Chosen wisely? Stress test rates already low for low-risk surgeries

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A 2011 campaign targeted at reducing rates of stress testing prior to low-risk surgeries may have aimed at the wrong thing. According to a research letter published online Feb. 9 in JAMA: Internal Medicine even before the Choosing Wisely campaign, few patients were being subjected to unnecessary stress testing.

Researchers collected retrospective data on 22,670 Veterans Affairs and 109,270 Medicare patients undergoing knee or shoulder arthroscopy or cataract surgery in 2009. They found that even though rates of stress testing before these low-risk surgeries varied by region, they were still low.

Stress testing occurred more frequently for patients of arthroscopy: Veterans Affairs and Medicare logged 1.56 percent and 4.37 percent, respectively. Cataract surgery was less than half that for either Veterans Affairs patients or Medicare patients: 0.62 percent and 1.76 percent, respectively.

The Choosing Wisely campaign was developed by seven specialty societies to improve practice by emphasizing recommendations and reducing inappropriate care. In 2011, the campaign impressed the need to reduce rates of cardiac stress tests prior to low-risk surgeries based on guidelines developed much earlier by the American College of Cardiology and the American Heart Association.

Eve A. Kerr, MD, MPH, of the Veterans Affairs Ann Arbor Healthcare System in Ann Arbor, Mich., and colleagues noted that “these absolute numbers suggest that interventions to further decrease the use of the testing would minimally improve quality while diverting attention away from higher-yield interventions that would more strongly affect care.”

Since the guidelines had already changed care, Kerr et al suggested that future recommendations through the Choose Wisely campaign should focus on improving quality by highlighting areas with higher baseline rates of inappropriate care to make the most impact.