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Original Research |

Overuse of Testing in Preoperative Evaluation and Syncope: A Survey of HospitalistsOveruse of Testing in Preoperative Evaluation and Syncope

Allen Kachalia, MD, JD; Aaron Berg, MD; Angela Fagerlin, PhD; Karen E. Fowler, MPH; Timothy P. Hofer, MD, MSc; Scott A. Flanders, MD; and Sanjay Saint, MD, MPH
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and University of Michigan Medical School, VA Ann Arbor Healthcare System, and University of Michigan, Ann Arbor, Michigan.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of Blue Cross Blue Shield of Michigan, the Department of Veterans Affairs, or the Society of Hospital Medicine.

Acknowledgment: The authors thank the Society of Hospital Medicine for its assistance with this project; Andrew Hickner for assistance with conducting the survey and preparing the manuscript; Wyndy Wiitalia, Edward Kennedy, and M. Todd Greene for assistance with statistical analysis; and David Studdert for his comments on an earlier version of the manuscript.

Financial Support: By the Blue Cross Blue Shield of Michigan Foundation, the Department of Veterans Affairs Health Services Research and Development Center for Clinical Management Research, the University of Michigan Specialist-Hospitalist Allied Research Program, and the Ann Arbor VA/University of Michigan Patient Safety Enhancement Program.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0694.

Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.

Requests for Single Reprints: Sanjay Saint, MD, MPH, George Dock Professor of Internal Medicine, University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800.

Current Author Addresses: Dr. Kachalia: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Drs. Berg and Flanders: University of Michigan, Department of Internal Medicine/General Medicine, 1500 East Medical Center Drive, 3119 Taubman Center, Ann Arbor, MI 48109-5376.

Dr. Fagerlin: University of Michigan Center for Health Communications Research, 300 North Ingalls Building, Room 7D17, Ann Arbor, MI 48109-5429.

Ms. Fowler and Dr. Hofer: VA Center for Clinical Management Research, VA Ann Arbor Healthcare System (152), PO Box 130170, Ann Arbor, MI 48113-0170.

Dr. Saint: George Dock Professor of Internal Medicine, University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800.

Author Contributions: Conception and design: A. Kachalia, A. Berg, A. Fagerlin, K.E. Fowler, T.P. Hofer, S.A. Flanders, S. Saint.

Analysis and interpretation of the data: A. Kachalia, K.E. Fowler, T.P. Hofer, S.A. Flanders.

Drafting of the article: A. Kachalia, K.E. Fowler, T.P. Hofer.

Critical revision of the article for important intellectual content: A. Kachalia, A. Berg, A. Fagerlin, S.A. Flanders, S. Saint.

Final approval of the article: A. Kachalia, A. Fagerlin, K.E. Fowler, T.P. Hofer, S.A. Flanders, S. Saint.

Provision of study materials or patients: A. Kachalia.

Statistical expertise: T.P. Hofer.

Obtaining of funding: K.E. Fowler, S.A. Flanders, S. Saint.

Administrative, technical, or logistic support: A. Kachalia, K.E. Fowler, S.A. Flanders.

Collection and assembly of data: A. Kachalia, K.E. Fowler.

Ann Intern Med. 2015;162(2):100-108. doi:10.7326/M14-0694
Text Size: A A A

Background: Health care reform efforts and initiatives seek to improve quality and reduce costs by eliminating unnecessary care. However, little is known about overuse and its drivers, especially in hospitals.

Objective: To assess the extent of and factors associated with overuse of testing in U.S. hospitals.

Design: National survey of practice patterns for 2 common clinical vignettes: preoperative evaluation and syncope. Respondents were randomly selected and randomly provided 1 of 4 versions of each vignette. Each version contained identical clinical information but varied in factors that could change physician behavior. Respondents were asked to identify what they believed most hospitalists at their institution would recommend in each vignette.

Setting: Mailed survey conducted from June through October 2011.

Participants: Physicians practicing adult hospital medicine in the United States.

Measurements: Responses indicating overuse (more testing than recommended by American College of Cardiology/American Heart Association guidelines).

Results: 68% (1020 of 1500) of hospitalists responded. They reported overuse in 52% to 65% of the preoperative evaluation vignettes and 82% to 85% of the syncope vignettes. Overuse more frequently resulted from a physician's desire to reassure patients or themselves than an incorrect belief that it was clinically indicated (preoperative evaluation, 63% vs. 37%; syncope, 69% vs. 31%; P < 0.001 for each).

Limitation: Survey responses may not represent actual clinical choices.

Conclusion: Physicians reported substantial overuse in 2 common clinical situations in the hospital. Improving provider knowledge of guidelines may help reduce overuse, but despite awareness of the guidelines, physicians often deviate from them to reassure patients or themselves.

Primary Funding Source: Blue Cross Blue Shield of Michigan Foundation, Department of Veterans Affairs Center for Clinical Management Research, University of Michigan Specialist-Hospitalist Allied Research Program, and Ann Arbor Veterans Affairs/University of Michigan Patient Safety Enhancement Program.


Grahic Jump Location

Study flow diagram.

SHM = Society of Hospital Medicine.

* Included society members and attendees of all prior SHM national meetings.

† The original mailing included 1600 surveys. Those that were returned with the incentive (e.g., because of a wrong address) were sent to the next physician on the randomized list, which increased the total number of mailed surveys.

‡ Surveys returned because of a wrong address and those from ineligible recipients were removed from the denominator to calculate the response rate (1020/1500).

Grahic Jump Location




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Submit a Comment/Letter
VA vs non-VA physicians
Posted on January 25, 2015
Viet Do, DO, FACP
Phoenix VA Healthcare System, University of Arizona College of Medicine-Phoenix
Conflict of Interest: None Declared
Thank you for this insightful study to illustrate the over utilization of limited resources. Interesting how VA affiliated physicians utilized less resources. Possible reasons include: less available resources to complete tests, availability of previous tests results from other VA facilities via EHR, greater awareness of evidence-based practice, etc. So clearly another studies needs to be considered about utilization of testing in common medical conditions comparing VA physicians versus non-VA physicians.

And clearly hospitalists need continued education and training about futility of testing in the scenarios presented and how to clearly communicate with family members, and not be swayed by outside pressures.
Submit a Comment/Letter

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