Intended for healthcare professionals

Practice Change

Reducing unnecessary preoperative testing

BMJ 2022; 379 doi: https://doi.org/10.1136/bmj-2022-070118 (Published 06 October 2022) Cite this as: BMJ 2022;379:e070118

Linked Editorial

Sustainable practice: what can I do?

  1. Lesly A Dossett, associate professor of surgery, chief of Division of Surgical Oncology1,
  2. Anthony L Edelman, clinical assistant professor, division director of Ambulatory Anesthesia2,
  3. Gloria Wilkinson, patient and family advisor,
  4. Shannon M Ruzycki, general internist, clinical assistant professor3
  1. 1Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
  2. 2Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
  3. 3Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
  1. Correspondence to: L A Dossett ldossett{at}umich.edu

What you need to know

  • Routine preoperative tests (such as electrocardiograms and blood tests) before low risk surgery do not prevent adverse events during or after surgery

  • Unnecessary testing is costly and can lead to other potentially unnecessary specialty consultations and invasive tests

  • Choosing Wisely and NICE guidelines provide multi-specialty recommendations to support the avoidance of unnecessary preoperative testing

  • Over-testing is rooted in the general misconception that medical screening cannot be harmful

  • Interventions shown to reduce unnecessary preoperative testing include local practice guidelines, clinician education, and audit and feedback

Preoperative evaluation is a component of risk stratification and mitigation for patients undergoing surgery. These evaluations include comprehensive histories, directed physical exams, and selected preoperative diagnostic testing. However, most people who undergo low risk surgeries do not need any preoperative tests. Routine and unnecessary use of preoperative tests is harmful to patients and can lead to unnecessary specialty consultations, invasive diagnostic and therapeutic interventions, delays in surgery, costs to patients (such as missed days of work, travel burden, out-of-pocket costs), wasted time for clinicians, and environmental harm.12345

The choice to conduct preoperative testing is guided by characteristics of the patient (which can be classified according to the American Society of Anesthesiologists (ASA)) and the planned procedure (emergent or minor, intermediate, or major elective surgery). While patients with significant systemic disease (ASA 3 or 4) and those undergoing major surgery typically require testing, asymptomatic patients undergoing low risk surgery do not require routine preoperative tests.

The UK National Institute for Health and Care Excellence (NICE) and the international Choosing Wisely campaign recommend against the use of routine laboratory studies, electrocardiograms, echocardiograms, cardiac stress tests, and chest radiographs in most patients undergoing low risk (such as eye and dental surgery, removal of skin lesions) and intermediate risk surgery (such as repair of inguinal …

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