Preprocedural Urinalyses Common but Often Not Indicated

(Reuters Health) – Urinalyses are done within 30 days of 25% of common surgical procedures, and are not indicated in 89% of the cases, a U.S. study suggests.

Researchers examined insurance claims data for 13.2 million inpatient and outpatient procedures from 2007 to 2017. Procedures included breast surgery, cardiac surgery, colorectal surgery, general abdominal surgery, gynecological surgery, joint replacement procedures, neurosurgical procedures, orthopedic trauma and limb procedures, pacemaker procedures, prostate surgery, spinal surgery, thoracic surgery, thyroid surgery, and vascular surgery.

Based on claims data, researchers classified urinalyses as indicated when patients had the following diagnoses: acute cystitis, other disorders of the urethra, urethritis, fever, dysuria, altered mental state, urinary frequency, or urinary urgency. Across all the procedure categories, the proportion of urinalyses that were not indicated ranged from 84% to 94%.

“In a way, it is not surprising in that practice patterns can remain entrenched despite guideline updates and evolution of best practices,” said lead study author Dr. Erica Shenoy, associate chief of the infection control unit at Massachusetts General Hospital and an associate professor at Harvard Medical School in Boston.

“That said, to find that about 90% of all preprocedural analysis were not plausibly indicated and that a subset of these were then linked to antibiotic prescribing shows us how much opportunity there is to improve the care of our patients,” Dr. Shenoy said by email.

Depending on the procedure, the proportion of urinalysis tests resulting in antibiotic prescriptions ranged from 5.8% to 28.0%, researchers report in JAMA Internal Medicine.

When patients got urinalyses, the mean price per test was $17 and a mean of 79.5% of the price was paid by insurance. The mean cost of antibiotics ranged from $20 to $65 per course, with course durations ranging from 5.9 to 10.5 days.

One limitation of the study is that it only used data from IBM Watson MarketScan and commercial and Medicare claims. Results also may not be generalizable to Medicaid patients or populations with different types of prescription drug benefits that have different coverage for antibiotics than what was available to patients in the study.

Another limitation is that researchers lacked detailed clinical information that might help more accurately determine whether urinalyses or antibiotics were indicated in individual cases.

“There are a select few indications for pre-procedural urinalysis and treatment in an asymptomatic patient including prosthesis implantation, urological procedure, and during pregnancy,” said Dr. Niloofar Latifi, who co-authored an editorial accompanying the study while at Beth Israel Deaconess Medical Center.

“Urine testing and treatment prior to procedures should otherwise only occur in the setting of symptoms of urinary tract infection,” said Dr. Latifi, now an assistant professor at Johns Hopkins University School of Medicine in Baltimore.

Clinicians can serve as advocates for reducing low-value perioperative testing by changing cultural and institutional standards, Dr. Latifi said by email.

“It is important to note that only focusing on the education of individual clinicians may not be sufficient as prior studies have shown that a supplemental strategy such as point of care guidance in EHR, auditing, and feedback will improve outcomes,” Dr. Latifi added.

SOURCE: and JAMA Internal Medicine, online August 2, 2021.

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