Understanding Why Less Is Not More in Preoperative Evaluation and Syncope

Journal Wrap | A national survey of more than 1,000 adult hospitalists given clinical vignettes found frequent overuse of testing/treatment in preoperative evaluation and management of syncope. The results, published in the Annals of Internal Medicine, suggest the primary determinant of overuse was often the desire to provide reassurance to patients or themselves.

The vignettes that comprised the survey 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. 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).

Overall results found that 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 61% of all responses, the primary determinant of treatment choice was a factor other than clinical guidelines. Study authors did note that practicing in a Veterans Affair setting significantly decreased the risk for overuse both in preoperative evaluation and syncope.

"This is an interesting survey that addresses factors that may underlie overutilization of health care in two commonly encountered scenarios: preoperative evaluation and syncope," according to Prashant Vaishnava, MD, in an ACC Journal Scan. "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."


  1. Kachalia A, Berg A, Fagerlin A, et al. Ann Intern Med. 2015;162:100-8.

Keywords: ACC Publications, CardioSource WorldNews

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