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WSMA Reports
November 19, 2018

Reducing unnecessary testing

By Jessica Martinson

The following article was featured in the November/December 2018 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may purchase a subscription.

John H. Vassall, MD, recently spoke with "a very thoughtful and efficient family physician" about a patient who was preparing for a total knee replacement.

The patient had come to her office with a request from the orthopedic surgeon for a preoperative evaluation and testing, including a CBC, EKG, and a nasal swab for MRSA. Dr. Vassall asked if she thought the CBC and EKG were indicated.

"She was initially puzzled by my question, but after some reflection, admitted that neither was likely to add value to this patient's care," said Dr. Vassall, who is physician executive for quality and safety at Qualis Health, a board member of the WSMA Foundation for Health Improvement, and a member of the Washington State Choosing Wisely Task Force.

So why would she order the tests?

"My colleague sees between 20 and 30 patients a day," Dr. Vassall said. "She must make about 10 decisions per patient, which means 200 to 300 decisions per day. Sending the patient for the requested tests requires only one decision; evaluating the need for each of the three tests increases her mental workload to four decisions, and involves an additional discussion with the patient, adding more time and effort. Her professional survival involves simplifying her workload and reducing the number of decisions. Add to that the prospect of explaining to her colleague why she did not follow his instruction and you can see that this becomes onerous.

"Of necessity, we must do many things by standardized routine," Dr. Vassall noted. "However, it's time for us to reevaluate some of the testing we order prior to low-risk, elective procedures on healthy patients."

That is the message of "Drop the Pre-Op," an initiative of the Washington State Choosing Wisely Task Force, which is co-sponsored by the WSMA, the Washington Health Alliance, and the Washington State Hospital Association. The initiative is a result from this year's report from the Washington Health Alliance, "First, Do No Harm: Calculating Health Care Waste in Washington State." The report found that at least 100,000 patients received unnecessary pre-op testing during a one-year period, at a statewide estimated cost of more than $92 million.

Naturally, physicians are well-intentioned in ordering the tests. They want to be thorough and they don't want a patient to be turned away on the day of surgery. Drop the Pre-Op points out that physicians agree that all patients need preoperative evaluation, but a low-risk patient having a low-risk procedure does not need pre-op testing.

The task force is spreading the word to the state's health care community about Drop the Pre-Op through a variety of channels, including an information sheet, PowerPoint decks to use at a staff meeting or during grand rounds, and more, all available on our Choosing Wisely Physician Tool Kit.

If you need additional information or resources on Drop the Pre-Op, contact me at

Jessica Martinson is WSMA's director of clinical education and professional development.

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