Understanding Why Less Is Not More in Preoperative Evaluation and Syncope | Journal Scan

Study Questions:

What are the extent of and factors associated with overuse of testing in preoperative evaluation and syncope?

Methods:

This was a national survey of adult hospitalists in the United States. The authors developed and administered a questionnaire that included clinical vignettes for two conditions: preoperative evaluation and management of syncope. Vignettes contained the same clinical presentation, but differed in the following two circumstances: whether a family member requested additional care and whether the family member’s occupation was provided (son identified as a physician or wife identified as an attorney). Treatment choice within each clinical vignette was the primary outcome, which was analyzed as a dichotomous variable (overuse vs. appropriate use). Overuse was defined as more testing than required by current guidelines. For preoperative testing, any response other than “no further testing” was considered overuse; for syncope, any response that included “hospitalization” constituted overuse. Respondents were also asked to provide “the most likely primary driver of the hospitalist’s decision” (in particular, whether the practice choices resulted from a desire to follow scientific guidance or some other motivation).

Results:

The response rate was 68% (1,020 responses from 1,500 surveys). Median time in practice was 9 years. Overuse was selected in 52-65% of the preoperative evaluation vignettes and 82-85% of the syncope vignettes. In preoperative evaluation, treatment choices were driven by something other than scientific evidence (e.g., reassurance for family member) in 38% of all responses. In syncope, in 61% of all responses, the primary determinant of treatment choice was a factor other than clinical guidelines. Practicing in a Veterans Affairs (VA) setting significantly decreased the risk for overuse both in preoperative evaluation and syncope.

Conclusions:

In a survey of hospitalists given clinical vignettes, there was frequent overuse of testing/treatment in preoperative evaluation and syncope. The primary determinant of overuse was often the desire to provide reassurance to patients or themselves.

Perspective:

This is an interesting survey that addresses factors that may underlie overutilization of health care in two commonly encountered scenarios: preoperative evaluation and syncope. Hospitalists selected unnecessary care in the majority of responses. What is perhaps most interesting is that the primary determinant for this practice pattern was often the need to provide reassurance for themselves and/or the patient. Lack of awareness of the guidelines was often not a key factor. Certainly, future efforts aimed at curbing overutilization should address the issue of reassurance behaviors.

Keywords: Data Collection, Hospitalists, Hospitalization, Lawyers, Occupations, Preoperative Period, Questionnaires, Syncope


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