Background: The healthcare system in the United States is often times costly and inefficient. Some estimates suggest that 20-34% of healthcare dollars are spent ineffectively. Despite efforts such as the Choosing Wisely Campaign to limit preoperative testing prior to low risk surgery, preoperative cardiac testing before low risk procedures remains common. This study assesses the frequency, outcomes, and costs associated with inpatient preoperative cardiology consultation prior to low risk inpatient procedures.
Methods: 1,284 consecutive patients underwent inpatient endoscopy or colonoscopy between November 1, 2011 and April 31, 2016 at a single academic tertiary referral center. 79 patients (6.2%) underwent preoperative consultation with a board certified cardiologist. 158 patients who did not undergo inpatient cardiology consultation prior to the procedure were matched to cases by age and gender in a 2:1 ratio. Retrospective chart review of clinical, demographic and economic variables was performed. Charges for diagnostic tests and the hospitalization were obtained from hospital billing.
Results: Patients with cardiology consultation were more likely to have coronary artery disease (32.9% vs 11.4%, p < 0.0001) but were similar with respect to other comorbidities. There were no differences in adverse cardiac events between the two groups. Patients who received cardiac consultation had more cardiac tests, including more echocardiograms (60.8% vs 22.2%, p < 0.0001) and 12 lead ECGs (98.7% vs 54.4%, p < 0.0001). While nuclear stress tests, coronary CT angiograms, and cardiac catheterizations were more frequent after cardiology consultation, the differences were not statistically significant. Patients who were seen by a cardiologist had a longer length of stay (4.35 days vs 3.46 days, p = 0.0032) and delay from admission to procedure (3.14 days vs 2.38 days, p = .001). Evaluation by a board-certified cardiologist led to an increase in estimated charges of $839,332 for the group as a whole and an average increase in estimated charges of $10,624 per patient.
Conclusion: Preoperative cardiac evaluation prior to low risk procedures remains common. Inpatient consultation to a cardiologist for pre-procedure evaluation generates a substantial increase in testing and cost without affecting outcomes. Further research into the reasons for persistent referral to cardiologists and overutilization of preoperative testing is needed to understand how to best implement recommendations made by campaigns such as Choosing Wisely.