Utilization of History and Physical Consultations Prior to Low-Risk Surgical Procedures and Association with Preoperative Testing

From the 2021 HVPAA National Conference

Allan Metz (University of Michigan Medical School), Nicholas Berlin (Section of Plastic Surgery, Department of Surgery, University of Michigan; National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation), Monica Yost, Bonnie Cheng, Tony Cuttitta, Hannah Lahti, John Syrjamaki, Eve Kerr, Hari Nathan, Lesly Dossett

Background

The Centers for Medicare and Medicaid Services has historically required documentation of a comprehensive preoperative history and physical (H&P) within 30 days of surgery. Although intended to reduce adverse events, this historical requirement may have instead led to unnecessary preoperative testing and specialty evaluations. This rule has subsequently been rescinded, yet patterns of separately-billed H&Ps before 3 common low-risk surgical procedures and their association with low-value testing prior to this policy remain unknown. Understanding use patterns for these consultations will inform efforts to tailor preoperative care and may contribute to the reduction of unnecessary testing as hospitals adapt to this policy change.

Objective

To assess interhospital and intrahospital variations in utilization of preoperative H&P visits before 3 low-risk surgical procedures, to describe the relationship between preoperative H&P utilization and preoperative testing, and to identify independent predictors of these consultations.

Methods

This retrospective review was conducted using claims data from Medicare and privately insured patients from a value collaborative of 63 hospitals across the state of Michigan. We identified a cohort of patients undergoing one of three ambulatory, low-risk procedures (lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair) from January 2015 to June 2019. Rates of H&P consultations within 30 days of surgical procedure were compared between and within hospitals in the collaborative. We then explored the association between H&P consultations and preoperative testing types (cardiac testing, laboratory studies, chest radiography, and pulmonary function testing) using bivariate statistics and assessed patient, practice-level, and hospital-level determinants of H&P consultations using multi-level mixed effects logistic regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in preoperative H&P utilization.

Results

In our cohort of 42,741 patients (n=9,908 [23.2%] lumpectomy, n=21,689 [50.7%] laparoscopic cholecystectomy, n=11,144 [26.1%] laparoscopic inguinal hernia repair), approximately 83.6% of patients underwent a preoperative H&P consultation. Preoperative H&Ps were more commonly performed for older patients (59.116.0 years vs 54.9 15.7 years; p < 0.001) and those with an increased number of comorbidities (1.9 2.2 vs 1.0 1.6; p < 0.0001). Patients undergoing H&Ps were more likely to have preoperative testing across all types of testing. In multivariable models, for-profit hospitals had higher utilization of preoperative H&Ps (89.4% vs 83.6%; p < 0.001). After adjusting for patient case-mix, interhospital and intrahospital variations in utilization of preoperative H&Ps remained.

Conclusions

H&Ps were common before 3 low-risk surgical procedures across Michigan with variation between and within hospitals prior to this CMS policy change. These consultations were more common at for-profit hospitals and for older patients with increased comorbidity burden. Preoperative H&Ps were strongly associated with low-value preoperative testing. Further research is needed to determine how the federal policy change will affect utilization of H&Ps. These findings will inform strategies for de-implementation of preoperative H&P use before low-risk surgical procedures and may help mitigate unnecessary preoperative testing.

Clinical Implications

Tailoring utilization of preoperative H&P consultations prior to low-risk surgical procedures may improve delivery of value-based perioperative care.