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Figure.  Proportion of Procedures With Preoperative Urinalyses, Nonindicated Urinalyses, and Nonindicated Urinalyses Followed by Antibiotic Prescriptions, 2007-2017
Proportion of Procedures With Preoperative Urinalyses, Nonindicated Urinalyses, and Nonindicated Urinalyses Followed by Antibiotic Prescriptions, 2007-2017

The outcomes, represented by the varied shading, each begin at 0% and are thus overlapping and not stacked.

Table.  Characteristics of Patients With and Without Preoperative Urinalyses (UA)
Characteristics of Patients With and Without Preoperative Urinalyses (UA)
1.
Shrank  WH, Rogstad  TL, Parekh  N.  Waste in the US health care system: estimated costs and potential for savings.   JAMA. 2019;322(15):1501-1509. doi:10.1001/jama.2019.13978PubMedGoogle ScholarCrossref
2.
Nicolle  LE, Gupta  K, Bradley  SF,  et al.  Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America.   Clin Infect Dis. 2019;68(10):1611-1615. doi:10.1093/cid/ciz021PubMedGoogle ScholarCrossref
3.
Henderson  JT, Webber  EM, Bean  SI.  Screening for asymptomatic bacteriuria in adults: updated evidence report and systematic review for the US Preventive Services Task Force.   JAMA. 2019;322(12):1195-1205. doi:10.1001/jama.2019.10060PubMedGoogle ScholarCrossref
4.
Shpunt  Y, Estrin  I, Levi  Y,  et al.  Antimicrobial use for asymptomatic bacteriuria—first, do no harm.   Infect Control Hosp Epidemiol. 2021;42(1):37-42. doi:10.1017/ice.2020.369PubMedGoogle ScholarCrossref
5.
IBM Watson Health. IBM MarketScan Research Databases for life sciences researchers. Published 2018. Accessed June 24, 2021. https://www.ibm.com/downloads/cas/0NKLE57Y
6.
Drekonja  DM, Zarmbinski  B, Johnson  JR.  Preoperative urine cultures at a Veterans Affairs medical center.   JAMA Intern Med. 2013;173(1):71-72. doi:10.1001/2013.jamainternmed.834PubMedGoogle ScholarCrossref
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    2 Comments for this article
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    Unnecessary preoperative urinalyses
    Paul Buehrens, MD, FAAFP | Retired
    This study nicely documents the extent of this wasteful and potentially harmful practice. More interesting to me is the apparent pressure on primary care physicians to reduce such procedures, when the choice is NOT made by the primary care physician, but by the surgeon. Patients present with required pre-op testing to the primary care physician, with the expectation that all of the requirements must be met or their elective procedure may be delayed. The responsibility for reducing unnecessary pre-operative testing may be with the requesting surgeon. Pushback from primary care not to perform unnecessary pre-op testing is, at least in the experience of this retired medical director, like tilting at windmills.
    CONFLICT OF INTEREST: None Reported
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    No preoperative testing
    Robert Burney, MD | Retired anesthesiologist
    In 1990, I was named Medical Director of a new surgery center. For a variety of reasons, we decided not to require any lab tests prior to surgery. None. At that time, the most common reason for an OR not starting on time was "looking for a lab test." There was a series of papers (from the U. of Chi, I think) looking at every lab test available. No value was found for any test as a preoperative test. Another paper (from Mayo, I think) looked at thousands of hematocrits done as preoperative tests. They found some abnormal values, but in no case did the results alter the planned surgery or anesthesia. We examined all our unexpected admissions and other problems but never found any problem that could have been predicted before surgery. You can eliminate the costs of preoperative testing by not doing any. None.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    Less Is More
    August 2, 2021

    Prevalence, Costs, and Consequences of Low-Value Preprocedural Urinalyses in the US

    Author Affiliations
    • 1Division of Infectious Diseases, Massachusetts General Hospital, Boston
    • 2Infection Control Unit, Massachusetts General Hospital, Boston
    • 3Department of Medicine, Harvard Medical School, Boston, Massachusetts
    • 4Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    JAMA Intern Med. 2021;181(11):1533-1535. doi:10.1001/jamainternmed.2021.4075

    Low-value care is a major concern, especially that which leads to additional low-value testing or treatment.1 Urinalyses are an underappreciated area of low-value care, often obtained before procedures despite guidelines from the Infectious Diseases Society of America and the US Preventive Services Task Force,2,3 as well as evidence that information obtained from urinalyses does not change subsequent management or reduce the risk of infectious complications following procedures. Unlike other low-value services, preprocedural urinalyses may result in use of antibiotics with consequences for both the individual patient and society, including the risk of antimicrobial resistance and adverse effects of antibiotics.4

    Methods

    We analyzed inpatient and outpatient episodes of procedural and surgical care using 2007 to 2017 IBM Watson MarketScan commercial and Medicare claims,5 with data analysis performed from September 2019 through January 2021. We defined 14 procedure-group families, with each preprocedural episode of care as the 30 days preprocedure. Urinalyses obtained during this time were identified using Current Procedural Terminology codes 81000 through 81020. We defined plausibly indicated urinalyses (clinically higher value) as those obtained in the presence of any of the following diagnoses: acute cystitis, other disorders of the urethra, urethritis, fever, dysuria, altered mental status, urinary frequency, or urinary urgency (eTable in the Supplement). All other urinalyses were deemed nonindicated (clinically lower value). The study was approved by the Institutional Review Board at Harvard Medical School, which waived patient informed consent for use of deidentified data.

    In analyses of antibiotic use, individuals with prescription drug coverage were included. Antibiotic prescriptions were associated with a urinalysis if the urinalysis was obtained 1 to 30 days prior to their procedure; urinalyses obtained on the day of the procedure were excluded.

    Kidney and urological procedures were excluded owing to the allowance for screening urinalysis in the absence of symptoms based on current guidelines. Cesarean deliveries were also excluded owing to screening recommendations for asymptomatic bacteriuria in pregnancy.

    Results

    Characteristics of procedure episodes that did and did not receive a urinalysis were similar (Table). Among 13 169 656 procedures, 25% were preceded by urinalyses within 30 days. The proportion of procedures with urinalyses, nonindicated urinalyses, and nonindicated urinalyses with antibiotic prescriptions varied across procedure categories (Figure). Among procedures for which urinalyses were obtained, 89% were not indicated (range, 84%-94% across procedure categories). Among this subset of urinalyses, the mean (SD) price per test was $17 ($108.48), with a mean of 79.5% of the price paid by the insurer. Across procedure categories, between 5.8% and 28.0% of these urinalyses were followed by an antibiotic prescription. Spending on antibiotics ranged from $20 to $65 per course, and the course duration ranged from 5.9 to 10.5 days across procedure groups. Total spending on antibiotic prescriptions declined from $40.61 to $18.19 during the period, mostly owing to decreases in spending on quinolone antibiotics.

    Discussion

    This study found that preprocedural urinalyses were common, but the vast majority were not plausibly indicated; associated antibiotic prescriptions should be considered of no benefit or possibly harmful. The consequences of low-value urinalyses include payer and patient spending on these tests and resulting antibiotics, as well as physician and hospital laboratory costs and transportation costs. Patients and society bear the risk of inappropriate antibiotic use, which can result in adverse drug reactions, increased risk of infections such as Clostridioides difficile, and emergence of antibiotic resistance.

    In this population, total spending on inappropriate urinalyses was $48 675 408. We estimated that total spending on antibiotics following inappropriate urinalyses was an additional $4 854 109.

    Limitations included potential unobserved factors that could affect the appropriateness of urinalyses or antibiotics, such as clinical information or patient factors that are not reflected in claims data. Moreover, the results may not generalize to other payer populations (eg, Medicaid) or those with different forms of prescription drug coverage that affect antibiotics.

    While several successful approaches to reducing both screening for asymptomatic bacteriuria as well as its treatment have been reported—including among preoperative patients—prevailing practice patterns remain entrenched.4,6 Insurers and employers also have a potentially influential role in reducing such low-value care. Through benefit design and payment policies, insurers may target wasteful spending and combat antibiotic resistance.

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    Article Information

    Accepted for Publication: April 23, 2021.

    Published Online: August 2, 2021. doi:10.1001/jamainternmed.2021.4075

    Corresponding Author: Erica S. Shenoy, MD, PhD, Massachusetts General Hospital, 55 Fruit St, BUL-3-334, Boston, MA 02114 (eshenoy@mgh.harvard.edu).

    Author Contributions: Drs Shenoy and Song and Ms Giuriato had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Shenoy, Giuriato.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Giuriato, Song.

    Obtained funding: Song.

    Administrative, technical, or material support: All authors.

    Supervision: Shenoy, Song.

    Conflict of Interest Disclosures: Dr Shenoy reported receiving a personal fee for a single lecture from Vertex Pharmaceuticals outside the submitted work. Dr Song reported receiving grants from the National Institutes of Health and the Laura and John Arnold Foundation during the conduct of the study; and personal fees from the Research Triangle Institute for work on Medicare risk adjustment, from Google Ventures and the International Foundation of Employee Benefit Plans for academic lectures outside of this work, and for providing consultation in legal cases. No other disclosures were reported.

    Funding/Support: This work was supported through the National Institutes of Health (Dr Song, DP5-OD024564, P01-AG032952) and the Laura and John Arnold Foundation (Dr Song).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank Andrew Hicks, MS, Harvard Medical School, for the derivation of diagnostic cost-group risk scores (without compensation).

    References
    1.
    Shrank  WH, Rogstad  TL, Parekh  N.  Waste in the US health care system: estimated costs and potential for savings.   JAMA. 2019;322(15):1501-1509. doi:10.1001/jama.2019.13978PubMedGoogle ScholarCrossref
    2.
    Nicolle  LE, Gupta  K, Bradley  SF,  et al.  Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America.   Clin Infect Dis. 2019;68(10):1611-1615. doi:10.1093/cid/ciz021PubMedGoogle ScholarCrossref
    3.
    Henderson  JT, Webber  EM, Bean  SI.  Screening for asymptomatic bacteriuria in adults: updated evidence report and systematic review for the US Preventive Services Task Force.   JAMA. 2019;322(12):1195-1205. doi:10.1001/jama.2019.10060PubMedGoogle ScholarCrossref
    4.
    Shpunt  Y, Estrin  I, Levi  Y,  et al.  Antimicrobial use for asymptomatic bacteriuria—first, do no harm.   Infect Control Hosp Epidemiol. 2021;42(1):37-42. doi:10.1017/ice.2020.369PubMedGoogle ScholarCrossref
    5.
    IBM Watson Health. IBM MarketScan Research Databases for life sciences researchers. Published 2018. Accessed June 24, 2021. https://www.ibm.com/downloads/cas/0NKLE57Y
    6.
    Drekonja  DM, Zarmbinski  B, Johnson  JR.  Preoperative urine cultures at a Veterans Affairs medical center.   JAMA Intern Med. 2013;173(1):71-72. doi:10.1001/2013.jamainternmed.834PubMedGoogle ScholarCrossref
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