Balancing patients’ safety, concerns and fears, and cost-effective medicine: American Society of Anesthesiologists

Choosing Wisely shouldn’t be confused with formal guidelines published by health professional societies such as the American Society of Anesthesiologists, says Richard W. Rosenquist, MD, chair, ASA Committee on Pain Medicine. Such guidelines are systematically developed recommendations to assist the practitioner and patient in making decisions about healthcare. “The bottom line of Choosing Wisely is to encourage physicians and patients to engage in conversations about specific tests and procedures that may or may not be truly necessary,” he says. “Every patient’s situation is different, and tests and procedures that are appropriate for one patient may not be appropriate for another patient.

“As leaders in patient safety, physician anesthesiologists want the most effective tests and treatments for our patients, and we want them to be used appropriately,” says Rosenquist. “ASA has taken the lead in improving patient safety related to anesthesiology and pain medicine, and ASA’s Choosing Wisely lists can make a positive and significant impact on patient care and quality.”

ASA physician leadership vetted both of its Top 5 lists, and there was broad agreement to endorse them, he says. Still, much work remains.

“There are numerous barriers to changing physicians’ behavior regarding tests and procedures, including both patient and financial factors,” says Rosenquist. “Physicians want to address their patients’ concerns and fears, which may be resolved by performing tests and procedures. In addition, current payment models often incentivize physicians to order more tests and perform procedures and do not reward physicians and hospitals for practicing cost-effective medicine.”

ASA: Five Things Physicians and Patients Should Question

From Choosing Wisely, an initiative of the ABIM Foundation,

  1. Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
  2. Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/ esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.
  3. Don’t use pulmonary artery catheters (PACs) routinely for cardiac surgery in patients with a low risk of hemodynamic complications (especially with the concomitant use of alternative diagnostic tools (e.g., TEE).
  4. Don’t administer packed red blood cells (PRBCs) in a young healthy patient without ongoing blood loss and hemoglobin of = 6 g/dL unless symptomatic or hemodynamically unstable.
  5. Don’t routinely administer colloid (dextrans, hydroxylethyl starches, albumin) for volume resuscitation without appropriate indications.