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

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

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.

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.

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.

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).