommendations as they relate to preprocedural testing prior to cataract surgery. Design: Retrospective cohort study. Setting: Single academic medical center. Participants: Patients undergoing cataract surgery from 01/02/2018 to 12/31/2018. Interventions: N/A. Main outcome measures: Prevalence of preprocedural testing in elevated versus low cardiac risk patients as defined by the Revised Cardiac Risk Index (RCRI). Results: Of a total 909 patients, 90 (9.9%) had some form of preprocedural testing ordered; testing was more common among elevated risk (n = 50/315, 15.9%) compared to low-risk patients (n = 40/594, 6.7%; p < 0.0001). Of the tests ordered, 9 were abnormal (4 in the low-risk cohort, 5 in the elevated risk cohort). ECGs were the vast majority of tests ordered (n = 88/90). No stress test orders or periprocedural adverse cardiovascular (CV) events were observed. Anesthesiology clinicians ordered 95.6% of preprocedural testing. “Routine” was the justification given for the substantial majority of tests ordered in both cohorts (90% low-risk, 86% elevated risk). Conclusion: Our investigation confirms that cataract surgery has exceptionally low rates of postprocedural CV events. In contemporary practice, preprocedural CV testing for cataract surgery is not highly prevalent, rarely abnormal, and also not well justified by ordering clinicians. Our results may be considered as justification for revisions of some CW recommendations to potentially target higher prevalence areas of low-value care.

Keywords

• Medical overuse
• Physician's practice patterns
• Cardiovascular diagnostic techniques