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Choosing Wisely in Anesthesiology The Gap Between Evidence and Practice Onyi C. Onuoha, MD, MPH; Valerie A. Arkoosh, MD, MPH; Lee A. Fleisher, MD
Editor's Note page 1396
To develop a “top-five” list of unnecessary medical services in anesthesiology, we undertook a multistep survey of anesthesiologists, most of whom were in academic practice, and a consequent iterative process with the committees of the American Society of Anesthesiologists. We generated a list of 18 low-value perioperative activities from American Society of Anesthesiologists practice parameters and the literature. Starting with this list and proceeding with a 2-step survey using a 5-point Likert scale questionnaire, we eventually identified 5 common activities that are of low quality or benefit and high cost and have poor evidence supporting their use. The 2 preoperative practices in the top-five list addressed the avoidance of unindicated baseline laboratory studies or diagnostic cardiac stress testing. The 3 intraoperative practices involved the avoidance of the routine use of the pulmonary artery for cardiac surgery and the use of packed red blood cells or colloid when not indicated. JAMA Intern Med. 2014;174(8):1391-1395. doi:10.1001/jamainternmed.2014.2309 Published online June 16, 2014.
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nnecessary health spending in the United States was estimated at $765 billion in 2009, one-quarter—$210 billion—of which was for the overuse of services, including those that are provided more frequently than necessary or that cost more but are no more beneficial than lower-cost alternatives.1 In 2002, the American Board of Internal Medicine (ABIM) Foundation, the American College of Physicians, and the European Federation of Internal Medicine jointly issued the “Physician Charter” outlining the physician’s professional responsibilities to ensure access to high-quality care by practicing evidence-based medicine, advocating for just and cost-effective distribution of finite resources, and maintaining trust by minimizing conflicts of interest.2,3 Today, more than 130 organizations, including the American Society of Anesthesiologists (ASA), have endorsed the Physician Charter. 3 However, the overuse of low-value ser vice s in low-risk patients undergoing low-risk surgery continues to increase substantially over time.4 With approximately 30 million people in the United States undergoing surgery annually and approximately 60% of them undergoing an ambulatory procedure, the elimination of tests and procedures that are not indicated could result in substantial savings.5 “Choosing Wisely” is an ongoing effort by the ABIM Foundation to help physicians become better stewards of finite health resources.6 We undertook a survey of anesthesiologists, most of whom were in academic practice, to identify a “top-five” list of activities to question in anesthesiology using practice parameters7-22 that were developed by the ASA and other perioperative guidelines.23-31 The ASA submitted the top-five list for inclusion in the Choosing Wisely campaign.
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Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Lee A. Fleisher, MD, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104 ([email protected]).
Methods The institutional review board of the Perelman School of Medicine, University of Pennsylvania, exempted our study from review because it did not involve human subjects research and did not require a separate written informed consent.
Data Sources We reviewed the literature and current practice parameters as approved by the ASA to identify possible evidence-based practices for inclusion in a top-five list in anesthesiology.7-31 Criteria for inclusion were (1) common clinical practices for which (2) avoidance would lead to improved quality of care and/or (3) reduced costs, (4) there is little or no evidence of benefit to patients, and (5) implementation of avoidance would be feasible to achieve.32 Candidate items were restricted to common preoperative and intraoperative practices, with the exclusion of postoperative and pain services.
Data Collection and Participants After compiling a list of 18 candidate items (7 preoperative and 11 intraoperative), we initiated a multistep survey process to reach consensus among practicing academic anesthesiologists. We first disseminated the list to academic anesthesia department chairs and program directors through the Society of Academic Anesthesiology Associations. After reducing the list to 11 candidate items (5 preoperative and 6 intraoperative practices), we disseminated the revised list to members of the Association of University Anesthesiologists and through the ASA to a subset of its members.
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Table 1. Demographic Characteristics: Round 1 (Society of Academic Anesthesiology Associations [SAAA]) and Round 2 (Association of University Anesthesiologists [AUA] and American Society of Anesthesiologists [ASA]) Respondents Responses, No. (%) Characteristic
SAAA (n = 64)
AUA and ASA (n = 218)
Practice type Academic practice
56 (88)
173 (79)
Private practice
0
34 (16)
Hybrid
7 (11)
10 (5)
Missing
1 (1)
1 (0.5)
who charged the relevant committees (surgical anesthesia, blood management, and cardiovascular and thoracic anesthesia) to review and comment.
Data Analysis The survey was Internet based and disseminated using SurveyMonkey. Data collection was conducted with a spreadsheet program (Microsoft Excel; Microsoft Corp). For the survey, we reported percentages in all 5 domains (frequency, quality, cost, evidence, actionability and/or implementation) for each activity. Percentages and freetext comments were used and compared across activities for final ranking of items.
Sex Male
47 (73)
173 (79)
Female
17 (27)
44 (20)
Missing
0
Year of residency graduation Before 1993
50 (78)
164 (75)
1993-2003
8 (13)
39 (18)
After 2003
4 (6)
11 (5)
Missing
1 (1)
3 (1)
Incorrect coding
1 (1)
1 (0.5)
Preoperative clinica Anesthesia-run clinic
NE
173 (79)
Non–anesthesia-run clinic
NE
41 (19)
Missing
1 (0.5)
Incorrect coding
2 (1)
Abbreviation: NE, not elicited. a
Round 2 respondents were asked to indicate whether they worked in a practice with an anesthesia-run preoperative clinic. This was included because of responses from round 1 surveys indicating the lack of control by some anesthesiologists over preoperative services offered to their patients prior to surgery.
Methods of Measurement Using a 5-point Likert scale questionnaire, participation in each round of the survey involved answering 5 questions about an activity pertaining to its frequency in practice, impact on quality of care, impact on cost of care, strength of evidence supporting the activity, and the ease in implementation of avoidance. Responses involved rating an item high (1-2), neutral (3), or low (4-5) as defined in the survey on the proposed Likert scale (eAppendix in Supplement). We performed descriptive data analysis after each round of the survey by examining the percentage of respondents rating an item high or low on the 5-point Likert scale. The avoidance of an activity was considered well supported if a majority of the respondents rated it as (1) being a frequent practice with (2) a weak impact on quality of care (low benefit), (3) a strong impact on cost of care (expensive), and (4) weak evidence for its recommendation in clinical practice. For both survey rounds, the selection of the final items was not dependent on the respondent’s assessment of his or her own ability to avoid the activity (implementation and/or actionability) as previously intended, as a result of the uniform consensus that anesthesiologists are unable to implement change in isolation from other physicians and health care personnel. Following a decision to collaborate with the ASA for submission to the Choosing Wisely campaign, the topfive items were subsequently sent to the president-elect of the ASA, 1392
Results
1 (0.5)
After 27 incomplete responses were eliminated, data from 64 of 126 respondents (51% response rate) were used in round 1. Subsequent data from a total of 218 respondents in round 2 were used to develop the top-five list. In round 2, after 37 incomplete responses were eliminated, data from 165 of 800 academic anesthesiologists were used (21% response rate). For private-practice anesthesiologists, after 38 incomplete responses were eliminated, data from 53 of 823 anesthesiologists were used (6% response rate).
Survey Table 1 shows the demographic characteristics of the respondents. In both rounds, a large proportion of respondents were male, from academic practice settings, and in practice for more than 20 years, with the year of graduation from residency ranging from 1974 to 2012 in round 1 and 1959 to 2012 in round 2. As expected among academic anesthesiologists, most respondents practiced in institutions with preoperative clinics run by anesthesiologists. Of the 18 survey items in round 1, 7 were eliminated because of their rarity in practice. In round 2, 6 more items were eliminated for other reasons (Table 2).
Top-Five List in Anesthesiology Table 3 shows the final top-five list. In general, there was consensus on the impact of quality, cost, and the availability of evidence for most items surveyed. Candidate items were eliminated mostly because of frequency—a lack of consensus that anesthesiologists practiced these activities routinely across institutions when compared with the final selected items. In addition, there was a discrepancy between the low frequency at which respondents practiced an activity (specifically with preoperative testing) and the frequency of the same activity in clinical settings noted in the free-text comments. Although some of the activities on the final list had frequency responses in numerical percentages similar to those of the activities that were eliminated, free-text comments by respondents consistently identified those on the top-five list. The ASA committees provided comments on the final list through an iterative process that involved responding to queries. The ASA endorsed all the preoperative recommendations, and the intraoperative recommendations with the exception of avoiding the routine use of colloids for volume resuscitation. Recent perioperative data on the use of colloids in some situations remain controversial; nevertheless, there was unanimity on the avoidance of the
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Table 2. Common Low-Value Activities to Question in the Field of Anesthesiology: List of Candidate Items Eliminated After Rounds 1 and 2 of Survey Items Eliminated
Panel A (Round 1 of Surveya)
Panel B (Round 2 of Surveyb)
Preoperative
1. Baseline testing such as PFTs and/or spirometry or ABG concentrations in asymptomatic stable patients with pulmonary disease (eg, COPD) 2. Routine administration of gastrointestinal stimulants (eg, metoclopramide hydrochloride), antacids, or histamine-2 receptor blockers before elective procedures requiring general anesthesia, regional anesthesia, or monitored anesthesia care
1. Baseline laboratory studies in healthy patients without significant systemic disease (ASA I or II)—specifically electrocardiography 2. Baseline imaging studies in healthy patients without significant systemic disease (ASA I or II)—specifically chest radiography 3. Baseline pregnancy testing in premenopausal women of childbearing age
Intraoperative
1. Administration of packed red blood cells in a patient with 1. Use of pulmonary artery catheters for noncardiac surgery systemic disease (eg, CAD) without ongoing blood loss and (peripheral vascular surgery, abdominal aortic reconstruction, hemoglobin concentration of >10 g/dL neurosurgery [venous air embolism], trauma surgery, obstetric 2. Administration of FFP without coagulation tests (ie, PT or INR procedures [preeclampsia]) and aPTT) (excluding the setting of massive transfusion) 2. Administration of FFP solely for augmentation of plasma volume 3. Administration of platelets to a patient with a platelet count of or albumin concentration >50 000 cells/mm3 without any known or suspected evidence 3. Administration of platelets without obtaining an intraoperative platelet count, with the criteria to transfuse based on visual of platelet dysfunction (eg, the presence of potent antiplatelet assessment of the surgical field for excessive microvascular agents, cardiopulmonary bypass) bleeding (excluding the setting of massive transfusion) 4. Administration of cryoprecipitate without obtaining an intraoperative fibrinogen concentration, with the criteria to transfuse based on visual assessment of the surgical field for excessive microvascular bleeding (excluding the setting of massive transfusion) 5. Administration of cryoprecipitate with a fibrinogen concentration of >150 mg/dL
Abbreviations: ABG, arterial blood gas; aPTT, activated partial thromboplastin time; ASA, American Society of Anesthesiologists; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; ECG, electrocardiography; FFP, fresh frozen plasma; INR, international normalized ratio; PFT, pulmonary function test; PT, prothrombin time.
multiply by 0.0294; to convert hemoglobin concentration to grams per liter, multiply by 10; to convert platelet count to billion cells per liter, multiply by 1. a
List of 18 potentially low-value activities (preoperative and intraoperative).
b
List of 11 potentially low-value activities (preoperative and intraoperative).
SI conversion factors: To convert fibrinogen concentration to micromoles per liter,
Table 3. Final “Top-Five” List of Common Low-Value Activities to Question in the Field of Anesthesiology Respondents,a %
Frequency Encountered
Impact on Quality of Care
Impact on Cost of Care
Strength of Evidence Supporting Performance of Activity
Difficult to Implement or Avoid
1. Baseline laboratory studies (CBC, BMP or CMP, coagulation studies) in healthy patients without significant systemic disease (ASA I or II), when blood loss (or fluid shifts) is expected to be minimal
(n = 217) ↑, 19.9 N, 6.5 ↓, 73.7
(n = 218) ↑, 11.0 N, 12.4 ↓, 76.6
(n = 217) ↑, 70.5 N, 12.4 ↓, 17.0
(n = 213) ↑, 23.0 N, 11.3 ↓, 65.7
(n = 215) ↑, 32.6 N, 20.9 ↓, 46.5
2. Baseline diagnostic cardiac testing (TTE or TEE) or cardiac stress test in asymptomatic stable patients with known cardiac disease (eg, CAD, valvular disease) undergoing low-risk or moderate-risk noncardiac surgery
(n = 188) ↑, 21.8 N, 29.3 ↓, 48.9
(n = 189) ↑, 31.7 N, 30.2 ↓, 38.1
(n = 188) ↑, 73.5 N, 13.8 ↓, 12.8
(n = 189) ↑, 25.4 N, 31.7 ↓, 42.9
(n = 188) ↑, 31.4 N, 27.1 ↓, 41.5
Abbreviations: Arrow down, decreased in my practice; arrow up, increased in my practice; ASA, American Society of Anesthesiologists; BMP, basic metabolic panel; CAD, coronary artery disease; CBC, complete blood cell count; CMP, comprehensive metabolic panel; N, neutral or average; TEE, transesophageal echocardiogram; TTE, transthoracic echocardiogram.
3. Routine use of pulmonary arterial catheter for cardiac surgery in patients with a low risk of hemodynamic complicationsb (especially with the concomitant use of alternative diagnostic tools, eg, TTE or TEE)
(n = 162) ↑, 33.3 N, 14.2 ↓, 52.5
(n = 161) ↑, 21.8 N, 26.7 ↓, 51.6
(n = 162) ↑, 62.4 N, 20.4 ↓, 17.3
(n = 158) ↑, 17.1 N, 24.1 ↓, 58.8
(n = 162) ↑, 35.8 N, 25.9 ↓, 38.3
SI conversion factor: To convert hemoglobin concentration to grams per liter, multiply by 10.
4. Administration of packed red blood cells in a young healthy patient without ongoing blood loss and hemoglobin concentration of >6 g/dL unless symptomatic or hemodynamically unstable
(n = 174) ↑, 38.5 N, 14.9 ↓, 46.5
(n = 174) ↑, 32.7 N, 28.7 ↓, 38.5
(n = 173) ↑, 63.5 N, 25.4 ↓, 11.0
(n = 174) ↑, 29.9 N, 29.3 ↓, 40.8
(n = 175) ↑, 42.8 N, 26.9 ↓, 30.3
5. Routine administration of colloid (dextrans, hydroxyethyl starches, albumin) for volume resuscitation without appropriate indications; clinicians should refer to current data for its use in specific populations
(n = 162) ↑, 51.2 N, 17.9 ↓, 30.9
(n = 161) ↑, 43.4 N, 27.3 ↓, 29.2
(n = 160) ↑, 54.4 N, 30.0 ↓, 15.6
(n = 161) ↑, 25.5 N, 41.0 ↓, 33.6
(n = 162) ↑, 33.9 N, 35.8 ↓, 30.2
Practice Activity Preoperative
Intraoperative
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a
Respondents from round 2 (Association of University Anesthesiologists and subset of ASA) on the top-five list of clinical activities.
b
Increased risk of hemodynamic complications was defined as patient with clinical evidence of significant cardiovascular disease, pulmonary dysfunction, hypoxia, renal insufficiency, or other conditions associated with hemodynamic instability (eg, advanced age, endocrine disorders, sepsis, trauma, burns).
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routine use of colloids for volume resuscitation in general surgery given the accumulating evidence of lack of benefit with possible harm to patients.23-31 After further discussions and revisions, the recommendations were endorsed by the ASA and submitted to the ABIM Foundation for inclusion in the Choosing Wisely campaign.
Discussion Through an iterative process of reviewing guidelines; surveying a group of anesthesiologists, most of whom were in academic practice; and working with the leadership of the ASA, we developed a top-five list for submission to the Choosing Wisely campaign. Given the challenge of translating guidelines into practice,33,34 evaluating the ability of anesthesiologists to actually implement these items was an important part of the survey. Despite a clear knowledge of evidence-based guidelines, a majority of the respondents indicated the inability to implement these recommendations in isolation. With physicians from multiple specialties cooperating in perioperative care, a multidisciplinary approach involving the primary care physician, the surgeon, and the anesthesiologist is needed to ensure that these recommendations are implemented. Our study highlights some implementation challenges. According to the survey, the use of low-value services is often driven by external factors such as lack of control over preoperative ordering of laboratory tests or imaging studies, surgical preference, patient preference or demand, medicolegal concerns, or postoperative needs such as the intraoperative placement of a pulmonary artery catheter for subsequent care. The most notable but modifiable challenge indicated by respondents was the lack of collaboration by all stakeholders involved, including the patient, especially in the area of preoperative testing. With preoperative testing, current data highlight the overuse of low-value services for routine preoperative evaluation in low-risk patients undergoing low-risk surgery. A recent study showed a significant increase in preoperative stress testing, from 1.72% in 1996 to 6.44% in 2007.4 Although preoperative clinics are effective,35-37 many patients are not seen in them, and such clinics
ARTICLE INFORMATION Accepted for Publication: April 15, 2014. Published Online: June 16, 2014. doi:10.1001/jamainternmed.2014.2309. Author Affiliations: Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Author Contributions: Drs Onuoha and Fleisher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Onuoha. Drafting of the manuscript: Onuoha. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Onuoha. Administrative, technical, or material support: Arkoosh. Study supervision: Arkoosh, Fleisher.
do not control the performance of all preoperative tests. Anesthesiologists, surgeons, and primary care physicians should collaborate to better define the groups of patients who may benefit from preoperative stress testing. Increasing awareness across the specialties is a first step in instituting change. Grand rounds and continuing medical education have a role to play. Creating uniform guidelines across specialties and discussing the perioperative plan with all clinicians involved prior to surgery should be encouraged. Seeking to diminish the popular perception that “more care is better care,” as Consumer Reports has done, is also important.32,38 Misunderstanding and miscommunication between physicians and patients is a major reason that unnecessary and even harmful tests are ordered.32 The primary care physician or surgeon can validate patient concerns but also provide factual information, in an easy-to-understand manner, about what tests and practices to avoid.32,39
Conclusions Our approach to developing a top-five list should also be considered in the context of important limitations. The recommendations were based on the opinions of participating physicians rather than empirical data or actual implementation in practice; hence, bias cannot be excluded. More notably, there was a sizeable overrepresentation of academic-practice, male, older, and more experienced anesthesiologists among the respondents. This, in part, can be attributed to the poor response rate of private-practice anesthesiologists in round 2 (6% as compared with 21% for anesthesiologists in academic practice), which may reflect the lack of an incentive to complete the online survey. The physicians who completed the survey may not be representative of anesthesiologists in practice. If the study had been performed using a more diverse sample of anesthesiologists, it is possible that a different top-five list may have been developed. Nonetheless, through a robust and transparent process, we developed a list of 5 activities in anesthesiology that should be avoided.
Previous Presentations: This study was presented as a poster presentation at the National Physicians Alliance Seventh Annual Conference; November 10-11, 2012; Alexandria, Virginia; and Seventh Annual Pennsylvania Anesthesiology Resident Research Conference; May 12, 2012; Philadelphia, Pennsylvania. Additional Contributions: The authors acknowledge the Society of Academic Anesthesia Associations, Association of University Anesthesiologists, and American Society of Anesthesiologists. REFERENCES 1. Berenson RA, Docteur E. Doing better by doing less: approaches to tackle overuse of services—timely analysis of immediate health policy issues. Robert Wood Johnson Foundation website. http://www.rwjf.org/content/dam/farm/reports /issue_briefs/2013/rwjf403697. Published January 2013. Accessed March 17, 2013.
Conflict of Interest Disclosures: None reported. 1394
2. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. 3. Medical professionalism in the new millennium: a physician charter. American Board of Internal Medicine Foundation website. http://www .abimfoundation.org/professionalism/~/media/files /physician%20charter.ashx. Accessed March 17, 2013. 4. Sheffield KM, McAdams PS, Benarroch-Gampel J, et al. Overuse of preoperative cardiac stress testing in Medicare patients undergoing elective noncardiac surgery. Ann Surg. 2013;257(1):73-80. 5. Fleisher LA. Preoperative consultation before cataract surgery: are we choosing wisely or is this simply low-value care? JAMA Intern Med. 2014;174 (3):389-390. 6. Choosing wisely: an initiative of the ABIM Foundation. American Board of Internal Medicine Foundation website. http://www .choosingwisely.org. Accessed July 30, 2012. 7. American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and
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Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006;105(1):198-208. 8. Apfelbaum JL, Connis RT, Nickinovich DG, et al; Committee on Standards and Practice Parameters; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012; 116(3):522-538. 9. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3): 495-511. 10. American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology. 2003;99(4):988-1014. 11. Practice guidelines for perioperative transesophageal echocardiography: an updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiology Task Force on Transesophageal Echocardiography. Anesthesiology. 2010;112(5):1084-1096. 12. Gross JB, Bachenberg KL, Benumof JL, et al; American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients With Obstructive Sleep Apnea. Anesthesiology. 2006; 104(5):1081-1093. 13. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists: an updated report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. 14. American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology. 2011;114(4):741-754. 15. Rupp SM, Apfelbaum JL, Blitt C, et al; American Society of Anesthesiologists Task Force on Central
Venous Access. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012;116(3):539-573. 16. American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Practice advisory for perioperative visual loss associated with spine surgery: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Anesthesiology. 2012; 116(2):274-285. 17. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients With Cardiac Implantable Electronic Devices. Anesthesiology. 2011;114(2):247-261. 18. American Society of Anesthesiologists Task Force on Intraoperative Awareness. Practice advisory for intraoperative awareness and brain function monitoring: a report by the American Society of Anesthesiologists Task Force on Intraoperative Awareness. Anesthesiology. 2006; 104(4):847-864. 19. Practice advisory on anesthetic care for magnetic resonance imaging: a report by the Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Anesthesiology. 2009;110(3):459-479. 20. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice alert for the perioperative management of patients with coronary artery stents: a report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2009;110(1):22-23. 21. Apfelbaum JL, Caplan RA, Barker SJ, et al; American Society of Anesthesiologists Task Force on Operating Room Fires. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2013;118(2):271-290. 22. Apfelbaum JL, Hagberg CA, Caplan RA, et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2): 251-270. 23. Perel P, Roberts I, Pearson M. Colloid vs crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2009;(3): CD000567. 24. Perel P, Roberts I, Ker K. Colloids vs crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567.
jamainternalmedicine.com
25. Perel P, Roberts I. Colloids vs crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2012;(6):CD000567. 26. Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2011;(3):CD000567. 27. Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2007;(4):CD000567. 28. Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004;(4):CD000567. 29. Kruer RM, Ensor CR. Colloids in the intensive care unit. Am J Health Syst Pharm. 2012;69(19): 1635-1642. 30. NATA (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis). Crystalloids vs colloids: the controversy. http://www.nataonline.com/np/158 /crystalloids-versus-colloids-controversy. Accessed April 30, 2014. 31. Reinhart K, Perner A, Sprung CL, et al; European Society of Intensive Care Medicine. Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients. Intensive Care Med. 2012;38(3):368-383. 32. The Good Stewardship Working Group. The “top 5” lists in primary care, meeting the responsibility of professionalism. Arch Intern Med. 2011;171:1385-1390. 33. Schuur JD, Carney DP, Lyn ET, et al. A top-five list for emergency medicine: a pilot project to improve the value of emergency care. JAMA Intern Med. 2014;174(4):509-515. 34. Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8)(suppl 2):II2-II45. 35. Katz RI, Dexter F, Rosenfeld K, et al. Survey study of anesthesiologists’ and surgeons’ ordering of unnecessary preoperative laboratory tests. Anesth Analg. 2011;112(1):207-212. 36. Pollard JB. Economic aspects of an anesthesia preoperative evaluation clinic. Curr Opin Anaesthesiol. 2002;15(2):257-261. 37. Foss JF, Apfelbaum J. Economics of preoperative evaluation clinics. Curr Opin Anaesthesiol. 2001;14(5):559-562. 38. Kuehn BM. Movement to promote good stewardship of medical resources gains momentum. JAMA. 2012;307(9):895-903. 39. Mangione-Smith R, McGlynn EA, Elliott MN, McDonald L, Franz CE, Kravitz RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155(7):800-806.
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Special Communication | LESS IS MORE
Choosing Wisely in Anesthesiology The Gap Between Evidence and Practice Onyi C. Onuoha, MD, MPH; Valerie A. Arkoosh, MD, MPH; Lee A. Fleisher, MD
Editor's Note page 1396
To develop a “top-five” list of unnecessary medical services in anesthesiology, we undertook a multistep survey of anesthesiologists, most of whom were in academic practice, and a consequent iterative process with the committees of the American Society of Anesthesiologists. We generated a list of 18 low-value perioperative activities from American Society of Anesthesiologists practice parameters and the literature. Starting with this list and proceeding with a 2-step survey using a 5-point Likert scale questionnaire, we eventually identified 5 common activities that are of low quality or benefit and high cost and have poor evidence supporting their use. The 2 preoperative practices in the top-five list addressed the avoidance of unindicated baseline laboratory studies or diagnostic cardiac stress testing. The 3 intraoperative practices involved the avoidance of the routine use of the pulmonary artery for cardiac surgery and the use of packed red blood cells or colloid when not indicated. JAMA Intern Med. 2014;174(8):1391-1395. doi:10.1001/jamainternmed.2014.2309 Published online June 16, 2014.
U
nnecessary health spending in the United States was estimated at $765 billion in 2009, one-quarter—$210 billion—of which was for the overuse of services, including those that are provided more frequently than necessary or that cost more but are no more beneficial than lower-cost alternatives.1 In 2002, the American Board of Internal Medicine (ABIM) Foundation, the American College of Physicians, and the European Federation of Internal Medicine jointly issued the “Physician Charter” outlining the physician’s professional responsibilities to ensure access to high-quality care by practicing evidence-based medicine, advocating for just and cost-effective distribution of finite resources, and maintaining trust by minimizing conflicts of interest.2,3 Today, more than 130 organizations, including the American Society of Anesthesiologists (ASA), have endorsed the Physician Charter. 3 However, the overuse of low-value ser vice s in low-risk patients undergoing low-risk surgery continues to increase substantially over time.4 With approximately 30 million people in the United States undergoing surgery annually and approximately 60% of them undergoing an ambulatory procedure, the elimination of tests and procedures that are not indicated could result in substantial savings.5 “Choosing Wisely” is an ongoing effort by the ABIM Foundation to help physicians become better stewards of finite health resources.6 We undertook a survey of anesthesiologists, most of whom were in academic practice, to identify a “top-five” list of activities to question in anesthesiology using practice parameters7-22 that were developed by the ASA and other perioperative guidelines.23-31 The ASA submitted the top-five list for inclusion in the Choosing Wisely campaign.
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Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Lee A. Fleisher, MD, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104 ([email protected]).
Methods The institutional review board of the Perelman School of Medicine, University of Pennsylvania, exempted our study from review because it did not involve human subjects research and did not require a separate written informed consent.
Data Sources We reviewed the literature and current practice parameters as approved by the ASA to identify possible evidence-based practices for inclusion in a top-five list in anesthesiology.7-31 Criteria for inclusion were (1) common clinical practices for which (2) avoidance would lead to improved quality of care and/or (3) reduced costs, (4) there is little or no evidence of benefit to patients, and (5) implementation of avoidance would be feasible to achieve.32 Candidate items were restricted to common preoperative and intraoperative practices, with the exclusion of postoperative and pain services.
Data Collection and Participants After compiling a list of 18 candidate items (7 preoperative and 11 intraoperative), we initiated a multistep survey process to reach consensus among practicing academic anesthesiologists. We first disseminated the list to academic anesthesia department chairs and program directors through the Society of Academic Anesthesiology Associations. After reducing the list to 11 candidate items (5 preoperative and 6 intraoperative practices), we disseminated the revised list to members of the Association of University Anesthesiologists and through the ASA to a subset of its members.
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Table 1. Demographic Characteristics: Round 1 (Society of Academic Anesthesiology Associations [SAAA]) and Round 2 (Association of University Anesthesiologists [AUA] and American Society of Anesthesiologists [ASA]) Respondents Responses, No. (%) Characteristic
SAAA (n = 64)
AUA and ASA (n = 218)
Practice type Academic practice
56 (88)
173 (79)
Private practice
0
34 (16)
Hybrid
7 (11)
10 (5)
Missing
1 (1)
1 (0.5)
who charged the relevant committees (surgical anesthesia, blood management, and cardiovascular and thoracic anesthesia) to review and comment.
Data Analysis The survey was Internet based and disseminated using SurveyMonkey. Data collection was conducted with a spreadsheet program (Microsoft Excel; Microsoft Corp). For the survey, we reported percentages in all 5 domains (frequency, quality, cost, evidence, actionability and/or implementation) for each activity. Percentages and freetext comments were used and compared across activities for final ranking of items.
Sex Male
47 (73)
173 (79)
Female
17 (27)
44 (20)
Missing
0
Year of residency graduation Before 1993
50 (78)
164 (75)
1993-2003
8 (13)
39 (18)
After 2003
4 (6)
11 (5)
Missing
1 (1)
3 (1)
Incorrect coding
1 (1)
1 (0.5)
Preoperative clinica Anesthesia-run clinic
NE
173 (79)
Non–anesthesia-run clinic
NE
41 (19)
Missing
1 (0.5)
Incorrect coding
2 (1)
Abbreviation: NE, not elicited. a
Round 2 respondents were asked to indicate whether they worked in a practice with an anesthesia-run preoperative clinic. This was included because of responses from round 1 surveys indicating the lack of control by some anesthesiologists over preoperative services offered to their patients prior to surgery.
Methods of Measurement Using a 5-point Likert scale questionnaire, participation in each round of the survey involved answering 5 questions about an activity pertaining to its frequency in practice, impact on quality of care, impact on cost of care, strength of evidence supporting the activity, and the ease in implementation of avoidance. Responses involved rating an item high (1-2), neutral (3), or low (4-5) as defined in the survey on the proposed Likert scale (eAppendix in Supplement). We performed descriptive data analysis after each round of the survey by examining the percentage of respondents rating an item high or low on the 5-point Likert scale. The avoidance of an activity was considered well supported if a majority of the respondents rated it as (1) being a frequent practice with (2) a weak impact on quality of care (low benefit), (3) a strong impact on cost of care (expensive), and (4) weak evidence for its recommendation in clinical practice. For both survey rounds, the selection of the final items was not dependent on the respondent’s assessment of his or her own ability to avoid the activity (implementation and/or actionability) as previously intended, as a result of the uniform consensus that anesthesiologists are unable to implement change in isolation from other physicians and health care personnel. Following a decision to collaborate with the ASA for submission to the Choosing Wisely campaign, the topfive items were subsequently sent to the president-elect of the ASA, 1392
Results
1 (0.5)
After 27 incomplete responses were eliminated, data from 64 of 126 respondents (51% response rate) were used in round 1. Subsequent data from a total of 218 respondents in round 2 were used to develop the top-five list. In round 2, after 37 incomplete responses were eliminated, data from 165 of 800 academic anesthesiologists were used (21% response rate). For private-practice anesthesiologists, after 38 incomplete responses were eliminated, data from 53 of 823 anesthesiologists were used (6% response rate).
Survey Table 1 shows the demographic characteristics of the respondents. In both rounds, a large proportion of respondents were male, from academic practice settings, and in practice for more than 20 years, with the year of graduation from residency ranging from 1974 to 2012 in round 1 and 1959 to 2012 in round 2. As expected among academic anesthesiologists, most respondents practiced in institutions with preoperative clinics run by anesthesiologists. Of the 18 survey items in round 1, 7 were eliminated because of their rarity in practice. In round 2, 6 more items were eliminated for other reasons (Table 2).
Top-Five List in Anesthesiology Table 3 shows the final top-five list. In general, there was consensus on the impact of quality, cost, and the availability of evidence for most items surveyed. Candidate items were eliminated mostly because of frequency—a lack of consensus that anesthesiologists practiced these activities routinely across institutions when compared with the final selected items. In addition, there was a discrepancy between the low frequency at which respondents practiced an activity (specifically with preoperative testing) and the frequency of the same activity in clinical settings noted in the free-text comments. Although some of the activities on the final list had frequency responses in numerical percentages similar to those of the activities that were eliminated, free-text comments by respondents consistently identified those on the top-five list. The ASA committees provided comments on the final list through an iterative process that involved responding to queries. The ASA endorsed all the preoperative recommendations, and the intraoperative recommendations with the exception of avoiding the routine use of colloids for volume resuscitation. Recent perioperative data on the use of colloids in some situations remain controversial; nevertheless, there was unanimity on the avoidance of the
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Table 2. Common Low-Value Activities to Question in the Field of Anesthesiology: List of Candidate Items Eliminated After Rounds 1 and 2 of Survey Items Eliminated
Panel A (Round 1 of Surveya)
Panel B (Round 2 of Surveyb)
Preoperative
1. Baseline testing such as PFTs and/or spirometry or ABG concentrations in asymptomatic stable patients with pulmonary disease (eg, COPD) 2. Routine administration of gastrointestinal stimulants (eg, metoclopramide hydrochloride), antacids, or histamine-2 receptor blockers before elective procedures requiring general anesthesia, regional anesthesia, or monitored anesthesia care
1. Baseline laboratory studies in healthy patients without significant systemic disease (ASA I or II)—specifically electrocardiography 2. Baseline imaging studies in healthy patients without significant systemic disease (ASA I or II)—specifically chest radiography 3. Baseline pregnancy testing in premenopausal women of childbearing age
Intraoperative
1. Administration of packed red blood cells in a patient with 1. Use of pulmonary artery catheters for noncardiac surgery systemic disease (eg, CAD) without ongoing blood loss and (peripheral vascular surgery, abdominal aortic reconstruction, hemoglobin concentration of >10 g/dL neurosurgery [venous air embolism], trauma surgery, obstetric 2. Administration of FFP without coagulation tests (ie, PT or INR procedures [preeclampsia]) and aPTT) (excluding the setting of massive transfusion) 2. Administration of FFP solely for augmentation of plasma volume 3. Administration of platelets to a patient with a platelet count of or albumin concentration >50 000 cells/mm3 without any known or suspected evidence 3. Administration of platelets without obtaining an intraoperative platelet count, with the criteria to transfuse based on visual of platelet dysfunction (eg, the presence of potent antiplatelet assessment of the surgical field for excessive microvascular agents, cardiopulmonary bypass) bleeding (excluding the setting of massive transfusion) 4. Administration of cryoprecipitate without obtaining an intraoperative fibrinogen concentration, with the criteria to transfuse based on visual assessment of the surgical field for excessive microvascular bleeding (excluding the setting of massive transfusion) 5. Administration of cryoprecipitate with a fibrinogen concentration of >150 mg/dL
Abbreviations: ABG, arterial blood gas; aPTT, activated partial thromboplastin time; ASA, American Society of Anesthesiologists; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; ECG, electrocardiography; FFP, fresh frozen plasma; INR, international normalized ratio; PFT, pulmonary function test; PT, prothrombin time.
multiply by 0.0294; to convert hemoglobin concentration to grams per liter, multiply by 10; to convert platelet count to billion cells per liter, multiply by 1. a
List of 18 potentially low-value activities (preoperative and intraoperative).
b
List of 11 potentially low-value activities (preoperative and intraoperative).
SI conversion factors: To convert fibrinogen concentration to micromoles per liter,
Table 3. Final “Top-Five” List of Common Low-Value Activities to Question in the Field of Anesthesiology Respondents,a %
Frequency Encountered
Impact on Quality of Care
Impact on Cost of Care
Strength of Evidence Supporting Performance of Activity
Difficult to Implement or Avoid
1. Baseline laboratory studies (CBC, BMP or CMP, coagulation studies) in healthy patients without significant systemic disease (ASA I or II), when blood loss (or fluid shifts) is expected to be minimal
(n = 217) ↑, 19.9 N, 6.5 ↓, 73.7
(n = 218) ↑, 11.0 N, 12.4 ↓, 76.6
(n = 217) ↑, 70.5 N, 12.4 ↓, 17.0
(n = 213) ↑, 23.0 N, 11.3 ↓, 65.7
(n = 215) ↑, 32.6 N, 20.9 ↓, 46.5
2. Baseline diagnostic cardiac testing (TTE or TEE) or cardiac stress test in asymptomatic stable patients with known cardiac disease (eg, CAD, valvular disease) undergoing low-risk or moderate-risk noncardiac surgery
(n = 188) ↑, 21.8 N, 29.3 ↓, 48.9
(n = 189) ↑, 31.7 N, 30.2 ↓, 38.1
(n = 188) ↑, 73.5 N, 13.8 ↓, 12.8
(n = 189) ↑, 25.4 N, 31.7 ↓, 42.9
(n = 188) ↑, 31.4 N, 27.1 ↓, 41.5
Abbreviations: Arrow down, decreased in my practice; arrow up, increased in my practice; ASA, American Society of Anesthesiologists; BMP, basic metabolic panel; CAD, coronary artery disease; CBC, complete blood cell count; CMP, comprehensive metabolic panel; N, neutral or average; TEE, transesophageal echocardiogram; TTE, transthoracic echocardiogram.
3. Routine use of pulmonary arterial catheter for cardiac surgery in patients with a low risk of hemodynamic complicationsb (especially with the concomitant use of alternative diagnostic tools, eg, TTE or TEE)
(n = 162) ↑, 33.3 N, 14.2 ↓, 52.5
(n = 161) ↑, 21.8 N, 26.7 ↓, 51.6
(n = 162) ↑, 62.4 N, 20.4 ↓, 17.3
(n = 158) ↑, 17.1 N, 24.1 ↓, 58.8
(n = 162) ↑, 35.8 N, 25.9 ↓, 38.3
SI conversion factor: To convert hemoglobin concentration to grams per liter, multiply by 10.
4. Administration of packed red blood cells in a young healthy patient without ongoing blood loss and hemoglobin concentration of >6 g/dL unless symptomatic or hemodynamically unstable
(n = 174) ↑, 38.5 N, 14.9 ↓, 46.5
(n = 174) ↑, 32.7 N, 28.7 ↓, 38.5
(n = 173) ↑, 63.5 N, 25.4 ↓, 11.0
(n = 174) ↑, 29.9 N, 29.3 ↓, 40.8
(n = 175) ↑, 42.8 N, 26.9 ↓, 30.3
5. Routine administration of colloid (dextrans, hydroxyethyl starches, albumin) for volume resuscitation without appropriate indications; clinicians should refer to current data for its use in specific populations
(n = 162) ↑, 51.2 N, 17.9 ↓, 30.9
(n = 161) ↑, 43.4 N, 27.3 ↓, 29.2
(n = 160) ↑, 54.4 N, 30.0 ↓, 15.6
(n = 161) ↑, 25.5 N, 41.0 ↓, 33.6
(n = 162) ↑, 33.9 N, 35.8 ↓, 30.2
Practice Activity Preoperative
Intraoperative
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a
Respondents from round 2 (Association of University Anesthesiologists and subset of ASA) on the top-five list of clinical activities.
b
Increased risk of hemodynamic complications was defined as patient with clinical evidence of significant cardiovascular disease, pulmonary dysfunction, hypoxia, renal insufficiency, or other conditions associated with hemodynamic instability (eg, advanced age, endocrine disorders, sepsis, trauma, burns).
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routine use of colloids for volume resuscitation in general surgery given the accumulating evidence of lack of benefit with possible harm to patients.23-31 After further discussions and revisions, the recommendations were endorsed by the ASA and submitted to the ABIM Foundation for inclusion in the Choosing Wisely campaign.
Discussion Through an iterative process of reviewing guidelines; surveying a group of anesthesiologists, most of whom were in academic practice; and working with the leadership of the ASA, we developed a top-five list for submission to the Choosing Wisely campaign. Given the challenge of translating guidelines into practice,33,34 evaluating the ability of anesthesiologists to actually implement these items was an important part of the survey. Despite a clear knowledge of evidence-based guidelines, a majority of the respondents indicated the inability to implement these recommendations in isolation. With physicians from multiple specialties cooperating in perioperative care, a multidisciplinary approach involving the primary care physician, the surgeon, and the anesthesiologist is needed to ensure that these recommendations are implemented. Our study highlights some implementation challenges. According to the survey, the use of low-value services is often driven by external factors such as lack of control over preoperative ordering of laboratory tests or imaging studies, surgical preference, patient preference or demand, medicolegal concerns, or postoperative needs such as the intraoperative placement of a pulmonary artery catheter for subsequent care. The most notable but modifiable challenge indicated by respondents was the lack of collaboration by all stakeholders involved, including the patient, especially in the area of preoperative testing. With preoperative testing, current data highlight the overuse of low-value services for routine preoperative evaluation in low-risk patients undergoing low-risk surgery. A recent study showed a significant increase in preoperative stress testing, from 1.72% in 1996 to 6.44% in 2007.4 Although preoperative clinics are effective,35-37 many patients are not seen in them, and such clinics
ARTICLE INFORMATION Accepted for Publication: April 15, 2014. Published Online: June 16, 2014. doi:10.1001/jamainternmed.2014.2309. Author Affiliations: Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Author Contributions: Drs Onuoha and Fleisher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Onuoha. Drafting of the manuscript: Onuoha. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Onuoha. Administrative, technical, or material support: Arkoosh. Study supervision: Arkoosh, Fleisher.
do not control the performance of all preoperative tests. Anesthesiologists, surgeons, and primary care physicians should collaborate to better define the groups of patients who may benefit from preoperative stress testing. Increasing awareness across the specialties is a first step in instituting change. Grand rounds and continuing medical education have a role to play. Creating uniform guidelines across specialties and discussing the perioperative plan with all clinicians involved prior to surgery should be encouraged. Seeking to diminish the popular perception that “more care is better care,” as Consumer Reports has done, is also important.32,38 Misunderstanding and miscommunication between physicians and patients is a major reason that unnecessary and even harmful tests are ordered.32 The primary care physician or surgeon can validate patient concerns but also provide factual information, in an easy-to-understand manner, about what tests and practices to avoid.32,39
Conclusions Our approach to developing a top-five list should also be considered in the context of important limitations. The recommendations were based on the opinions of participating physicians rather than empirical data or actual implementation in practice; hence, bias cannot be excluded. More notably, there was a sizeable overrepresentation of academic-practice, male, older, and more experienced anesthesiologists among the respondents. This, in part, can be attributed to the poor response rate of private-practice anesthesiologists in round 2 (6% as compared with 21% for anesthesiologists in academic practice), which may reflect the lack of an incentive to complete the online survey. The physicians who completed the survey may not be representative of anesthesiologists in practice. If the study had been performed using a more diverse sample of anesthesiologists, it is possible that a different top-five list may have been developed. Nonetheless, through a robust and transparent process, we developed a list of 5 activities in anesthesiology that should be avoided.
Previous Presentations: This study was presented as a poster presentation at the National Physicians Alliance Seventh Annual Conference; November 10-11, 2012; Alexandria, Virginia; and Seventh Annual Pennsylvania Anesthesiology Resident Research Conference; May 12, 2012; Philadelphia, Pennsylvania. Additional Contributions: The authors acknowledge the Society of Academic Anesthesia Associations, Association of University Anesthesiologists, and American Society of Anesthesiologists. REFERENCES 1. Berenson RA, Docteur E. Doing better by doing less: approaches to tackle overuse of services—timely analysis of immediate health policy issues. Robert Wood Johnson Foundation website. http://www.rwjf.org/content/dam/farm/reports /issue_briefs/2013/rwjf403697. Published January 2013. Accessed March 17, 2013.
Conflict of Interest Disclosures: None reported. 1394
2. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. 3. Medical professionalism in the new millennium: a physician charter. American Board of Internal Medicine Foundation website. http://www .abimfoundation.org/professionalism/~/media/files /physician%20charter.ashx. Accessed March 17, 2013. 4. Sheffield KM, McAdams PS, Benarroch-Gampel J, et al. Overuse of preoperative cardiac stress testing in Medicare patients undergoing elective noncardiac surgery. Ann Surg. 2013;257(1):73-80. 5. Fleisher LA. Preoperative consultation before cataract surgery: are we choosing wisely or is this simply low-value care? JAMA Intern Med. 2014;174 (3):389-390. 6. Choosing wisely: an initiative of the ABIM Foundation. American Board of Internal Medicine Foundation website. http://www .choosingwisely.org. Accessed July 30, 2012. 7. American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and
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Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006;105(1):198-208. 8. Apfelbaum JL, Connis RT, Nickinovich DG, et al; Committee on Standards and Practice Parameters; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012; 116(3):522-538. 9. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3): 495-511. 10. American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology. 2003;99(4):988-1014. 11. Practice guidelines for perioperative transesophageal echocardiography: an updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiology Task Force on Transesophageal Echocardiography. Anesthesiology. 2010;112(5):1084-1096. 12. Gross JB, Bachenberg KL, Benumof JL, et al; American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients With Obstructive Sleep Apnea. Anesthesiology. 2006; 104(5):1081-1093. 13. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists: an updated report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. 14. American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology. 2011;114(4):741-754. 15. Rupp SM, Apfelbaum JL, Blitt C, et al; American Society of Anesthesiologists Task Force on Central
Venous Access. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012;116(3):539-573. 16. American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Practice advisory for perioperative visual loss associated with spine surgery: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Anesthesiology. 2012; 116(2):274-285. 17. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients With Cardiac Implantable Electronic Devices. Anesthesiology. 2011;114(2):247-261. 18. American Society of Anesthesiologists Task Force on Intraoperative Awareness. Practice advisory for intraoperative awareness and brain function monitoring: a report by the American Society of Anesthesiologists Task Force on Intraoperative Awareness. Anesthesiology. 2006; 104(4):847-864. 19. Practice advisory on anesthetic care for magnetic resonance imaging: a report by the Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Anesthesiology. 2009;110(3):459-479. 20. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice alert for the perioperative management of patients with coronary artery stents: a report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2009;110(1):22-23. 21. Apfelbaum JL, Caplan RA, Barker SJ, et al; American Society of Anesthesiologists Task Force on Operating Room Fires. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2013;118(2):271-290. 22. Apfelbaum JL, Hagberg CA, Caplan RA, et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2): 251-270. 23. Perel P, Roberts I, Pearson M. Colloid vs crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2009;(3): CD000567. 24. Perel P, Roberts I, Ker K. Colloids vs crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567.
jamainternalmedicine.com
25. Perel P, Roberts I. Colloids vs crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2012;(6):CD000567. 26. Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2011;(3):CD000567. 27. Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2007;(4):CD000567. 28. Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004;(4):CD000567. 29. Kruer RM, Ensor CR. Colloids in the intensive care unit. Am J Health Syst Pharm. 2012;69(19): 1635-1642. 30. NATA (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis). Crystalloids vs colloids: the controversy. http://www.nataonline.com/np/158 /crystalloids-versus-colloids-controversy. Accessed April 30, 2014. 31. Reinhart K, Perner A, Sprung CL, et al; European Society of Intensive Care Medicine. Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients. Intensive Care Med. 2012;38(3):368-383. 32. The Good Stewardship Working Group. The “top 5” lists in primary care, meeting the responsibility of professionalism. Arch Intern Med. 2011;171:1385-1390. 33. Schuur JD, Carney DP, Lyn ET, et al. A top-five list for emergency medicine: a pilot project to improve the value of emergency care. JAMA Intern Med. 2014;174(4):509-515. 34. Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8)(suppl 2):II2-II45. 35. Katz RI, Dexter F, Rosenfeld K, et al. Survey study of anesthesiologists’ and surgeons’ ordering of unnecessary preoperative laboratory tests. Anesth Analg. 2011;112(1):207-212. 36. Pollard JB. Economic aspects of an anesthesia preoperative evaluation clinic. Curr Opin Anaesthesiol. 2002;15(2):257-261. 37. Foss JF, Apfelbaum J. Economics of preoperative evaluation clinics. Curr Opin Anaesthesiol. 2001;14(5):559-562. 38. Kuehn BM. Movement to promote good stewardship of medical resources gains momentum. JAMA. 2012;307(9):895-903. 39. Mangione-Smith R, McGlynn EA, Elliott MN, McDonald L, Franz CE, Kravitz RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155(7):800-806.
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