Reducing unnecessary preoperative testing in Day Surgery: a Choosing Wisely-based quality improvement study

Abstract

Routine preoperative laboratory testing is widely performed despite strong evidence and international guidelines indicating limited value for healthy patients undergoing low-risk surgery. Overuse contributes to unnecessary costs, delays, and potential patient harm through false positives and cascades of care.

Objective To evaluate the impact of a Choosing Wisely-based preoperative assessment model on testing rates, surgical delays, safety outcomes, and system efficiency in a Day Surgery setting.

Design, setting, and participants This is a retrospective pre-post quality improvement study conducted at a tertiary academic hospital in Italy. Two cohorts of adult Day Surgery patients were compared: A pre-intervention group (June 2022–June 2023) and a post-intervention group following implementation of a redesigned preoperative pathway (July 2023–July 2024).

Intervention It involves the implementation of a new preoperative model separating minor Day Surgery cases (ASA I–III) from intermediate/major surgery, eliminating routine testing unless clinically indicated after anesthesiologist evaluation.

Main outcomes and measures These are proportion of patients receiving laboratory tests, ECG, or chest radiography, rate of surgery cancellations or delays, need for postoperative admission, time from anesthesiology visit to surgery, and estimated cost reduction.

Results A total of 1059 patients formed the pre-intervention group and 1790 the post-intervention group. After implementation, testing decreased substantially: laboratory testing dropped to 2.6%, ECG to 6.7%, and chest radiography to 0.3%. No surgeries were cancelled due to insufficient work-up. No unplanned postoperative admissions occurred. Wait times were dramatically reduced from weeks to less than 7 days, eliminating previous structural bottleneck.

Conclusions and relevance A Choosing Wisely aligned preoperative pathway safely reduced unnecessary testing, improved efficiency, shortened wait times, and lowered costs. This approach is scalable and may inform national policy and Value-Based Health Care strategies.

Introduction

Routine preoperative testing is commonly embedded in surgical pathways despite a growing body of evidence demonstrating limited utility in low-risk patients undergoing minor procedures. Studies estimate that up to 25% of healthcare expenditure may be wasteful, with preoperative testing representing a significant portion of low-value care [1]. There is strong evidence of widespread overuse of several specific medical services in multiple countries, suggesting that overuse is common around the world and may be growing, included over testing [2].

The Choosing Wisely campaign [3], launched in 2012, represents a physician-driven effort to create conversations between physicians and patients around overuse and waste [4]. It explicitly recommends avoiding routine laboratory testing in asymptomatic, low-risk patients, emphasizing individualized assessment over protocol-driven workups. Similar recommendations appear in NICE guidelines (NG45), the ASA 2012 and 2022 updates, and multiple international specialty societies [5, 6].

Yet, adoption remains inconsistent. Barriers include defensive medicine, institutional inertia, and workflow constraints.

Day Surgery represents an ideal context for deimplementation of low-value practices due to its low morbidity profile, high patient turnover, and increasing role in modern surgical care. Recent deimplementation studies confirm that eliminating routine testing does not compromise patient safety and improves system efficiency [7].

Thus, in our hospital, we changed the organization of our centralized prehospitalization service, which had been managed by a multidisciplinary medical team, including anesthesiologists who, however, did not work in the operating rooms and where there was no differentiation of pathways based on surgical grading.

After reviewing the guidelines and the literature on this topic, we developed a new organization for prehospitalization that includes the following:

• The unchanged standard pathway, which is used for all ASA I, II, III, and IV patients who are to undergo intermediate and major surgical procedures, underwent full routine preoperative testing (laboratory panel, ECG, chest X-ray per institutional protocol).

• Patients ASA IV follow this pathway also for minor surgery, and the new pathway, which concerns ASA I, II, and III patients who are to undergo minor surgical procedures in a Day Surgery setting

Objective

To evaluate the impact of a redesigned, Choosing Wisely aligned preoperative pathway on testing rates, clinical outcomes, and operational efficiency in a hospital Day Surgery Unit.

Methods

Study design and setting

Adult patients (≥ 18 years) scheduled for minor Day Surgery procedures were eligible. The inclusion criteria were ASA physical status I–III and the ability to attend the preoperative anesthesiology evaluation. Exclusion criteria included urgent/emergent surgery, ASA IV status, and incomplete clinical documentation. The patient selection and allocation process is illustrated in Fig. 1.

Fig. 1.

Patient selection and allocation process

Minor Day Surgery procedures were defined as low-complexity interventions with predictable short duration, minimal physiological stress, and suitability for same-day discharge. Procedures typically involved local, regional, or short general anesthesia, with low expected blood loss and no need for postoperative monitoring beyond the recovery room. Examples included the following: Inguinal and umbilical hernia repair, diagnostic knee or shoulder arthroscopy, carpal tunnel release, excision of skin lesions without reconstruction, and cataract surgery. These criteria align with the institutional protocol and international definitions of ambulatory surgery.

Before the implementation of the new model, all patients underwent a centralized preoperative process managed by a multidisciplinary team. The pathway required routine preoperative testing for all patients, including a complete laboratory panel (CBC, coagulation, renal function), ECG, and chest radiography, regardless of ASA class or surgical complexity. Testing was performed before the anesthesiology visit, and clearance was issued only after all results were available, often resulting in delays of weeks.

After July 2023, ASA I–III patients undergoing minor Day Surgery were evaluated directly by an anesthesiologist, and diagnostic tests were ordered only when clinically indicated.

New preoperative pathway

Beginning July 2023, the Day Surgery Unit implemented the new assessment model.

Day Surgery pathway (new)

For ASA I–III patients scheduled for minor surgery as follows:

• They directly underwent anesthesiology evaluation without prior testing.

• Testing (labs, ECG, chest X-ray) was ordered only if clinically indicated.

• If tests were required, they were performed the same day.

• Clearance for surgery was issued immediately if results were normal.

This model removed automatic orders and empowered anesthesiologists to decide based on history and physical examination (https://www.scamilloforlanini.rm.it/web/guest/qualit%C3%A0/-/document_library/yjhl/view_file/63158?_com_liferay_document_library_web_portlet_DLPortlet_INSTANCE_yjhl_redirect=https%3A%2F%2Fwww.scamilloforlanini.rm.it%3A443%2Fweb%2Fguest%2Fqualit%25C3%25A0%2F-%2Fdocument_library%2Fyjhl%2Fview%2F62864) (Fig. 2).

Fig. 2.

Model of history and physical examination

Outcomes

Primary outcomes

• Rate of laboratory testing, ECG, and chest X-rays

• Rate of surgery cancellations or postponements

Secondary outcomes

• Frequency of unplanned postoperative admissions

• Time from anesthesiology evaluation to surgery

• Estimated cost savings associated with reduced testing

Statistical analysis

Continuous variables were summarized as mean ± standard deviation (SD). Normality of distribution was assessed using visual inspection and the Shapiro–Wilk test. Differences in age between pre- and post-intervention cohorts were evaluated using the independent samples t-test.

Categorical variables are presented as counts and percentages and were compared using the chi-square test. Fisher’s exact test was used when appropriate.

Primary outcomes (laboratory testing, ECG, chest radiography) were analyzed as binary variables (performed vs not performed). Effect sizes were expressed as risk ratios (RR) and risk differences (RD), each with corresponding 95% confidence intervals (CI). Confidence intervals were calculated using standard Wald methods with continuity correction when appropriate.

Secondary outcomes (surgical cancellations and unplanned postoperative admissions) were analyzed descriptively. Given the absence of events in the post-intervention group for some safety outcomes, formal comparative statistical testing was not performed.

All tests were two-sided, and a p-value < 0.05 was considered statistically significant. All analyses were performed using R statistical software (version 4.2.1; R Foundation for Statistical Computing, Vienna, Austria).

Given the protocol-driven nature of the intervention and the near-universal baseline testing in the pre-intervention cohort (100% across modalities), multivariable regression modeling was not performed.

Results

A total of 2849 patients were included:

• 1059 in the pre-intervention cohort (Table 1)

• 1790 in the post-intervention cohort (Table 2)

Table 1.

Patient characteristics and preoperative testing (pre-intervention)

	No. of patients	Male	Female	ASA 1	ASA 2	ASA 3	Average age	Lab. tests	ECG	Chest X-ray
Hand surgery	90	56	34	36	44	10	51.4	90	90	90
General surgery	98	67	31	25	65	8	62.8	98	98	98
Orthopedic surgery	183	103	80	62	116	5	63.6	183	183	183
Maxillofacial surgery	47	33	14	23	17	7	48.9	47	47	47
ENT surgery	37	25	12	16	20	1	58.1	37	37	37
Plastic surgery	157	88	69	15	63	79	81.3	157	157	157
Urologic surgery	47	29	18	6	29	12	76.8	47	47	47
Eye surgery	400	139	261	0	83	317	81	400	400	400
Tot.	1059	540	519	183	437	439	65.49	1059	1059	1059

Table 2.

Patient characteristics and preoperative testing (post-intervention)

	No. of patients	Male	Female	ASA 1	ASA 2	ASA 3	Average age	Lab. tests	ECG	Chest X-ray
Hand surgery	102	62	40	28	60	14	53.7	3	8	0
General surgery	196	129	67	57	122	17	61.2	8	12	2
Orthopedic surgery	176	102	74	67	101	8	65.9	7	10	1
Maxillofacial surgery	42	30	12	18	17	7	53.6	2	4	0
ENT surgery	59	36	23	18	36	5	55.5	1	4	0
Plastic surgery	237	134	103	19	121	97	79.4	16	34	2
Urologic surgery	58	36	22	6	34	18	77.3	3	8	0
EYE surgery	920	421	499	4	316	600	80.7	6	40	0
Tot.	1790	950	840	217	807	766	65.91	46	120	5

Baseline characteristics were broadly comparable between cohorts (Table 3). Detailed comorbidities were not available in a structured format within the administrative databases used for data extraction. However, the ASA classification, recorded for all patients, represents a well-established clinical proxy for complexity and preoperative health status and allows for adequate comparison between the pre- and postoperative groups.

Table 3.

Baseline characteristics of pre- and post-intervention cohorts

Characteristic	Pre-intervention (n = 1059)	Post-intervention (n = 1790)	p-value
Age, mean (years)	65.49	65.91	0.42a
Male sex, n (%)	540 (51.0%)	950 (53.1%)	0.29b
Female sex, n (%)	519 (49.0%)	840 (46.9%)	—
ASA I, n (%)	183 (17.3%)	217 (12.1%)
ASA II, n (%)	437 (41.3%)	807 (45.1%)
ASA III, n (%)	439 (41.4%)	766 (42.8%)	0.08b
Surgical specialty, n (%)			< 0.001b
Eye surgery	400 (37.8%)	920 (51.4%)
Plastic surgery	157 (14.8%)	237 (13.2%)
Orthopedic surgery	183 (17.3%)	176 (9.8%)
General surgery	98 (9.3%)	196 (10.9%)
Hand surgery	90 (8.5%)	102 (5.7%)
ENT	37 (3.5%)	59 (3.3%)
Maxillofacial	47 (4.4%)	42 (2.3%)
Urologic	47 (4.4%)	58 (3.2%)

^at-test, and ^bchi-square test

There were no statistically significant differences in age (p > 0.05), sex distribution (p > 0.05), or ASA physical status classification (p > 0.05).

However, a statistically significant difference was observed in the distribution of surgical specialties (p < 0.05), reflecting a higher proportion of ophthalmologic procedures in the post-intervention period. This variation is attributable to institutional case-mix changes over time and is unlikely to account for the importance of reduction observed in diagnostic testing.

Although the proportion of ophthalmology patients increased in the post-intervention group, subgroup analysis confirms that the reduction in testing was consistent and statistically significant across all surgical specialties. For example, laboratory testing in general surgery and orthopedics decreased from 100% to approximately 4%, demonstrating that the intervention’s effectiveness is independent of the surgical case mix.

Reduction in testing

Compared with the pre-intervention period, the new pathway produced a dramatic reduction in testing. Laboratory testing decreased from 100% to 2.6% (RR 0.0257, 95% CI 0.019–0.034; RD −0.974, 95% CI −0.977 to −0.971; p < 0.0001). ECG use decreased from 100% to 6.7% (RR 0.067, 95% CI 0.056–0.080; RD −0.933, 95% CI −0.939 to −0.927; p < 0.0001). Chest radiography decreased from 100% to 0.28% (RR 0.0028, 95% CI 0.0012–0.0065; RD −0.997, 95% CI −0.998 to −0.996; p < 0.0001) (Table 4).

Table 4.

Effect sizes and confidence intervals for primary outcomes

Test	Pre (%)	Post (%)	Risk ratio (95% CI)	Risk difference (95% CI)	p-value
Laboratory tests	100	2.57	0.0257 (0.019–0.034)	−0.974 (−0.977 to −0.971)	< 0.0001
ECG	100	6.70	0.067 (0.056–0.080)	−0.933 (−0.939 to −0.927)	< 0.0001
Chest X-ray	100	0.28	0.0028 (0.0012–0.0065)	−0.997 (−0.998 to −0.996)	< 0.0001

Compared with the previous year, this reflects an absolute reduction exceeding 80–90% across modalities.

Safety and clinical outcomes

The safety of the redesigned preoperative model was rigorously evaluated through perioperative clinical outcome monitoring. To ensure data integrity and methodological standards, all safety data were extracted via systematic electronic health record (EHR) review and hospital administrative databases.

• Unplanned postoperative admission: This was defined as any unanticipated conversion from Day Surgery to inpatient status (overnight stay) due to clinical complications or hemodynamic instability.

• Follow-up and monitoring window: The safety assessment period extended from the initial surgical admission to discharge, with a specific follow-up window covering 24–48-h post-surgery to track any related emergency department visits or readmissions.

• Safety results: No major adverse events or unplanned postoperative admissions occurred following the implementation of the new pathway. The small subset of patients referred to ordinary hospitalization (n = 13) consisted exclusively of ASA III cases with unstable comorbidities or significant geographical distance from the hospital, all of whom were appropriately identified during the anesthesiology evaluation.

• Surgical cancellations: No surgeries were cancelled or postponed due to insufficient preoperative workup or inadequate testing. This confirms that the elimination of routine testing did not compromise patient safety or clinical workflow.

Operative efficiency and workflow optimization

The implementation of the new pathway led to a significant improvement in surgical throughput by streamlining the preoperative phase.

• Operational definition: We defined “time to surgery” as the interval from the initial anesthesiological evaluation to the day of the procedure. The transition from weeks to < 7 days reflects a structural change: by removing the requirement to complete routine tests prior to the anesthesia visit, we eliminated the primary administrative and diagnostic bottleneck of the previous system. Detailed time-to-surgery data (median and IQR) were not available in extractable or structured format within the hospital scheduling system used for this study. However, administrative records and workflow analysis consistently showed that before the intervention, the requirement to complete routine testing created delays of several weeks, whereas after implementation of the new pathway the vast majority of ASA I–III patients were scheduled within 7 days of the anesthesiology evaluation. Although precise numerical distributions could not be retrieved, the structural reduction in waiting times was clear, consistent, and directly attributable to the redesigned preoperative process.

• Pre-intervention timeline: In the previous model, patients underwent routine testing (labs, ECG, CXR) before the anesthesiology visit. This created a “bottleneck” effect, as clearance was issued only after all results were available, often leading to delays ranging from several weeks.

• Post-intervention timeline: By adopting an “anesthesiologist-driven” selective testing model, ASA I–III patients were evaluated directly. If tests were deemed necessary, they were performed and reviewed on the same day. This change reduced the time from visit to surgery to less than 7 days.

• Administrative burden: The elimination of automatic order sets for 95.5% of laboratory tests and 93.3% of ECGs significantly reduced the administrative workload for both the medical staff and the booking office, allowing for clearer prioritization of surgical lists.

Cost analysis

The cost analysis was conducted from the hospital/provider perspective, focusing on direct diagnostic costs. Unit costs for laboratory panel, ECG, and chest radiography were obtained from the 2022 Regional Unified Tariff Catalogue of Lazio (16.63 €, 11.62 €, and 15.49 €, respectively). Total savings were estimated by multiplying the reduction in the number of tests performed in the post-intervention period by the corresponding unit costs. Indirect costs (staff time, administrative burden, patient-related costs) were not included in the base-case analysis.

Cost savings

Compared with the pre-intervention period, the new pathway led to a marked reduction in diagnostic expenditures. A total of 1013 laboratory panels, 939 ECGs, and 1054 chest radiographs were avoided, corresponding to an estimated direct cost saving of approximately 44,000 € per year from the hospital perspective.

The mean direct diagnostic cost per patient decreased from 43.74 € in the pre-intervention period to 1.54 € post-intervention, corresponding to a 96.5% relative reduction (Fig. 3). These estimates likely underestimate the total economic benefit, as indirect savings related to reduced administrative processing, shorter waiting times, and improved operating room scheduling were not included.

Fig. 3.

Direct preoperative diagnostic costs. Comparison of average costs per patient for laboratory panels, electrocardiograms (ECG), and chest X-rays (CXR) before and after the implementation of the new pathway. Unit costs are derived from the 2022 Regional Unified Tariff Catalogue (Lazio, Italy). The selective testing model achieved a 96.5% relative reduction in direct diagnostic expenditure per patient

Discussion

This study demonstrates that a Choosing Wisely-oriented preoperative pathway for Day Surgery substantially reduced unnecessary testing while maintaining excellent safety outcomes. The impact extended beyond clinical appropriateness, improving system efficiency and patient flow. Our findings are consistent with high-quality evidence in cataract surgery demonstrating no benefit of routine preoperative testing in low-risk patients [8]. Our findings reinforce earlier studies showing that routine tests rarely change perioperative management in healthy patients, ASA I–II [9, 10]. Despite consistent guideline recommendations, routine testing remains common due to defensive medicine pressures, lack of standardized local protocols, automatic order sets, clinician uncertainty, and institutional habit. Our intervention addressed these barriers by creating a clear, structured, evidence-based workflow.

Day Surgery is especially suited for deimplementation because of the following: Patients are healthier (ASA I–II), procedures have low physiological impact, postoperative monitoring is limited, and surgical timing is predictable. Reducing waste is by far the largest, most humane, and smartest opportunity for evolving an affordable healthcare system [11].

Our results align with VBHC principles [12]: Improved outcomes (no delays, no complications), reduced costs (fewer tests, fewer hospital access points), and enhanced patient experience (less bureaucracy, shorter waiting times).

Recent literature shows that deimplementation initiatives can save millions annually in large hospital systems without compromising safety [7]. The ASA III patients included in our study were managed safely within the new pathway, as they were in stable clinical conditions and had their chronic pathologies already well documented through regular specialist follow-ups.

Avoiding unnecessary tests prevents anxiety from incidental findings, cascade testing, and overtreatment. Clinicians can refocus time on meaningful risk stratification (history and physical exam). Patients benefit from shorter pathways and clearer expectations.

The operative model is easily replicable: Internal guidelines, clinician education, electronic order set redesign, and continuous audit.

Evidence suggests it can also be extended to ASA I–II patients undergoing intermediate-risk surgery, as supported by NICE 2016 and ASA 2022 updates [5, 6].

Beyond direct cost containment, our results highlight the alignment with Value-Based Health Care (VBHC) principles, where reducing low-value care directly translates into more sustainable hospital resource management.

Limitations

This study has several limitations. First, it was conducted in a single center, which may limit generalizability to other institutional settings with different organizational structures.

Second, the retrospective pre-post design does not allow full control for potential temporal confounders. Although baseline characteristics were broadly comparable, minor differences in surgical specialty distribution were observed between cohorts.

Third, safety outcomes were assessed using perioperative and immediate postoperative data, without extended long-term follow-up. Therefore, rare delayed complications may not have been captured.

Fourth, the economic analysis was limited to direct diagnostic costs from a hospital perspective; therefore, total system savings—including administrative and staff time—were not fully captured.

Finally, no multivariable adjustment was performed, as the intervention effect was large and consistent across subgroups; however, residual confounding cannot be entirely excluded.

Conclusions

A Choosing Wisely aligned preoperative pathway in Day Surgery dramatically reduced unnecessary testing without compromising safety or efficiency. Adoption of similar models may support broader healthcare efforts to decrease low-value care, reduce costs, and enhance patient-centered perioperative management.

Implications for clinical practice

• Routine testing in healthy Day Surgery patients can be safely eliminated.

• Anesthesiologist-driven selective testing improves efficiency and reduces waste.

• Hospitals may significantly reduce costs while improving patient satisfaction.

• This model is scalable across surgical specialties and may inform national policies aimed at reducing low-value care.

Authors’ contributions

*LTe, GS, ADP and LT wrote the main manuscript; MA, ODC, MM and TV prepared Fig. 1 and Table 1; all authors reviewed the manuscript.*

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.