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Patient, provider, and system-level factors associated with preoperative cardiac testing: A systematic review
Michael I Ellenbogen1, Aleksandra Drmanovic1,2, Jodi B Segal1,3
1Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Insights
Preoperative cardiac testing varies significantly. Older age and higher comorbidity are linked to more testing, while primary care focus reduces it. Interventions can decrease low-value testing.
Area of Science:
- Cardiology
- Health Services Research
- Perioperative Medicine
Background:
- Overutilization of preoperative cardiac testing increases healthcare costs and delays surgeries.
- Existing research has explored factors influencing preoperative cardiac testing variation.
- Patient, provider, and system-level factors driving this variation remain understudied.
Approach:
- Systematic review of adult US studies published since 2012.
- Searched Ovid MEDLINE and Embase for terms related to preoperative testing, cardiac diagnostics, and care variation.
- Qualitative analysis of extracted study characteristics and influencing factors, with risk of bias assessment.
Key Points:
- Older age and higher comorbidity strongly correlate with increased testing intensity.
- Evidence for provider and system-level factors is less robust.
- Shifting focus from preoperative clinics to primary care is associated with reduced testing; interventions can successfully lower low-value testing.
Conclusions:
- Significant inter-provider and inter-hospital variation in preoperative cardiac testing exists.
- The specific factors driving this variation require further investigation.
- Understanding these correlates is crucial for optimizing preoperative care.
Background:
Overuse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system-level factors associated with variation in testing have not been systematically studied.
Objective:
To conduct a systematic review to better delineate the patient, provider, and system-level factors associated with variation in preoperative cardiac testing.
Methods:
We included studies of an adult US population evaluating a patient, provider, or system-level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle-Ottawa Scale and Evidence Project Risk of Bias tool.
Results:
Twenty-eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher-intensity testing. The evidence for provider and system-level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low-value testing can be successful.
Conclusions:
There is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well-defined. Further work should aim to better understand these factors.
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