# Choosing Wisely: Barriers to De-Implementation, Patterns, and Costs of Low Value Preoperative Testing for Veterans Undergoing Low Risk Procedures

> **NIH VA I01** · VETERANS ADMIN PALO ALTO HEALTH CARE SYS · 2020 · —

## Abstract

Background and Anticipated Impacts on VA Patient Care: Pre-operative testing practices have
received considerable scrutiny over the past decade as sensitivity to risks and costs of unnecessary
testing have increased. Preoperative tests can only be justified if they reveal actionable data that
alters clinical management in a way that improves patient safety and outcomes. A recent Cochrane
review of three randomized trials including over 21,000 cataract surgeries concluded that pre-
operative testing does not reduce the risk of intraoperative or postoperative adverse events compared
to no testing. Other studies indicate that routine testing, especially in patients without significant
systemic disease undergoing low risk procedures, often does not change perioperative management,
may lead to follow-up testing and invasive interventions with normal results, and can unnecessarily
delay surgery or other procedures. Accordingly, the American Society of Anesthesiologists' recent
“Top-5 Activities to Avoid” include the following recommendation: “Specific pre-operative laboratory
studies should not be obtained in patients without significant systemic disease undergoing low-risk
surgery.” Because they do not alter clinical management or improve patient outcomes, we define
routine preoperative testing of any patients before cataract surgery and routine preoperative testing of
patients without significant systemic disease undergoing other low-risk procedures as low value
tests.
Even in light of these research results and professional standards, several descriptive studies in
diverse settings outside the Veterans Health Administration (VHA) have found that low value testing
is still very common. Despite the large numbers of surgeries conducted within VHA (e.g. >50,000
cataract surgeries annually), little data exists on associated patterns of preoperative testing. If
patterns of low value preoperative testing are found within VHA, an important practice improvement
or “de-implementation” target exists that could afford significant opportunities to redirect resources to
other organizational priorities, such as improved access and the provision of evidence-supported
treatments. Therefore, in order to ensure that VHA patients receive the highest value care, are not
subjected to low value testing with little or no benefit and potential unintended harm, and to ensure
that VHA uses its resources to produce the largest possible positive impact on health outcomes, this
study has the following aims:
Aim 1: Describe system-wide and facility-level rates and associated costs of low value pre-operative
testing in the 30 and 60 days before high-frequency low-risk procedures including cataract surgery
(>50,000 annually), carpal tunnel release (>9,500 annually), and upper and lower digestive tract
endoscopy (>500,000 annually).
Aim 2: Examine the patient factors (e.g., comorbidities), clinician factors (e.g., ordering clinician
specialty), and facility-level factors (e.g., surg...

## Key facts

- **NIH application ID:** 9883773
- **Project number:** 5I01HX002314-03
- **Recipient organization:** VETERANS ADMIN PALO ALTO HEALTH CARE SYS
- **Principal Investigator:** Seshadri Mudumbai
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2020
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2018-01-01 → 2020-12-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9883773

## Citation

> US National Institutes of Health, RePORTER application 9883773, Choosing Wisely: Barriers to De-Implementation, Patterns, and Costs of Low Value Preoperative Testing for Veterans Undergoing Low Risk Procedures (5I01HX002314-03). Retrieved via AI Analytics 2026-06-16 from https://api.ai-analytics.org/grant/nih/9883773. Licensed CC0.

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